Consumer and Family Psychoeducation: Assessing the Evidence

The level of evidence for consumer psychoeducation is high, although not as strong as the evidence for family psychoeducation. This rating is based on three reviews of 32 RCTs of consumer psychoeducation alone (5,18,19) plus two RCTs that were published more recently (20,21). (Some RCTs were evaluated in multiple reviews.) The focus of each review was sufficiently different from most of the others to make it challenging to assess the evidence base for psychoeducation as a stand-alone service. For example, one review targeted psychoeducation in support of medication adherence only (5), and two reviews provided an overview of various psychosocial interventions for bipolar disorder (18,19). One, a Cochrane review, covered psychoeducation as an addition to standard treatment for schizophrenia but merged various forms of psychoeducation (22). Limitations in research on this topic covered in the reviews included the heterogeneity of the services examined and the methods used to study them. For example, a 2006 review of 21 RCTs of the effects of educational interventions for users of mental health services who were receiving psychotropic medication found that results could not be pooled because there was so much variability in the measurement of outcomes (5). We noted a 2013 review by Addington and other experts (23) in which the level of evidence was rated as moderate on the basis of a Delphi model of the consensus of experts. However, more recent studies with improved methods have assessed functioning, quality of life, adherence to treatment, hospitalization rates, and client satisfaction (18,20,22). For example, a 2011 Cochrane review of psychoeducation as an addition to standard treatment cited 44 RCTs involving more than 5,000 participants (22). Thus the level of evidence in support of consumer education can be described as high, with the caveats noted here.

The level of evidence for psychoeducation for family members of consumers with schizophrenia or other psychotic disorders is even higher than the level of evidence for consumer education. We found eight reviews of family psychoeducation alone that analyzed more than 100 RCTs (1,2,13,14,24–27) and five reviews in which consumer and family psychoeducation were summarized together (3,7,23,28,29) (Table 3). (Some RCTs were evaluated in multiple reviews.) In addition, we found two recently published RCTs that were not included in other reviews (30,31) (Table 4). Addington and colleagues (23) rated the evidence level for psychoeducation for families coping with first-episode psychosis as strong in single-family interventions and in multifamily groups. As noted in a review by McFarlane and colleagues (2), as of 2003 numerous reviews (at least eight systematic reviews in the past decade; the number of studies covered in these reviews was not reported) had found significant effects for family psychoeducation for schizophrenia (1,6,14,32–38). One meta-analysis of 25 studies (mainly RCTs) that was published in 2001 found a high level of evidence supporting the positive effects of family psychoeducation on relapse and rehospitalization rates (14). However, this study merged various family psychoeducation models, thus affecting the level of evidence for any specific model. A comprehensive review in 2004 by Murray-Swank and Dixon (13) cited more than 30 RCTs supporting the effectiveness of family psychoeducation compared with control groups. In 2007, Lincoln and colleagues (24) conducted a meta-analysis of 18 RCTs (selected from 199 abstracts) that examined the effects of consumer-only versus family psychoeducation in the treatment of schizophrenia and other psychotic disorders, which also supported a high level of evidence.

The evidence in support of this approach with individuals who have bipolar disorder is growing (18,28), but evidence is less extensive for families of adults with other disorders. Indeed, Zaretsky (3) noted that research on the use of this approach for individuals with bipolar disorder lags about a decade behind schizophrenia research. A systematic review of seven RCTs and a number of quasi-experimental studies assessing family psychoeducation for individuals with bipolar disorder noted that the evidence was insufficient to draw conclusions that could be generalized to everyday practice (25). In contrast, a subsequent review of controlled trials examining treatments for bipolar disorder concluded that there was sufficient evidence for various family interventions, including psychoeducation, as adjuncts to pharmacotherapy (19). As recently as 2011, an RCT of family psychoeducation for people with major depression was conducted by Shimazu and colleagues (30), which suggests that the evidence base in this diagnostic area continues to grow.

A Cochrane review including more than 5,100 participants with schizophrenia (mostly in hospital settings) from 44 trials conducted between 1988 and 2009 found that there were fewer incidents of nonadherence and relapse in groups that were receiving consumer psychoeducation than in groups that were not, both for the medium and long term (22). The authors concluded that consumer psychoeducation promotes better social and global functioning, improves satisfaction with mental health services, and supports quality of life. However, this review merged individual and group consumer education models; thus it does not provide evidence regarding whether one approach is more effective.

We were unable to find other reviews that examined the effects of psychoeducation alone with individual consumers compared with standard care (that is, usual therapies not involving psychoeducation). A review by Zaretsky and colleagues (40) found that consumer psychoeducation as an adjunct to pharmacotherapy was related to better medication adherence, fewer hospitalizations, delayed time to mania, and improved social and vocational functioning, compared with pharmacotherapy without consumer education. A 2007 review by Lincoln and colleagues (24) involving people with schizophrenia and other psychotic disorders compared individual and family psychoeducation models. They found that psychoeducation interventions that included families were more effective than psychoeducation with consumers alone in reducing symptoms and preventing relapse in the one-year follow-up and that pre-post effects were not significant for the comparison group of consumers who participated alone in psychoeducation.

We also found a review of the use of information technology (that is, electronic media, such as video and audio recordings; television, radio, and telephonic communications; and computers) in consumer psychoeducation for people with schizophrenia (29). The authors examined six studies with a total of 1,063 participants. They did not find any significant improvements over standard care (usual treatment without technology-enhanced psychoeducation) in the primary outcomes of participant adherence and global state. However, people in the experimental group perceived that they received more social support than did those in the standard care group, and their mental state improved in the short term. When technology-mediated psychoeducation was added to standard care and compared with standard care alone, adherence to medication was significantly improved in the long term, but general adherence to treatment was not improved in the short term. In addition, general mental and global states, symptoms, level of knowledge, and quality of life did not improve relative to the control group. The authors concluded that they found “no clear benefit” from using information technologies in consumer psychoeducation to improve various outcomes, although their findings regarding long-term adherence were encouraging. However, the authors noted that education and support that used technology showed great promise and that further research is warranted.

Group psychoeducation for people with bipolar disorder has been a growing focus of research in the past decade. In a 2006 review of psychosocial interventions for the treatment of bipolar disorder, Miklowitz (28) cited three RCTs (41–43) that found significant results for group psychoeducation models. Together, these studies indicated that both short-term interventions (seven to 12 sessions) and longer-term interventions (21 sessions in combination with pharmacotherapy) reduced manic relapses and increased time between them and also improved social functioning relative to control groups receiving pharmacotherapy without psychoeducation. These studies did not find significant reduction of depressive symptoms in bipolar cycles (41–43).

One review of 45 articles published between 2000 and 2012 examined a variety of interventions under the broad category of “psychosocial” (18). The authors reviewed cognitive-behavioral, psychoeducational consumer groups and “systematic care” models (that is, combined psychosocial interventions with an emphasis on psychoeducation and ongoing communication with a team of professionals supporting connection with medical services, in particular) as well as interpersonal and family therapy interventions. They found that this range of interventions contributed to significant improvements in therapeutic adherence and in consumer functioning. However, because the authors combined the results from these models in their evaluation, it is difficult to isolate the effects of consumer psychoeducation in this review.

A subsequent RCT, published in 2012, examined group psychoeducation for people hospitalized with various serious psychiatric disorders (20). The authors found that the experimental group had higher levels of treatment adherence and a lower suicide rate at the three-month follow-up compared with a “nonspecific” intervention control group, but they found no other significant differences between groups for most other outcome variables.

As early as the 1998 Patient Outcomes Research Team (PORT) study, family psychoeducation was recommended as one component in the treatment of adult schizophrenia (26). In the 2009 follow-up PORT study, one recommendation was to offer family-based services to individuals with schizophrenia who have ongoing contact with their families (27). The authors identified the key elements of effective family interventions as “illness education, crisis intervention, emotional support, and training in how to cope with illness symptoms and related problems.”

A more recent RCT compared the effectiveness of two approaches—routine outpatient care without psychoeducation and a six-session, nurse-led, psychoeducation program in conjunction with routine outpatient care—for Chinese patients with mental health problems who were newly referred to an outpatient clinic in Hong Kong (21). Compared with patients receiving routine outpatient care only, the psychoeducation group had significantly greater improvements in mental and overall health status, insights into their treatment and illness, and hospitalization rates at the six-month follow-up assessment. This suggests that brief family psychoeducation models in conjunction with standard treatment may be effective, at least in some cases. In their 2003 review, McFarlane and colleagues (2) noted that when families in treatment participated in psychoeducation, the average relapse rate among individuals with schizophrenia was 15% per year, compared with 30%−40% in comparison groups receiving only individual therapy with medication or medication alone. The authors noted that only three studies out of nearly 30 reviewed found no effect for family psychoeducation.

There is a body of research suggesting that the multifamily group model may be more effective than psychoeducation for single families. Two RCTs by McFarlane and colleagues (44,45) comparing these models found significantly lower relapse rates in the multifamily group.

Shimazu and colleagues (30) examined family psychoeducation for people who were in maintenance treatment for depression. They found that time to relapse was significantly longer in the psychoeducation group than in the control group (no psychoeducation). The relapse rates at the nine-month follow-up were 8% in the experimental group and 50% in the control group. The researchers concluded that family psychoeducation is effective in the prevention of relapse among adult patients with major depression.

In their review of psychosocial treatments for bipolar disorder, Miklowitz and Scott (7) noted that “to be effective, adjunctive psychosocial treatments must go beyond simply educating patients about the illness and the pharmacological strategies to avoid relapse.” They also described a 2009 study of hospitalization rates by Scott and colleagues (46) suggesting that structured psychoeducation approaches can produce significant cost savings by reducing inpatient days.

Our review suggests that including families in psychoeducational interventions is likely to be more effective than providing psychoeducation to consumers alone, depending on the willingness and ability of the consumers and their family members to participate. A number of authors, including Dixon and colleagues (1) and McFarlane and coauthors (2), have noted that involving families in consumer education services occurs far less often than it should. Some families are difficult to engage, some consumers resist the involvement of family members, and, in the case of multifamily groups, the logistics of involving multiple families at the same time and over a long period can be challenging. However, research underscores the power of bringing families together to support each other and share their experiences and knowledge. The group format of this approach can reduce stigma and create a network of family peer support that can sustain adaptive functioning and prevention of relapse beyond the termination of treatment.

In their PORT study, Kreyenbuhl and colleagues (27) concluded that the evidence supported psychoeducational interventions of at least six months. If this is not feasible, the authors recommended that the intervention should last a minimum of four sessions (as noted above, others have recommended as few as two sessions under certain circumstances). Kreyenbuhl and coauthors recommended treatment that includes education, training, and support for people with schizophrenia. However, McFarlane and colleagues (2) described a study by Cuijpers (47) that concluded that interventions of less than ten sessions had no significant effects on family burden. Similarly, Pitschel-Walz and colleagues (14) found that family psychoeducational interventions were most effective when they were of at least three months’ duration. Moreover, McFarlane and coauthors (2) advised that for families, the long-term symptoms and burdens of schizophrenia are likely to erode any short-term positive effects of family psychoeducation models. These authors concluded that the significant difference in relapse rates between people in family psychoeducation services and those in nonpsychoeducation control groups increases with time in treatment, such that relapse rates after two years in treatment are well below 50% of the rates for control participants.

Most reviews did not address differential effects of consumer and family psychoeducation across subpopulations and, in fact, did not report any ethnic, racial, or linguistic characteristics. However, on the basis of a single study, McFarlane and colleagues (2) suggested that psychoeducation for an individual family may be more effective than psychoeducation for multifamily groups among African-American families with low expressed emotion (that is, low negative emotional reactivity to the illness). The authors also noted that studies in China found positive effects that were comparable to those found in studies with European-American populations. Nearly a decade later, Chien and colleagues (21) found similarly positive results in current work with participants from Hong Kong, as described above.

In 1995, Telles and colleagues (48) conducted a small (N=42) cross-cultural study with first-generation, Spanish-speaking individuals with schizophrenia who were immigrants to the United States. As reported in a meta-analysis by Pitschel-Walz and colleagues (14), there was a small effect size for improved outcomes in favor of the control group, which received individual psychotherapy with case management. However, participants in the experimental group (who received behavioral family intervention) who were the least acculturated had the most negative outcomes. Hence, the authors suggested that levels of acculturation might have moderated treatment effects.

Kopelowicz and colleagues (31) conducted an RCT of multifamily groups involving Mexican Americans with schizophrenia in which the usual multifamily group model was compared with an adaptation of that model. The adaptation focused specifically on medication adherence and sought to address beliefs and attitudes of the subgroup of Mexican-American people living in that particular local culture, such as social norms and perceived lack of resources. For example, the leaders corrected the misconception of family members that they and the consumer were not eligible for medication reimbursement. The authors found significantly higher medication adherence, lower likelihood of hospitalization, and longer time to hospitalization among those in the adapted group model compared with those in the standard multifamily group. The results of this study suggest that assessing the beliefs, attitudes, and social norms of the target population and adapting family psychoeducation models accordingly may help to improve outcomes for various populations. In fact, these adaptations would seem to be essential given the varying cultural beliefs about mental illness. This type of cross-cultural research is likely to be especially important for underserved populations.