Enhanced relapse prevention for bipolar disorder by community mental health teams: cluster feasibility randomised trial.

BACKGROUND: Relapse prevention for bipolar disorder increases time to relapse but is not available in routine practice. AIMS: To determine the feasibility and effectiveness of training community mental health teams (CMHTs) to deliver enhanced relapse prevention. METHOD: In a cluster randomised controlled trial, CMHT workers were allocated to receive 12 h training in enhanced relapse prevention to offer to people with bipolar disorder or to continue giving treatment as usual. The primary outcome was time to relapse and the secondary outcome was functioning. RESULTS: Twenty-three CMHTs and 96 service users took part. Compared with treatment as usual, enhanced relapse prevention increased median time to the next bipolar episode by 8.5 weeks (hazard ratio 0.79, 95% CI 0.45-1.38). Social and occupational functioning improved with the intervention (regression coefficient 0.68, 95% CI 0.05-1.32). The clustering effect was negligible but imprecise (intracluster correlation coefficient 0.0001, 95% CI 0.0000-0.5142). CONCLUSIONS: Training care coordinators to offer enhanced relapse prevention for bipolar disorder may be a feasible effective treatment. Large-scale cluster trials are needed.

Needs-based cognitive-behavioural family intervention for patients suffering from schizophrenia: 5-year follow-up of a randomized controlled effectiveness trial.

OBJECTIVE: To determine whether a 24-week, needs-based cognitive-behaviourally oriented family intervention for patients suffering from schizophrenia led to improved relapse profiles over a 5-year follow-up period. METHOD: The case notes of 60 patients who had participated in a randomized, controlled effectiveness trial were examined to determine relapse rates over a 5-year period. RESULTS: Patients were less likely to relapse over the 5-year follow-up when they received the needs-based family intervention, especially in relation to exacerbations of symptoms not requiring inpatient admissions: 86.7% of control participants relapsed compared with 53.3% (P = 0.01). Survival analysis indicated that the relapse risk was 2.5 times higher for patients receiving routine care, compared with those receiving family intervention. A similar trend was observed for the final 4 years of follow-up. CONCLUSION: The present study provides some tentative support for the long-term effectiveness of family-based interventions for the management of schizophrenia in general mental health services.

The family and compliance in schizophrenia: the influence of clinical variables, relatives' knowledge and expressed emotion.

BACKGROUND: . A variety of factors are related to compliance with medication in schizophrenia, but little attention has been paid to the role of families. Carers' knowledge or expressed emotion (EE) may be related to compliance. The aim of the present study was to evaluate the relevance of these two factors, as well as their relationships with other variables for the prediction of compliance. METHOD: A sample of patient-carer pairs (N = 79) involved in a family intervention for schizophrenia trial was recruited. Compliance, symptoms, social functioning and attitudes to their carers were assessed in patients. Carers' EE, knowledge and psychopathology were also evaluated. RESULTS: A number of factors were related to compliance, including carers' EE and patients' psychotic symptoms, which contributed independently to not taking medication. Carers' knowledge about schizophrenia and other groups of symptoms was not related to compliance. CONCLUSIONS: EE may be an important factor to account for in the understanding of patients' compliance and the direction of the relationship between EE and compliance should be the subject of further study.

Needs-based cognitive-behavioural family intervention for carers of patients suffering from schizophrenia: 12-month follow-up.

OBJECTIVE: To examine longer-term effectiveness of a needs-based family intervention for carers and out-patients suffering from schizophrenia. METHOD: Seventy-nine unselected patient-carer pairs were recruited from a geographical area and allocated randomly to one of two conditions. One group received needs-based cognitive-behavioural family intervention in combination with general family support plus the standard care. The control group received the general family support and standard care only. RESULTS: Analysis was carried out on an intention-to-treat basis. There was a significant advantage for family intervention, in terms of relapse (37% relapsed compared to 72%, NNT=3) and on other clinical measures. Treatment group and medication compliance were significant and independent predictors of relapse. There was a significant reduction in carer needs in the intervention group. CONCLUSION: Family intervention directed at carers' needs within a standard mental health service can produce benefits for patients beyond the term of intervention.

Compliance and psychological reactance in schizophrenia.

OBJECTIVES: Non-compliance with neuroleptic medication in schizophrenia is a major cause of relapse. A number of sociodemographic variables, and illness, attitudinal and treatment variables, have been demonstrated to be associated with non-compliance. The present study examined a range of these variables and their predictive value in determining past and current compliance. METHODS: Thirty-nine patients suffering from schizophrenia and three patients suffering from schizoaffective disorder completed a series of questionnaires assessing psychological reactance, insight, subjective response to medication, perceived threat to freedom of choice, and degree of current and past compliance. Logistic regression analyses were performed to determine which factors best predicted past and current compliance. RESULTS: Psychological reactance and age were found to be the best predictors of past compliance, with an interaction between reactance and perceived threat to freedom of choice posed by treatment provision also making a significant contribution. Past compliance behaviour and subjective response to medication predicted current compliance most significantly. CONCLUSIONS: Reactance is an important predictor of compliance history especially when patients perceive treatment to be a threat to freedom of choice. Subjective response to neuroleptics is most important in predicting current compliance. Implications for intervention are discussed.

A randomised controlled trial of home-based rehabilitation versus outpatient-based rehabilitation for patients suffering from chronic schizophrenia.

BACKGROUND: Outpatient-based treatments for patients suffering from chronic schizophrenia inadvertently exclude a significant proportion of subjects because they are often too poorly motivated to attend for treatment. In addition there are also concerns about whether the skills that are learnt in a hospital setting will generalize to situations when the individuals are at home. This study attempted to redress some of these potential deficiencies and followed on from an earlier local study which found that a community-based team met more of the needs of patients suffering from chronic schizophrenia. METHOD: Seventy-five patients suffering from chronic schizophrenia were allocated randomly to receive traditional outpatient-based or home-based rehabilitation from a clinical psychologist and an occupational therapist. They were assessed before and after 9 months of treatment on a range of clinical, social and quality of life outcomes. Distress to carers was also assessed. Readmission to hospital was recorded for each subject. RESULTS: There were significant reductions in socially embarrassing behaviour (SBS), increases in interpersonal functioning and recreational activities and a trend for quality of life to improve in the home-based group. There were fewer admissions in the home-based group but the differences, although financially substantial, were not statistically significant. CONCLUSIONS: The home-based rehabilitation service was well received by the majority of patients suffering from chronic schizophrenia and led to some improvement in social behaviour, interpersonal functioning, recreational activities and quality of life.

Randomised controlled effectiveness trial of a needs-based psychosocial intervention service for carers of people with schizophrenia.

BACKGROUND: Family interventions are effective in reducing relapse in patients with schizophrenia, but there is little work demonstrating the effectiveness of the interventions in routine service settings. AIMS: To test the effectiveness of a needs-based family intervention service for patients recruited as out-patients and their carers, including those of low expressed emotion status. METHOD: Carers of out-patient schizophrenia sufferers selected only on illness history factors were randomly allocated to receive either family support alone or in combination with systematic psychosocial interventions based on an assessment of need. Delivery of family interventions attempted to involve the clinical team. RESULTS: Relapse outcomes were superior for family-treated patients at six-month follow-up, although most of the clinical and symptom patient variables assessed remained stable, as did measures of carer burden. CONCLUSIONS: The study demonstrated the effectiveness of family interventions in routine service settings. Problems with staff, patient and carer engagement and participation were identified.

Assessing relatives' needs for psychosocial interventions in schizophrenia: a relatives' version of the Cardinal Needs Schedule (RCNS).

BACKGROUND: The methodology for measuring the needs of patients with severe mental illness is now well established through the MRC Needs for Care Assessment Schedule and its modification in the form of the Cardinal Needs Assessment. This paper reports the rationale and construction of a relatives' version of the Cardinal Needs Schedule and looks at preliminary data reporting on reliability and validity. METHODS: Potential problem areas for relatives were identified from the literature. The criteria determining Cardinal Needs for each problem included objective threshold, carer concern, and carer cooperation. The reliability of the Schedule was assessed in a study whereby 27 relatives of patients with established schizophrenic illness completed two Schedules administered by two independent raters within a short time period. RESULTS: The Schedule was acceptably reliable for most areas of need although there were some difficulties associated with the cooperation criteria. Concurrent measures of relatives and patients including EE, relative distress and patient psychopathology indicated that the Relatives' Cardinal Needs Schedule shows acceptable validity when used with a sample of 45 relatives. CONCLUSIONS: The paper suggests that the Schedule may prove to be a useful tool for both clinicians and researchers interested in establishing and evaluating family interventions.

Demographic factors associated with extreme non-compliance in schizophrenia.

Having identified total non-compliance with neuroleptic medication as a major problem in a significant proportion of schizophrenic patients, an analysis of potentially important demographic factors associated with this problem was carried out. The in-patient records of 256 schizophrenic patients were examined with reference to ethnicity, gender, age, number of admissions and amount of time spent in hospital over a 3-year period. Non-compliant patients differed from those who were at least partially compliant in that they were more likely to be Afro-Caribbean and male, have shorter stays in hospital and have more admissions. There was no difference between these groups in terms of age, although certain subgroups exhibited some age differences. Logistic regression analyses revealed that gender and ethnicity were significant predictors of extreme non-compliance, to the extent that in male Afro-Caribbeans there was a 31% chance that prophylactic medication would be completely refused. The implications of these results and methodological issues are discussed.

Demographic factors associated with extreme non-compliance in schizophrenia

Having identified total non-compliance with neuroleptic medication as a major problem in a significant proportion of schizophrenic patients, an analysis of potentially important demographic factors associated with this problem was carried out. The in-patient records of 256 schizophrenic patients were examined with reference to ethnicity, gender, age, number of admissions and amount of time spent in hospital over a 3-year period. Non-compliant patients differed from those who were at least partially compliant in that they were more likely to be Afro-Caribbean and male, have shorter stays in hospital and have more admissions. There was no difference between these groups in terms of age, although certain subgroups exhibited some age differences. Logistic regression analyses revealed that gender and ethnicity were significant predictors of extreme non-compliance, to the extent that in male Afro-Caribbean there was a 31 percent chance that prophylactic medication would be completely refused. The implications of these results and methodological issues are discussed (AU)