Background

Recent years have seen a growing interest in the early detection of and intervention for psychosis, a mental illness characterized by impaired thinking or emotions.1 Psychotic episodes tend to occur in people diagnosed with schizophrenia or mood disorders. They are a relatively rare phenomenon, and so it can take time to confirm a diagnosis.2,3 In 1997, the World Health Organization (WHO) estimated a global lifetime prevalence of between 0.1% and 3.0% for schizophrenia, and between 0.2% and 1.6% for bipolar disorder.4 A more recent large-scale epidemiological survey in Finland specifically examined the prevalence of psychosis, including both schizophrenia and bipolar disorder, reporting a figure of approximately 3%.5

Untreated psychosis leads to a poor prognosis.6 Therefore, it is important to treat first-episode psychosis (FEP), defined as the first treatment contact, even before the final diagnosis is confirmed.7 Furthermore, even after successful early intervention, treatment for patients with FEP should be continued to prevent relapse. Previous reviews have reported that patients with FEP tend to relapse within a few years following treatment discontinuation.8 Indeed, the relapse rate one year after treatment discontinuation has been estimated at approximately 80%.9 In patients with FEP, a reduced effect of medication is seen as the number of repeated episodes increases.8 These results highlight the importance of early intervention and continuing treatment in FEP.

The main treatment of choice for FEP is medication. However, pharmacological treatment offered without supplemental therapy can increase the risk of relapse.10-13 Supplemental therapy for FEP can include cognitive behavior therapy (CBT), family interventions and psychoeducation. Psychoeducation aims to educate patients with psychiatric disorders and their families about their illness.14 Through psychoeducation, the patient and their families hope to better understand and cope with the presenting illness. Furthermore, it can strengthen the patient's self-efficacy and empower them to improve their wellbeing.15

Several reviews have highlighted the importance of psychoeducation, which is offered in in-patient or outpatient settings, acute care settings and in the community. Alvarez-Jimenez and colleagues16 reported several risk factors for relapse in FEP, including medication non-adherence and critical comments from carers. Furthermore, a meta-analysis by Lincoln and colleagues17 concluded that psychoeducational interventions that included the family were more effective in reducing symptoms and preventing relapse. Another meta-analysis limited to patients with schizophrenia reported the overall relapse rate was significantly lower in the intervention group compared with a standard care group [relative risk = 0.70, 95% confidence interval (CI): 0.61-0.81].14 Further, there were fewer incidences of noncompliance in the intervention group than in control group (relative risk = 0.52, 95% CI: 0.40-0.67).14 However, these reviews did not focus specifically on FEP.

In contrast, Bird et al.18 did not report that family therapy was effective in improving outcomes. However, they only included two studies in their review, both of which had small samples, and so were underpowered.18 Penn et al. suggested that specific components of family therapy may have differential impacts on the study outcome.19 In their review, family therapy focusing on training in communication and problem-solving skills was not effective in preventing relapse. However, family therapy that emphasized psychoeducation, identification of warning signs and stress management produced positive results, including reduced readmission.19

Cognitive behavior therapy is another increasingly popular supplementary therapy for FEP and it has been evaluated in two reviews.18,19 Cognitive behavior therapy is used for the management of psychotic symptoms and has been reported to be effective in reducing symptoms.18,19 However, it appears to have little impact on the relapse rate.19,20 Cognitive behavior therapy and family therapy are increasingly offered as part of a comprehensive treatment package, which includes medication management and case management. The components of comprehensive treatment vary among studies, but psychoeducation as a form of family therapy remains a core element of supplemental therapy for continuing treatment.15

Previous systematic reviews and meta-analyses evaluating the effectiveness of psychoeducational interventions in psychiatric patients have not focused specifically on patients with FEP, which is a critical period for intervention. Further, these reviews have not conducted subgroup analyses to examine specific factors associated with outcomes, for example, the study setting (acute versus community care).14

We searched the Cochrane Library, MEDLINE, CINAHL and PsycINFO to identify existing systematic reviews and found no review focusing on FEP. Therefore, this systematic review will review relevant studies to synthesize the best available evidence for the effectiveness of psychoeducational programs for patients with FEP.

Inclusion criteria

Types of participants

The review will consider studies that include patients diagnosed with International Statistical Classification of Diseases and Related Health Problems (ICD-10) or Diagnostic and Statistical Manual of Mental Disorders (DSM III-V) schizophrenia spectrum disorders, mood disorders or not otherwise specified mental disorders. Diagnoses will have been received at first contact with mental health services, such as psychiatric clinics or hospitals, or the episode may be classified as a first episode of psychosis by researchers in the included study. Age, sex and ethnicity of participants will not be limited. Moreover, we will include studies in both acute and community care settings. We will exclude people diagnosed with mental and behavioral disorders because of psychoactive substance use or organic mental disorders.

Types of intervention(s)

Interventions of interest will be psychoeducational programs for patients with FEP. We define psychoeducation as the education of patients with psychiatric disorders and their families about their disease and its treatment with the aim to increase knowledge and promote understanding.14 We will consider interventions taking either individual or group approaches. Psychoeducational programs may also target just patients, or both patients and their relatives. No limit is set for the study duration or number of sessions provided in an intervention. Treatment for FEP should be provided immediately after onset but the duration between symptom onset and access to mental health services inevitably varies. Therefore, we do not limit the timeframe from FEP to intervention in this review. We will compare psychoeducational interventions with usual care, that is, antipsychotic medication and medical examinations by psychiatrists.

Outcomes

The primary outcome measure will be relapse rate in the year following the intervention. Relapse will be indicated by either worsening of psychiatric symptoms or readmission to a psychiatric hospital. Worsening of psychiatric symptoms will be measured using symptoms scales such as the Brief Psychiatric Rating Scale or the Positive and Negative Syndrome Scale.

Secondary outcome measures include treatment adherence, level of knowledge of the disease and its treatment and quality of life. Treatment adherence can be measured using various scales, such as the Schedule for Assessment of Insight. Level of knowledge can be measured using instruments such as the Knowledge about Schizophrenia Questionnaire. Quality of life can be measured with tools such as the Lehman's Quality of Life Interview.

Types of studies

The review will include any experimental study design, including randomized controlled trials, non-randomized controlled trials and quasi-experimental before and after studies. This will enable the identification of the current best evidence regarding psychoeducation for FEP. Studies published in English and Japanese will be considered for inclusion in this review.

Search strategy

Our search strategy aims to find both published and unpublished studies using a three-step approach. An initial limited search of MEDLINE, CINAHL and PsycINFO will be undertaken, followed by analysis of the text words contained in the title and abstract and the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. We will search for studies published from 1970 to 2016. The reason for the date restriction is that the 1970s is the period when research on psychoeducation started to become prevalent.21

The databases to be searched will include: MEDLINE, CINAHL, PsycINFO, Scopus, Ichu-shi Web (Japan Medical Abstracts Society), Cochrane Library, Open Grey, Google Scholar, OAlster, ProQuest Dissertations and Theses Database, KAKEN, CiNii, British Library, Worldwide Science and PsycEXTRA. Our initial keywords will be: "psychoeducation," "patient education," "health education," "first episode," "psychosis" and "schizophrenia."

Assessment of methodological quality

The primary and secondary reviewer will each independently review the titles, abstracts and full text of identified studies to determine which studies fulfil the inclusion criteria for this review. Studies selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data extraction

Data will be extracted from included studies using the standardized data extraction tool from JBI-MAStARI (Appendix II). The extracted data will include specific details about the interventions, populations, study methods and outcomes with significance for the question and objectives of our review. If the included studies have unclear data, we will contact the authors of the primary studies.

Data synthesis

Wherever possible, quantitative data will be pooled in a statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% CIs will be calculated. Heterogeneity will be assessed statistically using the standard [chi]² and explored using subgroup analyses.

Preliminary analysis showed that the unit of intervention was either an individual or a group, and some interventions targeted patients only, whereas others targeted both patients and their families.14 The duration of psychoeducation reported varied from one session to a few years.14 Study settings included acute and community care.14 Therefore, we will conduct subgroup analyses of the intervention duration, the unit of intervention (i.e. group or individual; only patients or both patients and their relatives) and the study setting (i.e. hospital or community). Data will not be pooled in the following situation: differences in the content of the interventions, wide variation in the length or strength of intervention. Where statistical pooling is not possible, the findings will be presented in narrative form, including tables and figures to aid in data presentation, wherever appropriate.

Appendix I: Appraisal instruments

MAStARI appraisal instrument

Appendix II: Data extraction instruments

MAStARI data extraction instrument

References