Family treatment for schizophrenia? |
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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. MethodsThe 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.ResultsFamily 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
Practice points
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