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Family treatment for schizophrenia?

Schizophrenia is a serious mental illness with a lifetime risk of about 1% in most countries, including the developing world. Its hallmarks are delusions (false, culturally inappropriate beliefs) and hallucinations (especially hearing voices), with associated abnormal behaviour. The condition sometimes has a good outlook, but often becomes chronic, with relapses and remissions, and a general decline in self-care and the capacity to lead an independent life. A recent systematic review [1] examines whether treating the family as a whole benefits the member with schizophrenia or the family itself.

Do abnormal families cause schizophrenia?

Schizophrenia usually begins in adolescence or early adulthood, so the possible role of the family in the course or even the causation of the illness has long been studied. Families with "high expressed emotion" towards their schizophrenic member (such as criticism, arguments, etc) have higher rates of relapse in the patient, though it remains unclear if emotion causes relapse or vice versa. Nevertheless, randomised trials have been done to see if reducing this expressed emotion by family treatment might help.

Helping schizophrenics by treating their families?

The treatment involves psychotherapy from a doctor, nurse or other professional, aimed at changing behaviour in various ways, such as reducing expressions of anger and guilt, constructing an alliance with carers and improving adverse family atmosphere.

In view of the inherent difficulty of the subject, the number of trials [1] is surprisingly high, perhaps reflecting the popularity of theories (associated with the "anti-psychiatry" movement of the 1960s and 70s) suggesting explanations in family, environment or society for psychotic symptoms. However, the existence of the trials must not be taken as supporting notions such as the "schizophrenogenic mother", which have wrongly led many families to perceive the illness as their fault [2]. The results of the review do not support such simplistic interpretations.

Methods

The review used Cochrane Collaboration methodology, finding trials by methodical electronic and journal hand searching. It has excited wide interest, with notices in the BMJ and in Evidence Based Medicine. The outcomes chosen were dichotomous (yes/no: e.g. comparing odds of relapse on treatment and control using the odds ratio (OR )), since simple statistical methods are available, and used here, to combine ORs from different studies. It is clearly a high quality review, which provides the best available summary of the present evidence on this topic.

Results

Family therapy reduces relapse during the year following treatment: it is necessary to treat at least six families to prevent one relapse at one year (number needed to treat, NNT = 6.5, 95% confidence intervals 4.3 - 14.0. The NNT is worked out from the OR using a simple calculation reported previously in Bandolier). There is a similar reduction in re-admission to hospital, and in improvement of compliance with medication. There was no effect on the levels of expressed emotion in the families, or the burden they perceive.

Conclusions

  1. Family treatment reduces relapse and rehospitalisation: about 6 families need to be treated to prevent one such event.
  2. Family treatment improves compliance with medication.
  3. Family treatment does not alter the emotional climate or perceived burden in the family.

Practice points

  1. Family treatment helps prevent relapse, but, as delivered in the trials, is expensive. About six families require a large amount of expensive therapist time to prevent one relapse.
  2. The benefits of the treatment seem likely to be due to improved compliance with medication (e.g. long acting "depot" injections). Cash-strapped mental health trusts seem unlikely to purchase a family therapy Rolls Royce if feel they can get to the same place on a push bike.
  3. Further research into patient (and family) treatment preferences is needed: should they value a talking treatment which has little or no effect apart from increasing compliance, there will nevertheless be a case to provide, if not a Roller, then at least an Austin Allegro.

References:

  1. Mari J, Streiner D. The effects of family intervention on those with schizophrenia. In Adams C, Anderson J, De Jesus Mari, eds. Schizophrenia module, Cochrane Database of Systematic Reviews (updated 23 Feb 1996) Available in the Cochrane Library, London: BMJ Publishing, 1996.
  2. Amis, Kingsley: Stanley and the Women, Penguin Books, 1980.

David Gill
Cochrane Depression Group
University of Oxford Institute of Health Sciences
PO Box 777, OXFORD OX3 7LF, UK
Tel: +44 1865 226609 Fax: 01865 226775
david.gill@psychiatry.oxford.ac.uk



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