CLINICAL HANDBOOK OF SCHIZOPHRENIA

22. Family Intervention 219come. The Pharoah and colleagues (1999) analysis adopted more stringent inclusion criteria(excluding studies with nonrandom assignment, those restricted to an inpatientintervention, those not restricted to schizophrenia, and those in which intervention wasless than five sessions) and included 13 studies. The review confirmed the findings of earlier,descriptive accounts of the studies. It concluded that family intervention as an adjunctto routine care decreases the frequency of relapse and hospitalization, and thatthese findings hold across the wide age ranges, sex differences, and variability in thelength of illness in the different studies. Moreover, the analysis suggested that these resultsgeneralize across care cultures in which health systems are very different: Trials fromthe United Kingdom, Australia, Europe, the People’s Republic of China, and the UnitedStates were included. However, more recent reviews have been less conclusive and havehighlighted the large degree of heterogeneity in findings.Pitschel-Walz and colleagues (2001) examined 25 studies spanning 20 years (1977–1997). Table 22.1 contains a subgroup of these studies, selecting those that had a treatmentduration of at least 10 sessions. Their meta-analysis confirmed the superiority offamily treatment over control groups relative to patient relapse rates, with a relapse ratedecrease of 20% in patients whose families received an intervention. Although this treatmenteffect may seem relatively low, one must bear in mind that this analysis includedstudies in which the intervention was extremely brief, with little resemblance to the intensiveprograms in the original studies. For example, as shown in Table 22.1, the studies ofFalloon and colleagues (1982), Leff, Kuipers, Berkowitz, Eberlein-Fries, and Sturgeon(1982), and Tarrier and colleagues (1988) demonstrated decreased relapse rates of approximately40% in patients whose families received treatment. Unfortunately, the absenceof treatment fidelity measures makes it very difficult to judge quality control withinor between studies. Further comparison analyses within the Pitschel-Walz and colleaguesreview drew attention to some of the wide variations in the content and duration of programsin recent years. It seems that there was considerable dilution of the potency of thefamily interventions in the large meta-analyses in which there was no quality control.Categorizing studies into those lasting more or less than 10 weeks, they found that longterminterventions were more successful than short-term interventions, and that moreintensive family treatments were superior to a more limited approach (e.g., in which relativeswere offered little more than brief education sessions about schizophrenia). For familiesprovided with a longer and more intense intervention, the Pitschel-Walz and colleaguesreview suggested some evidence of the long-lasting effects from family treatment.However, it must be emphasized that all the studies indicated that relapses increased withthe number of years from termination of the intervention.The more recent meta-analysis by Pilling and colleagues (2002) included 18 studies,and its conclusions were in line with previous reviews in confirming the efficacy of familyintervention for reducing patient relapse. In a comparison of single-family and groupfamily treatments, group treatments had poorer outcomes in terms of the reemergence ofpatients’ psychotic symptoms or readmission to hospital. Pilling and colleagues agreedwith previous reviewers (Mari & Streiner, 1994) that the effects from family interventionshave decreased over the years, and suggested that this might in part be explained by theincreased use of family group approaches. However, they added that this might not bedue to the group format per se, but rather to other factors: the variable content of thegroup treatments; the fact that group treatments may have benefits not measured by thestudies (e.g., on caregiver burden); or the fact that group treatments may have particularbenefit for subpopulations.One of the criticisms of family intervention studies has been their narrow focus onthe end results of reductions in patient relapse and hospitalizations. The inclusion of