Good Literature Review About Psychoeducation In Management Of First Episode Psychosis Among Young Adults

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Introduction
Psychosis is a psychological illness that has been subjected to a lot of research over the years. As an illness, it causes people to perceive things differently from their peers and compatriots. Cases of psychosis are usually accompanied by delusions and hallucinations. According to Keshavan et al., (2005) as well as many other authors who have researched the issue, individuals suffering from this disorder will break from reality and will start believing, hearing and even seeing things that are not real. These delusions and hallucinations work in combination to disrupt one’s thinking, perception, emotions and even behavior (Breitborde et al., 2009, Keshavan et al., 2005). An individual who experiences these symptoms is said to be going through a psychotic episode (Breitborde et al., 2009). It is estimated that three out of every 100 people will at one time or another experience an episode of psychosis in their lives. This psychological disorder can affect anyone regardless of their age but there is a higher prevalence for the disorder among young people (Keshavan et al., 2005). Researchers attribute the higher prevalence of psychosis among young people to hormonal changes that occur to their brains during puberty (Keshavan et al., 2005).
As mentioned, there has been a lot of research conducted on psychosis especially among the youth. The research has adopted different dimensions and designs and the objectives of each has also been varied. For example, some of the research has concentrated on the causes of psychosis among the youth. Other studies have sought to establish the people who are at the highest risk of going through psychotic episodes. There are still other studies that have sought to explain the effects of psychosis on the patient.
Another aspect of this topic that has also been subjected to much research is in regards to treatment and management of psychosis. Researchers have sought to establish the most viable treatment and management options for young psychotic patients (Simonsen et al., 2007). However, the research done on this subject has not been very efficient and there is a lot more that needs to be conducted in order to come up with comprehensive deductions and conclusions. In addition, research on this area has been very general and perhaps this is why fully efficient treatment and management options have not been established.
It is this realization that forms the premise of this particular research study. One of the treatment or management options that has been suggested for psychotic patients is psycho education. Psycho education is a special brand of education that is offered to individuals who have a mental condition together with family members and that is aimed at assisting them to deal with the condition and also empowering them so that their lives are not completely governed by the disorder. This has been suggested particularly for young people who have experienced their first episode of psychosis.
A lot of research has been conducted to test the efficacy of this management option and countless arguments and conclusions have been made on whether it is indeed effective. This literature review aims to appraise this research and possibly come up with accurate conclusions about the efficacy of psycho education in management of first episode psychosis among young adults. The research will particularly appraise five research articles and evaluate their arguments about the efficacy of this method of management in young adults with first episode psychosis.
It is hoped that this activity will help to shed more light on this topic of psychosis and hopefully contribute towards the development and advancement of viable treatment and management options with psycho-education being one of them. As mentioned, research on the issue has not been fully conclusive and it is hoped that this literature review will contribute to this deficiency by appraising one of the management options that has been suggested to be viable for this kind of psychological disorder.

Search Strategy

There has been a considerable number of research studies conducted on the subject of psychosis among the youth. Research articles on this issue have been published across a variety of journals and many are electronically contained in thousands of online libraries and databases. Unfortunately, not all research articles can be considered to be valid and reliable, especially those that are not peer reviewed. This is why this research was restricted to peer reviewed articles.
When it came to the search strategy, several databases were utilized to search for relevant articles on the issue. The primary database utilized included Google Scholar. JSTOR, EBSCO Host, Wiley Online Library and Science Direct. These are credible and reliable databases housing millions of research articles on different subjects and topics.
In addition, these databases contain a lot of filters that can be used to refine the search for relevant articles, for example, they allow one to filter the time period and even the specific journal from which one wants to acquire relevant articles. Furthermore, most of the journals contained in these databases are peer reviewed meaning that they are both valid and reliable and the contents in them represent facts.
In searching for relevant articles on this database, several key words were utilized. The primary keyword was “psychosis” since this is the particular subject in which this research is based on. This keyword was the only one used independently when it came to this research. The reason for this was to get general information about psychosis before moving into a more specific direction.
The other keywords utilized in the research, albeit in combination included management, young adults, treatment, psycho-education and first episode psychosis. Some of the search words that were utilized to look for relevant articles included; management of psychosis in young adults, psychosis among young adults, treatment and management of first episode psychosis among young adults, psycho-education for young psychotic adults, efficacy of psycho-education in managing first episode psychosis among young adults among several others. These key words and search terms generated thousands of relevant research articles on this issue.
One of the key elements of the inclusion criteria was that the articles had to be based in the United Kingdom. This literature review was confined to articles from the United Kingdom since it is the main country of interest.
The prevalence and approach towards psychosis in the United Kingdom are relatively similar to those in other nations such as the United States and therefore, research on the issue inside the United Kingdom would give a relative depiction of the situation in the international arena regarding the management of psychosis using psycho education.
This review hoped to be as relevant and as updated as possible and therefore, intentional efforts were made to concentrate more on articles published not more than ten years ago. However, it was found that this criteria would exclude some brilliant research articles on the issue that were published more than 10 years ago and that contained information and content that is still relevant and applicable in the modern scenario. Therefore, this criteria was loosened so as to ensure that those articles published more than ten years ago and that contained relevant information were not left out.
Out of all the databases mentioned, Wiley Online Library, Google Scholar and Science Direct yielded the biggest percentage of articles. The other databases also yielded a lot of useful and relevant research articles but since this literature review was mainly restricted to five articles, only the best had to be chosen in order to be compressively reviewed and evaluated.

Literature Review

In looking at research related to psychosis among young adults, several themes exhibited themselves. The first of these is the format of elements of an effective psycho education program.
The other theme related to the topic is the actual effects of an effective psycho-education program and the positive adjustment in behavior brought about by it when conducted in a multifamily group setting.

The other theme that was prevalent was the advantageous aspects of psycho-education when compared with other management options.

For the purposes of this research, the main focus will be on the second theme of this topic and this is the actual effects of an effective psycho-education program and the positive adjustment in behavior brought about by it when conducted in a multifamily group setting

Psychoeducation in a Multifamily Group Context

Before experiencing an episode of psychosis, it is not easy to diagnose or identify a young adult who may be at risk of the disorder and at this juncture, there are no clear cut preventive options. The first episode of psychosis is usually not very severe and may not display the full characteristics of psychosis. Here, immediate intervention should commence. Lack of intervention could lead to the development of full psychosis. Normally, an integrated psychological intervention model is utilized. One of the elements of this integrated model is psycho-education.
Xia et al (2001) has studied on the efficacy of psychoeducation in the management of schizophrenia or first episode psychosis. Xia et al (2011) writes that schizophrenia is often accompanied by poor insight and lack of compliance to medication and treatment. However psychoeducational approaches can be used to alleviate this problem since they increase the knowledge of patients as well as his or her insight into the disorder and its treatment. The authors conducted a study to investigate the effects of psychoeducational interventions. These were compared to the standards level of knowledge provision (Xia et al., 2001). The authors conducted a review of randomized controlled trials that focused on psychoeducation for schizophrenia/first episode psychosis or other related mental illnesses. A total of 5142 participants from 44 trials were involved in these randomized control trials. The researchers extrapolated various sets of data from these randomized control trials including risk ratios, 95% confidence intervals and weighted means for continuous data. The findings revealed several things about the effectiveness of psychoeducation as a management technique for schizophrenia. First of all, incidences of non-compliance to treatment were lower in the psychoeducational group. Relapse was also lower in this group. Additionally, scale driven data from the study suggested that when used, psychoeducation promotes better social as well as global functioning (Xia et al., 2001). Data from the randomized control trials also seemed to indicate that people who receive psychoeducation are generally more satisfied with mental health services (Xia et al., 2001). Therefore, this study shows that psychoeducation generally improves the wellbeing of the schizophrenia patients both clinically and socially. However, one standout weakness of this study is that it does not consider the efficacy of different formats of psychoeducation and it is therefore unclear which format has more benefits than the other.
According to James et al (2006), there is currently very strong evidence supporting the utilization of psychoeducation approaches in psychosis. One thing that has however proven to be quite problematic is families’ engagement in this approach. Some families of psychosis patients may completely disregard therapy or may take part initially only to quit later on. Around 7-35% of families who are offered psychoeducational family interventions ultimately refuse them while 7-50% withdraw from such session after participating for a short time (James et al., 2006). The reasons for non-engagement are wide and varied. In light of this, James et al (2006) conducted a qualitative study that sought to find out the factors or issues that families and therapists believe are helpful or non-helpful in the engagement of families when it comes to behavioral family therapy (James et al., 2006). The method of data collection interviews with family members and trained therapists while in the analysis of interview sheets or transcripts, a grounded theory approach was used. The study revealed several interesting findings. On the part of the therapists, it emerged that successful engagement with family members was partly dependent on the possession of certain qualities by the therapists (James et al., 2006). These included aspects of ‘being oneself” and perceiving family members “like self”. This simply translates to an absence of a defense mechanism to protect oneself from some of the major challenges of working in a mental health environment. Competence was another key element. This particularly refers to the ability of a therapist to prove his or her knowledge in the field of psychosis and the ability to establish a collaborative working relationship in a family. In addition, confidence was a crucial determinant of a therapist’s engagement with family members. This study proves that although psycho-education is a key element in the management of psychosis, family engagement which has the potential to improve the workability of this approach is problematic to achieve (James et al., 2006). One limitation of this study however is that it concentrated too much on the qualities of therapists that determine engagement of families and it therefore failed to give attention to the characteristics of families and family members that may also play a role in determining whether whether family engagement will occur (James et al., 2006).
Bechdolf et al., (2012) conducted a study that sought to investigate the effects of an integrated intervention model in curbing progression of prodromal state of psychosis which is normally associated with the first episode. One of the primary components of this model was psycho-educational multifamily groups where the patients together with their families were counseled and educated on this disorder after experiencing the first episode.
The study adopted a randomized control model. The study involved a total of 128 participants comprising of help seeking students who had experienced an initial prodromal state. These were randomized for this study (Bechdolf et al., 2012).
The students were subjected to the integrated psychological model that included the psychoeducational family groups. The primary measurement of outcome was progression to psychosis after 12 and 24 months. In fact, follow up to the studies were conducted after this period. A control group comprising of young adults exposed to supportive counseling alone without the psycho-education or the other elements of the psychological integrated model was used (Bechdolf et al., 2012).
The results of the study found that an integrated model encompassing psycho-education was very effective in delaying the onset of full scale psychosis when compared to mere counseling. It is important to once again note that psycho-education was one of the primary elements of this integrated model and therefore, it is safe to conclude that the efficacy of education in the management of psychosis after the first episode in young adults is quite effective, especially when used in a multifamily group context (Bechdolf et al., 2012).
This study is however limited because the study design that is almost longitudinal in nature cannot be trusted to predict the progression of psychosis. Psychosis does not necessarily exhibit itself after12 and 24 months and may take longer than that. In addition, the sample size of 128 is not enough to give generalizable results.
Additionally, the study did not go into details about the magnitude of the effect brought about by each element in the integrated treatment model. These are areas that could be improved. Nevertheless, one of the strengths of this study is that it shows that counselling alone is not enough and an integrated model that includes psycho education may be more effective.
The above study is supported by another study that sought to explore the efficacy of psycho-education as part of an integrated intervention model. It is important to note that when it comes to the management of psychosis, the family plays a very important role. The family can be the determinant of whether a patient will be able to cope with the problem or will be overwhelmed by it. However, families of patients who have first episode psychosis lack support and experience.
Jeppesen et al., (2005) carried out a study to investigate the effect of an integrated treatment model on the family’s burden of illness, illness knowledge, expressed emotion and satisfaction with the treatment available. In this study, 325 patients who had experienced first episode psychosis were assigned randomly to two options of treatment, the standard treatment and the integrated treatment involving psychoeducational multifamily groups (Jeppesen et al., 2005).

The study was longitudinal in nature where participants were assessed after one year using the Social Behavior Assessment Schedule.

The findings showed that relatives of patients who had been subjected to integrated treatment that involved psychoeducational multifamily groups had less feelings of burden and were generally happier and satisfied with the treatment than the relatives of patients exposed to standard treatment (Jeppesen et al., 2005).
It can therefore be concluded that psycho-education when used as part of an integrated treatment model has a high efficacy not only in first episode psychosis patients but their families as well. However, the main limitation of this study is that results were carried out after only one year period which is barely enough for conclusive results.
Sin et al (2007) conducted a study on carer’s needs and experiences from a group of carers providing care for a young adult suffering from first psychosis. This took place in Berkshire, England. The researchers established a host of needs for this group of carers, many of who were in fact in the caring career for a short time. One of the needs that was identified in this study was that for a specific, care friendly and succinct information on first episode psychosis and its common treatments (Sin et al., 2007). The researchers indicate that this information should not only be on the relevant treatment models for the young adults suffering from first episode psychosis but should also encompass the available support systems as well as information on how to cope with or address emotional experiences such as shame and guilt (Sin et al., 2007). Another primary finding was that parents make up the largest proportion of carers to young adults suffering from first episode psychosis. The next item that the authors of this article evaluated was an Early Intervention in Psychosis Service (EIPS) that had been established in Reading since 2005 (Sin et al., 2007). One of the most distinctive characteristic of this service is that it had used the family/career inclusive approach from the time of its incorporation. After the study on carer’s needs and experiences, the findings were used to expand the EIPS model and additional guidelines from the Initiatives to Reduce the Impact of Schizophrenia (IRIS) were also added. Ultimately, one of the elements of this adjusted care pathway was psycho-educational multifamily groups (Sin et al., 2007). In the course of the study, carers had express feelings of isolation and postulated that meeting other carers who were in a similar situation and being educated together would at least alleviate some feelings of loss and augment their coping strategies (Sin et al., 2007). As part of the new care pathway, multifamily group education enabled carers to meet with other carers who had similar experiences and this somehow led to a lessening of the feeling of burden. These multifamily group sessions were conducted in a friendly manner where the main literature provided to members include that on general psychosis, problems and symptoms of the disorder as well as coping strategies (Sin et al., 2007). The general feedback of the carers in regards to this multifamily group psycho education groups was very positive indeed and many indicated that the groups had been of enormous value to them and they had not only learnt important concepts but also felt less burdened. This study therefore without a doubt proves the efficacy of psycho education especially in a multifamily group setting in the management of first episode psychosis among young adults. The study was efficient throughout and there are not any identifiable weaknesses.
McWilliams et al., (2010) also conducted a study on the role of psychoeducation in first episode psychosis. The researchers subjected a total of 31 families to a six weeks multifamily psycho-educational program. After the program, the authors measured the families’ attitudes to treatment as well as knowledge on psychosis (McWilliams et al., 2010). The findings showed an increased general knowledge on psychosis as well as increased knowledge in medication meaning that the families, who are the primary caretakers can take better care of first episode psychosis patients and possibly prevent relapse (McWilliams et al., 2010). The main limitation of this study is that there was no control group. Nevertheless, the study provides a good foundation for further research into the issue.

Conclusion

The above literature review reveals several things about psychosis in young adults and its management. First of all, it is clear that psychoeducation has a host of benefits not only to the patient, but to the families of the patients as well, who are the primary caregivers. The literature shows that the efficacy of psychoeducation is particularly very high when this education is included as part of an integrated treatment model and when applied in a multifamily group setting. It not only has clinical health benefits to the patient but also reduces the feeling of burden in family members who have to take care of first episode psychosis patients. In terms of clinical health benefits, one of is reduced rates of relapse. There is also a reduced risk of progression to full psychosis. Patients also show positive outcomes when it comes to the symptoms of psychosis. Psychoeducation also promotes better social as well as global functioning. Additionally, an observed benefit of psychoeductaion is that it exposes family members to increased knowledge on psychosis in general as well as increased knowledge on appropriate medication for the patient meaning that the family can take even better care of the patient when the need arise. Nurses are primarily the individuals who are involved in psycho-educational activities. The findings of this research indicate that psychoeducation is very beneficial especially when conducted in a multi-family group setting and as part of an integrated treatment model. Therefore, in terms of nursing implications, this is something that nurses should observe keenly, that is, when carrying out psychoeducation programs, it is most advisable to carry them out in a multifamily group setting. However, there is still a lot of research that still needs to be conducted on this issue. There particularly needs to be more research on the components of psychoeductaion or how psychoeducation can be modelled to ensure that it equips the patient as well as the family members with sufficient knowledge to adequately deal with the first episode psychosis problem and ensure that the problem does not define the lives of the people who suffer from it. In addition, there also needs to be research on the factors that can make psychoeducation non-effective so that they can be weeded out.

References

Breitborde NJK, Srihari VH, Woods SW., 2009. Review of the operational definition of first-episode psychosis. Early Intervention in Psychiatry, 3, pp. 259-265
Bechdolf, A., Wagner, M., Ruhrmann, S., Harrigan, S., Putzfeld, V., Pukrop, R. & Klosterkötter, J., 2012. Preventing progression to first-episode psychosis in early initial prodromal states. The British Journal of Psychiatry, 200(1), pp.22-29.
James, C., Cushway, D., & Fadden, G., 2006. What works in engagement of families in behavioural family therapy? A positive model from the therapist perspective. Journal of mental health, 15(3), pp. 355-368.
Jeppesen, P. I. A., Petersen, L., Thorup, A., Abel, M. B., Øehlenschlæger, J., Christensen, T. Ø.. & Nordentoft, M., 2005. Integrated treatment of first-episode psychosis: effect of treatment on family burden OPUS trial. The British journal of psychiatry, 187(48), pp. 85-90.
Keshavan, M. S., Berger, G., Zipursky, R. B., Wood, S. J., & Pantelis, C., 2005. Neurobiology of early psychosis. The British Journal of Psychiatry, 187(48), pp. 8-18.
McWilliams, S., Egan, P., Jackson, D., Renwick, L., Foley, S., Behan, C., & O’Callaghan, E., 2010. Caregiver psychoeducation for first-episode psychosis. European Psychiatry, 25(1), pp. 33-38.
Simonsen, E., Friis, S., Haahr, U., Johannessen, J. O., Larsen, T. K., Melle, I., & McGlashan, T., 2007. Clinical epidemiologic first‐episode psychosis: 1‐year outcome and predictors. Acta Psychiatrica Scandinavica, 116(1), pp. 54-61.
Sin, J., Moone, N., & Newell, J., 2007. Developing services for the carers of young adults with early‐onset psychosis–implementing evidence‐based practice on psycho‐educational family intervention. Journal of psychiatric and mental health Nursing, 14(3), pp. 282-290.
Xia, J., Merinder, L. B., & Belgamwar, M. R., 2011. Psychoeducation for schizophrenia. The Cochrane Library.