Hong Kong Journal of Psychiatry (1998) 8 (1) 17-19

Mental Health and Services

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INTRODUCTION

In recent years, research on family management of schizophrenia has flourished in China. Articles on family management can be divided into three categ­ ories: family intervention, family psychoeducation, and home-care program. However, the essence of these programs is quite similar to each other and their operations are also partially overlapping. In a broad sense, all these programs can be named "Family intervention", and belong to the scope of psychosocial interventions. In this brief review, the development of these programs in China will be summarized.

FAMILY INTERVENTION

There are different schools and models of family intervention in western countries. (Liberman et al, 1984; Falloon, 1985; Goldstein & Strachan, 1986; Hogarty, 1986; Leff, 1990). Most of the programs carried out in China are adopted from the psychoeducational and behavioral schools. The major studies of family intervention for schizophrenia in China are listed in Table 1.

Although there were methodological differences among the above-mentioned studies, all of them were designed with control subjects and used standard diagnostic criteria such as DSM-III­ R or CCMD-II. These studies included either individual or group psychoeducation, and were often combined with antipsychotic drug treatment. Furthermore, almost all studies applied the basic concepts of family intervention developed in western countries, though changes were made to address Chinese cultural chara cteristics. The content of psychoeducation in these studies included general information on mental illness and medication, communication and problem-solving skills, coping strategies for mal adaptive behaviours and other skills for coping with daily living. In implementing psychoeducation, researchers put much emph asis on the participation and cooperation of patients' family members. The aim of psychoeducation was to rebuild the confidence of patients and their relatives, and to help them support one another.

The advantages of family intervention programs were clearly demonstrated in these studies. There was marked reduction in relapse rates, an enhancement of patients' quality of life and social functioning, and an improvement in family relationship and social environment.

However, these positive results came from pilot studies with relatively small samples size (n=20-60) and thus might not be generalized to the large schizophrenic population of China. Besides, practical problems such as insufficient manpower and financial restraint, and the uncooperative attitude of some family members made it difficult to adopt family intervention programs. As a result, family intervention programs are still not widely used as an adjunctive treatment in community mental health services in China.

FAMILY PSYCHOEDUCATION

Supported by WHO, Zhang & Yang (1993) and his colleagues conducted a random sampling cohort study in five Chinese cities (Shanghai, Hangzhou, Jinan, Shengyang and Suzhou) to explore the feasibility and effectiveness of group psychoeducation for relatives of schizophrenic patients. The experimental group (n=2076) received psychoeducation as well as routine community mental health care, while the control group (n=l016) received routine services only. Psychoeduc­ ation was given by psychiatrists to groups of 20-40 relatives. The program consisted of 10 lectures and 3 sessions of group discussions. During the first five weeks, lectures and group discussions were held weekly. In subsequent months, such activities were held on a monthly basis. From the 7th to the 12th month, they were held once every two months. At the end of the study, researchers found that the annual relapse rate was 20.4% (n=424) in the experimental group, and 31.1% (n=316) in the control group, the difference being statistically highly significant (P<0.001). Total scores on the DAS (an instrument assessing disability and social functioning) were 16.7±11.1 in the experimental group, and 20.6±12.8 in the control (p<0.001). Mean total scores of the RS (Family Burden Interview Schedule) were 11.5±10.4 in the experimental group and 17.7±14.0 in the control group (p<0.001). After one year, more experimental than control subjects showed good compliance to treatment [1692 (81.5%) vs 581 (57.2%) p<0.001]. Relatives in the experimental group had more knowledge about schizophrenia and better coping strategies in dealing with abnormal behavior (Zhang et al, 1994).

In sum, the results of this study suggested that family psychoeducation program could benefit both the mentally ill patients and their caregivers. The effectiveness of psycho­ education for relatives in acquiring a basic understanding of schizophrenia was also confirmed.

HOME-CARE PROGRAM

Over the past three decades, the home-care program has been developed as a major community health care service in China. Because of its outreaching effects, home care program was also introduced in the management of mentally ill patients in many provinces, particularly in some rural areas. However, as this type of service has been mostly conducted at primary care level, there has been little scientific research conducted and insufficient data collected to evaluate its effectiveness, especially in relapse prevention of schizophrenia. Nevertheless, some of the recent studies are briefly sumarized in Table 2.

Although the procedures and methods of home-care programs reported by these authors tended to be incomplete and oversimpllfied, their results did indicate some favorable effects. There was marked clinical improvement with diminished relapse rate. In addition, many patients managed to return to work. Because the home-care program was carried out on primary health care level, the most significant implication for clinical practice appears to be its applicability in community settings.

CONCLUSION

Family management is obviously an effective and promising treatment modality in rehabilitating chronic schizophrenic patients in the community. There are still some problems in developing a model of family management most suitable for the Chinese culture. Furthermore, the widespread application of such family intervention in areas with large patient population remains a major challenge. With regard to future directions, it is proposed that an integrative program of family management should be adopted, in which out-reach home-care and family psychoeducation approaches are combined having the flexibility to engage individual famines as well as groups of families in the community. More research is needed in this area of psychosocial rehabilitation to develop the most cost-effective model of family management.

REFERENCES

Chen K., Weng Z., Zao G. F. (1994). The effectiveness of home care program in rehabilitation of schizophrenia. Chinese Mental Health Journal, 8: 206-207.

Falloon I.RH., Boyd, J.L., McGill, C.W., et al. (1985). Family management in the prevention of morbidity of schizophrenia: clinical outcome of a two-year longitudinal study. Archives of General Psychiatry , 42: 887-896.

Goldstein, M.J. & Strachan, AM. (1986) The impact of family intervention programs in family communication and the short­ term course of schizophrenia. In Treatment of schizophrenia: Family assessment and intervention. (Ed. M.J. Goldstein, I. Hand, & K. Hahlweg) Heidelberg. Springer­ Verlag.

Hogarty, G., Anderson, C.M., Reiss, D.J. et al (1986). Family psychoeducation, social skills training and maintenance chemotherapy in the aftercare treatment of schizophrenia, !:One-year effects of a controlled study on relapse and expressed emotion. Archives of General Psychiatry, 43: 633-642.

Kang M., Li J., Xie J. (1992). Family therapy of psychosocial intervention and rehabilitation of schizophrenia. Chinese Journal of Nervous and Mental Diseases, 18: 258-260.

Leff , J., Berkowitz, R, Shavit, N., Strachan, A., Glass, I. and Vaughn, C. (1990). A trial of family therapy versus relatives' group for schizophrenia: two-year follow-up. British Jounal of Psychiatry, 157: 571-577.

Liberman, R P., Falloon, I.R H. & Aitchison, R.A. (1984) Multiple family therapy for schizophrenics: A behavioural approach. Psychosocial Rehabilitation Journal, 4: 60-77.

Shen Y. C., Zhang W. X., Chen C. H. (1990). Psychosocial rehabilitation of mentally ill in community mental health home care program. Shanghai Archives of Psychiatry, 2: 108-11. Wang S. C., Zhou T. X., Zhang M. Y. et al (1993). The family intervention of schizophrenia in community. Chinese Journal of Rehabilitation, 8: 57-60.

Xiong W., Phillips M., Hu X. et al (1994). Family-based intervention for schizophrenic patients. British Journal of Psychiatry, 165: 239-247.

Yao J. Y. (1990). Prevention treatment and rehabilitation of psychotic patients in Yentai rural area. Shanghai Archives of Psychiatry, 2: 127-29.

Zhang M. L., Wang M. T., Li J. J., Phillips M. (1994). A randomized-control trial of family intervention for 78 first­ episode male schizophrenic patients. British Journal of · Psychiatry, 165 (suppl.24): 96-102.

Zhang M. Y., Yan H. Q. (1993). Effectiveness of psychoeducation of relatives of schizophrenic patients. International Journal of Mental Health: 22, 47-59.

Zhang W. H., Zhou M. C., Hu H. M. (1994). The investigation of home-care program of schizophrenia in rural area. Journal of Clinical Psychiatry, 4: 96-97.

Wang Shan-Cheng, M.D. Chairman, Chinese Psychiatric Rehabilitation Association; Professor of Psychiatry, Shanghai Medical University; Senior Psychiatrist, Shanghai Mental Health Center, 600 Wan Pin Nan Road, Shanghai 200030, People's Republic of China.