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5.1.6. Pyschoeducational interventions The pyschoeducational type approach is frequently used in interventions with patients affected by schizophrenia and bipolar disorders, both in hospitals and outpatients. This intervention involves transmitting information about the disease to patient and families; it is not always done in an organised manner and the inclusion of family members is not normal practice. It is important to know the effectiveness of these interventions, which are usual in practice. Problems have been encountered to focus the search for scientific evidence due to the fact that the majority of studies associate pyschoeducation as an essential part of family intervention, although the surveys on clinical activity inform us that family incorporation is very scarce and not generalised in clinical practice. This CPG development group decided to focus the search on pyschoeducation programmes for users that were compared with an inactive control group. They included studies that evaluated the impact of the pyschoeducation of family members/caregivers in group format on results in patients with bipolar disorders. Those studies that included non-specific cognitive-behavioural interventions were excluded for the pyschoeducation of people with bipolar disorders. An important overlapping is observed between user-orientated pyschoeducation and standard treatment when the standard treatment includes transmission of relevant information as well as coping and handling strategies for the disease, both if carried out individually and with the incorporation of family members. There is a lack of knowledge about whether the mere family involvement in the treatment is per se the determining factor for the improvement of treatment adherence (pharmacological) and these condition the results, or if what is important is to give adequate information, or achieve a change in the transactional patterns 105 . It is difficult to find control groups that incorporate the family without having carried out any specific intervention with them. The protocolisation and standardisation of pyschoeducational intervention (for example, inclusion of contents in a manual, with a specific timeframe) may be a reason for not accepting the intervention for quite a large subgroup of patients, above all if the content does not adapt to the evolutionary moment of the disorder or to the attitudinal state of the patient. Another factor to be taken into account is that when the presentation is more interactive, it incorporates more behavioural components and the content is understood and accepted better, the impact of the intervention is optimised. Studies that assess exclusively user-orientated pyschoeducational programmes do not “continue” with the patient when they end and do not involve support and intervention to incorporate the different issues dealt with in their daily lives. Thus, the long-term assessment of the results may produce evidence of ineffectiveness when compared with interventions that incorporate family members and which, therefore, get “co-therapists” in the home, outside the intervention hours. The relapse ratios seem to be strongly related to the medication adherence, and the question of whether the efficiency of the family pyschoeducational interventions is the consequence mainly of the increase in adherence still cannot be answered 104 . Providing suitable information about the disorder with a view to improving its handling, by patients or by their family members, is an act that is carried out from the moment of the referral, at the time when admission is decided, when the treatment is proposed and prescribed, or when pharmacological treatment is advised, or when a periodical check-up is carried out, etc. Therefore, a good knowledge of the effectiveness of this intervention may help improve the use of resources and clinical practice. 66 CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS
Question to be answered • Are pyschoeducational interventions effective in people with SMI? • What are the key components in pyschoeducational interventions in people with SMI? • What is the most adequate level of pyschoeducational intervention: individual, group or family? The review carried out by Lincoln et al 107 (18 studies; n = 1543) was designed to assess the long and short-term efficiency of exclusively user-orientated pyschoeducation and user and family-orientated pyschoeducation. The result variables taken were the reduction of relapses and symptomatic severity, improvement of knowledge about the disorder, medication adherence and global functioning of the patients diagnosed with schizophrenia and related disorders (schizoaffective, delirium disorder, brief psychotic disorder and schizotypal disorder). Both interventions were compared with normal treatment or non-specific intervention without proven efficiency. The studies included had to satisfy the requirement that pyschoeducation (understood as the transmission of relevant information about the disorders and its treatment whilst better coping is promoted) was the main element of the intervention. Bauml et al 108 carried out a study (n=101) in a European context whose objective was to evaluate the effectiveness of parallel bifocal pyschoeducational intervention and its long-term effect. People diagnosed with schizophrenia and their family members were randomised either to group pyschoeducational intervention, both groups separately, or to the control group that consisted in normal treatment. Three RCTs were included in the NICE bipolar disorder CPG 7 , two of which (n = 170) by Colom et al 109,110 , compare the effect of a complex group pyschoeducation programme (including pyschoeducation on bipolar disorder and training in communication improvement and problemsolving) with a non-directive support intervention control group in addition to the psychopharmacological treatment. The programmes consisted in 20 sessions of pyschoeducation each week with a 24-month follow-up, and with euthymic patients. Perry et al 111 performed a RCT (n = 69) comparing an individual pyschoeducational programme on people who suffer bipolar disorder that incorporated training in recognition of prodromes and pharmacological treatment compared with pharmacological treatment alone. The intervention lasted for 3 to 6 months with an 18-month follow-up. Pyschoeducation for people with SMI and diagnosed with schizophrenia and related disorders Psychoeducation vs. non-intervention Pyschoeducation, when compared with non-intervention or non-specific intervention, does not produce a significant drop in relapses or readmissions (follow-up of more than 12 months) (3 RCT; n = 144; p = 0.07) 107 . There are no data to support that pyschoeducation represents a reduction in symptoms at the end of the programmes (6 RCT; n = 313; p = 0.08) or in follow-ups at 7 to 12 months (3 RCT; n = 128; p = 0.14) 107 . Pyschoeducation improves the knowledge of the disease when this knowledge is assessed at the end of the programmes (4 RCT; n = 278; p = 0.00) but there are no data from the follow-up periods 107 . SR (1++) CLINICAL PRACTICE GUIDELINES FOR PSICHOSOCIAL INTERVENTIONS IN SEVERE MENTAL ILLNESS 67
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Clinical Practice Guidelines for Ps
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This CPG is an aid for decision mak
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Table of Contents Presentation 7 Au
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Presentation Healthcare practice is
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Authorship and collaborators CPG de
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José Manuel Lalana Cuenca. Special
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c) SERVICE LEVEL INTERVENTIONS •
Page 18 and 19: A B A A B B B C Psychosocial inter
Page 20 and 21: B B B C A C C 5.3. SERVICE LEV
Page 22 and 23: 20 CLINICAL PRACTICE GUIDELINES IN
Page 24 and 25: independence, quality of life, pers
Page 26 and 27: This guideline is aimed at mental h
Page 28 and 29: Figure 1. Search Strategy Search fo
Page 30 and 31: The highest evidence level found wa
Page 33 and 34: 4. Characteristics of the CPG 4.1.
Page 35 and 36: The main focus of rehabilitation is
Page 37 and 38: 5. Psychosocial type rehabilitation
Page 39 and 40: From another point of view, social
Page 41 and 42: defined as “standard care” or
Page 43 and 44: General global state In the short r
Page 45 and 46: Specific symptoms: when CBT was com
Page 47 and 48: In the systematic review by Kurtz a
Page 49 and 50: Summary of evidence 1- 1- 1- 1- 1-
Page 51 and 52: People with SMI and a diagnosis of
Page 53 and 54: 5.1.3. Interpersonal therapy The li
Page 55 and 56: weekly or fortnightly sessions. The
Page 57 and 58: 5.1.5. Family interventions There a
Page 59 and 60: In the RCT carried out by Hogarty e
Page 61 and 62: A family intervention of more than
Page 63 and 64: After two years’ treatment, and b
Page 65 and 66: Family intervention vs. other psych
Page 67: 1- 1- 1- 1- 1- 1- 1- 1- 1+ No diffe
Page 71 and 72: Summary of evidence Pyschoeducation
Page 73 and 74: with schizophrenia and that the tre
Page 75 and 76: With reference to the type of train
Page 77 and 78: would normally receive and which in
Page 79 and 80: Hypnosis vs. relaxation No improvem
Page 81 and 82: Supervised fl ats are a community h
Page 83 and 84: 3 Programmes directed to leisure an
Page 85 and 86: SMI (schizophrenia, affective schiz
Page 87 and 88: When PVT is compared with standard
Page 89 and 90: Patients included in the individual
Page 91 and 92: 1+ 1+ 1++ 1+ 1+ 1+ 1+ The people in
Page 93 and 94: Music therapy Music therapy + stand
Page 95 and 96: A series of Case Management systems
Page 97 and 98: • The satisfaction data originati
Page 99 and 100: Loss of contact With respect to the
Page 101 and 102: There is not sufficient evidence, e
Page 103 and 104: 1+ 1+ 1+ 1+ Respect to ICM teams or
Page 105 and 106: Finally, in the RCT by Cheng et al
Page 107 and 108: 5.4.2. “Homeless” with SMI The
Page 109 and 110: Patients who access housing with no
Page 111: ceptive disorders. This series of c
Page 115 and 116: 7. Recommendations for Future Resea
Page 117: Appendices
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Appendix 2. Information obtained fr
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Appendix 4. Information for people
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4. Regulatory and legal framework 1
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Several protocols have been publish
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The coordination of these resources
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Social protection systems Pursuant
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Specifi c regulation • (SPANISH)
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Service Management: The first anti-
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on Mental Health and the future Eur
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Spanish Society of Legal Psychiatry
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Appendix 5. Abbreviations ACT Asser
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Appendix 6. Glossary Therapy adhere
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Appendix 7. Declaration of interest
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15 Rossler W. Psychiatric rehabilit
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53 Graeber DA, Moyers TB, Griffi th
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86 Schooler NR, Keith SJ, Severe JB
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117 Sohlberg MM, Mateer CA. Effecti
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154 López M, García-Cubillana P,
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190 Bond GR, Drake RE. Predictors o
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225 Hurley AD. Individual psychothe
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