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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 8
| Issue : 2 | Page : 74-80 |
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Effectiveness of family-focused psycho-education on expressed emotions among caregivers of persons with bipolar affective disorder: An interventional study
K Ashalata, Sateesh Rangarao Koujalgi
Department of Psychiatric Social Work, Dharwad Institute of Mental Health and Neurosciences, Dharwad, Karnataka, India
| Date of Submission | 11-Jan-2022 |
| Date of Decision | 24-Mar-2022 |
| Date of Acceptance | 30-Mar-2022 |
| Date of Web Publication | 16-Dec-2022 |
Correspondence Address:
Dr. Sateesh Rangarao Koujalgi
Department of Psychiatric Social Work, Dharwad Institute of Mental Health and Neurosciences, Dharwad, Karnataka
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/tjp.tjp_4_22
Background: Expressed emotion (EE) is a significant characteristic of the family milieu that has been found to predict symptom relapse in bipolar affective disorder (BPAD). The need for family-focused psychosocial intervention in BPAD suitable to our culture is poorly understood. Therefore, this study was designed to discover the effectiveness of Barcelona family-focused group psycho-education on EE in BPAD.
Aim: The aim of the present study is to assess the effectiveness of family-focused psycho-education on EE among caregivers of patients with BPAD.
Materials and Methods: The interventional study included forty primary caregivers of patients diagnosed with BPAD. Caregivers were randomly allocated into five groups of eight each. BPAD was diagnosed by using the International Classification of Diseases-10, Classification of Mental and Behavioral Disorders, and Diagnostic Criteria for Research. The researcher had used the purposive sampling technique. Assessed EE by administering Family Attitude Scale (FAS) at pre- and postinterventional phases, family-focused group psycho-education module of Barcelona was adopted as an interventional method.
Results: Totally 23 (57.5%) male and 17 (50.75%) female caregiver respondents participated in the study. The mean value of the overall pretest FAS score of total respondents was 94.33, critical comments = 43.75, hostility actions = 29.98, and distancing = 28.53. With EE dimensions, a greater difference in pre-intervention mean of 94.33±8.48 and a post-intervention value of 37.28±13.07 could be observed (t = 25.20, P = 0.001 and P< 0.05, respectively).
Conclusion: Barcelona family-based psycho-educational intervention model is effective in reducing higher EE in families of patients with BPAD.
Keywords: Bipolar affective disorder, caregiver, expressed emotions, family-focused psycho-education
How to cite this article:
Ashalata K, Koujalgi SR. Effectiveness of family-focused psycho-education on expressed emotions among caregivers of persons with bipolar affective disorder: An interventional study. Telangana J Psychiatry 2022;8:74-80 |
How to cite this URL:
Ashalata K, Koujalgi SR. Effectiveness of family-focused psycho-education on expressed emotions among caregivers of persons with bipolar affective disorder: An interventional study. Telangana J Psychiatry [serial online] 2022 [cited 2023 Jun 5];8:74-80. Available from: https://tjpipstsb.org/text.asp?2022/8/2/74/363986 |
| Introduction | |  |
According to Murthy, in the National Mental Health Survey of India, bipolar affective disorder (BPAD) accounts for 10% of all mental disorders, with a female majority in depressive disorders (both present [female: 3% and male: 2.4%]).[1] Expressed emotion (EE) is a family environment indicator based on how the caregivers interpret the patient in a casual family situation.[2] A high level of EE in the home can affect the prognosis of patients with mental illnesses.[3],[4] It has been proven that high EE can lead to relapse in mental disorders.[2],[5],[6] The disease psycho-education model mainly focuses on relapse prevention of mental disorders.[6] There are no studies on EE on BPAD in India. Hence, the present study aims to assess the effectiveness of Barcelona family-based psycho-education on EE among caregivers of persons with BPAD.
| Materials and Methods | | |
The study contacted forty primary caregivers (the primary caregiver checklist by Pollak and Perlick was used to identify primary carers)[7] of patients with BPAD who were getting inpatient treatment and were between the ages of 25 and 65 during the field study period. This research was conducted in the inpatient wards of Dharwad Institute of Mental Health and Neurosciences, Dharwad, between January and June 2021. Primary family members of the person diagnosed with BPAD for 2 years and above, knowing Kannada language, and willing to participate in the interventional study only were included in the study and those who have scored above 60 on FAS were included in the study. A primary caregiver is one who satisfies greatest no. (>3) of the following five criteria: spouse, parent or spouse equivalent and who is more frequently in contact with the patient, supports patient financially, most frequent collateral participant in patient's treatment, person contacted in emergency.[7] Other far relatives, relatives of persons suffering from other mental illnesses, persons receiving outpatient-based services, having language barriers, and unwilling to participate in the interventional study had been excluded from the study. Primary caregivers below the age group of 25 years and above 65 years were excluded from the study. The interventional program had been executed after the pretest of on EE obtained through the Family Attitude Scale (FAS) by Kavanagh et al.[8].Psycho-education was conducted in groups, sessions limited to 7 of 90 min each, and the observation period lasted for 3 months to administer the posttest assessment. There were no participant dropouts during the study period. The study had adopted a quasi-experimental research design and used purposive sampling technique. The sociodemographic schedule prepared by the researcher was containing the following areas such as gender, age, education, occupation, and type of family. The caregiver sociodemographic data contain age, family income, marital status, and relationship with patient. The clinical profile included diagnosis and duration of the illness. Patients were diagnosed as having BPAD using the International Classification of Diseases-10.[9] FAS was administered to assess the EE among the respondents. This 30-item self-reported questionnaire (with 0–120 scoring and the 60 as cutoff point, higher the score represents high EE). Responses are on a 5-point Likert scale (0–4) from “every day” to “never,” with higher scores representing a more negative affectionate quality of the dyadic relationship. The internal consistencies for these factors were very satisfactory (hostile acts, 0.897; criticism, 0.886; and distancing, 0.799). The overall internal consistency of the FAS was 0.92. The three factors of FAS are criticism, hostile act, and distancing. Out of 30 items in the scale, item nos. 5, 6, 7, 8, 14, 18, and 19 fall under hostile acts, whereas item nos. 2, 3, 4, 10, 11, 13, 16, 17, 22, 23, 24, 26, 27, and 29 fall under criticism, and item nos. 1, 9, 12, 15, 20, 21, 25, 28, and 30 fall under distancing factors. Similarly, item nos. 1, 9, 12, 15, 16, 20, 24, 28, and 30 have reversed scoring.[8]
Procedure
A total of forty primary caregivers were given the schedule. During the first interview, the participants were given the FAS, and then, they were given family-focused psycho-education for BPAD, the Barcelona module by Colom and Vieta.[10] The interventional sessions lasted 7 days and were 90 min long each day. Following that, 3 h of follow-up sessions was held. A total of eight groups were formed in the same time span. The first two groups were formed with only male caregivers, the other two groups were formed with only female caregivers, and the rest were formed with both genders. The letters A, B, C, D, and E were assigned to each of these groups [Table 1].
At the beginning of each session, the researcher explained the topic selected for that session for 15 min. Then, participants were asked to discuss their experience in 20 min. The researcher taught the families about the selected topic in 40 min. In the remaining 15 min, a conclusion was made. Session of the family Barcelona Psycho-education Program for bipolar disorder was introduced in the interventions. The session content is described in [Table 2].
Participants were instructed to meet on follow-up days for further assessment. The FAS was re-administered on posttest assessment after 3 months of regular follow-up to find out the effectiveness of the intervention on EE. Prior consent was obtained by the respondents. Confidentiality was maintained throughout the study. The research was presented before the institutional ethical committee during March 2020 and obtained ethical clearance. The data collected have been analyzed using the one-way analysis of variance followed by t-tests, based on the SPSS 25.0 version of statistical software (IBM Corp. IBM SPSS Statistics for Windows, Armonk, NY).
| Results | | |
[Table 3] shows the sample of 40 caregiver respondents – 23 males and 17 females.
[Table 4] indicates the age, education, and type of family of the persons with BPAD. Out of 20 males, 7 (35%) were belonging to the age group of 19–28 years, 7 (35%) were of 29–38 years of age, 3 (15%) were of 39–48 years, and the remaining 3 (15%) had belonged to 59–68 years' age group. On the other hand, out of 20 female persons with BPAD, a majority (35%) were belonging to the age group of 19–28 years and 29–38 years' age group, 5 (25%) were of 49–58 years' age group, and the remaining 1 had belonged to 39–48 years' age group. Therefore, it could be stated that a maximum (35%) of each of the male and female persons with BPAD of the study were belonging to either 19–28 years or 29–38 years of age group. Out of 40 persons with BPAD, 29 (72.5%) were literates and the remaining 11 (27.5%) were illiterates. Similarly, 16 (80%) male and 13 (65%) female persons with BPAD were literates and 4 (20%) males and 7 (35%) females were illiterates. Fifty percent of the male persons with BPAD in this study have completed their primary education, whereas 35% of the female persons with BPAD were found to be having primary education. Further, 20% of male persons with BPAD and 25% of female persons with BPAD had completed their high school education, and 10% of male persons with BPAD and 5% of female persons with BPAD had studied up to preuniversity examination. As compared with the gender, 12 (52%) male and 5 (29%) female persons with BPAD were belonging to a nuclear family, whereas 6 (26%) male and 3 (18%) female persons with BPAD were hailing from joint families. Extended family system was found more among female persons with BPAD (53%). However, out of 40 persons with BPAD, 17 (42.5%) were belonging to nuclear families followed by extended (35%) and joint families (22.5%). | Table 4: Age, education, and type of family of the persons with bipolar affective disorder
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[Table 5] explains the premorbid and current occupational status of the persons with BPAD to their gender. It could be understood that, out of 40, 17 (42.5%) were unemployed, 11 (27.5%) were attending to farming/agricultural work of their family, 7 (17.5%) were into daily wage, 3 (7.5%) were housewives, 1 was handling private business, and the remaining 1 was the student during their premorbid state. The data show that 72.5% of persons with BPAD had experienced occupational dysfunction caused due to mental illness. To correlate the findings of premorbid and current occupational conditions to their gender, 70% of males and 45% of females were employed before the onset of illness; however, a fall in the number of employed persons was observed in the morbid condition. | Table 5: Premorbid and current occupational status of the persons with bipolar affective disorder
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[Table 6] is drawn with the purpose to represent the distribution of caregiver respondents according to gender, age, monthly family income, marital status, and relationship with the patient. Out of 23 males, 8 (35%) were of 35–44 years of age; again, 8 (35%) had belonged to 55–64 years' age group; 4 (17%) were belonging to the age group of 25–34 years; and the remaining 3 (13%) were of 45–54 years. On the other hand, out of 17 female respondents, a majority 6 (35%) were belonging to the age group of 35–44 years, 4 (23.5%) were of 25–34 years, and the remaining 3 (18%) had belonged to 55–64 years' age group. All respondents had belonged to the monthly income group of less than Rs. 25,000/. Out of 40 participants, 30 (75%) were married and currently living with their life partners, 2 (5%) were unmarried, and the remaining 8 (20%) were widowed. Out of 40 participants, 18 males and 12 females were married and currently living with their partners, 2 males were unmarried and the remaining 3 male and 5 female respondents were widowed. Ten of them were parents, 3 of them were the grandparents, 10 of them were spouses, 9 were siblings, 7 were off-springs, and one 1 was the in-law. | Table 6: Age, monthly family income, marital status, and relationship with patient of distribution of the caregiver respondents
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[Table 7] indicates findings pertaining to the current status of diagnosis and duration of illness of the patient with BPAD, which reveals that, out of 40 persons with BPAD, 19 (47.5%) were diagnosed with BPAD mania with psychotic symptoms, 7 (17.5%) were suffering from BPAD depression with psychotic symptoms, 8 (20%) were diagnosed with BPAD mania without psychotic symptoms, and the remaining 6 (15%) were getting treated for BPAD depression without psychotic symptoms. 13 (65%) male and 6 (30%) females were diagnosed with BPAD current episode mania with psychotic symptoms, 2 (10%) males and 5 (25%) females were suffering from BPAD current episode depression with psychotic symptoms, 5 (25%) males and 3 (15%) females were diagnosed with BPAD current episode mania without psychotic symptoms, 6 (30%) females had BPAD current episode depression without psychotic symptoms. It could be understood that, out of 40, 14 (35%) were diagnosed with the illness for 5 years, and the remaining 26 (65%) were suffering from the illness for more than 5 years. To correlate the duration of illness with respect to their gender, 30% of males and 40% of females were diagnosed with the illness for 5 years, and the remaining 14 (70%) males and 12 (60%) females were suffering from the illness for more than 5 years. | Table 7: Gender-wise distributions of current diagnosis of the persons with bipolar affective disorder and duration of illness
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[Table 8] explains the total number of episodes and number of hospitalizations of patients with BPAD. It could be understood that, out of 40, 8 (20%) have had lesser than 2 episodes, and the remaining 32 (80%) have had more than 2 episodes of the current illness. To correlate the duration of illness with respect to their gender, 20% of males and 20% of females have had lesser than 2 episodes, and the remaining 16 (80%) of each gender have had more than 2 episodes of the current illness. Out of 40, 12 (30%) have had been hospitalized <2 times, and the remaining 28 (70%) have had been hospitalized more than 2 times during the span of their illness. To correlate the duration of illness with respect to their gender, 30% of males and 30% of females have had lesser than 2 hospitalizations, whereas the remaining 70% have had more than 2 hospitalizations. | Table 8: The total number of episodes and number of hospitalizations of patients with BPAD
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[Table 9], [Table 10], [Table 11] explain the preintervention test results of FAS administered on 40 caregivers who had detected a high mean value of overall pretest scores (94.33 ± 8.48), in which the critical comments dimension of FAS had a higher mean value (43.75 ± 4.58) followed by hostility (29.98 ± 2.57) and distancing (28.53 ± 3.53). The mean value of the total FAS score was observed among the higher age groups (55–65 years of age group had a mean score of 98.55 ± 5.556). Male and female caregiver respondents did not differ significantly with respect to their overall pretest FAS score (t = 0.543, P > 0.05), critical comments (t = 0.017, P > 0.05), and distancing (t = 0.905, P > 0.05); however, they did differ significantly with respect to hostility scores (t = 0.002, P < 0.05), and the male had more of hostility actions toward their patient. | Table 9: Mean and standard deviation values of overall pre-test Family Attitude Scale and its dimensions
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 | Table 10: Mean and standard deviation of pretest Family Attitude Scale overall score and its dimensions by age groups
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 | Table 11: Results of t-test between male and female caregiver respondents with respect to their overall pretest Family Attitude Scale score and its dimensions
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[Table 12] explains that the mean value of overall posttest FAS of total respondents was 37.28 ± 13.07. In the post intervention period the critical comments dimension of FAS had a mean value of 16.53 (±7.23) as followed by distancing (14.48 ± 3.34) and hostility actions (6.28 ± 3.69). | Table 12: Mean and standard deviation values of overall posttest Family Attitude Scale and its dimensions
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[Table 13] indicates that the caregiver respondents' pre- and postinterventional levels of EE did differ significantly with respect to their overall pre- and posttest FAS score (t = 25.20, P = 0.001 and P < 0.05, respectively), with the pretest mean value of 94.33 to the posttest mean value of 37.28, with the greater difference of 57.05. | Table 13: Results of t-test of Family Attitude Scale score in pre- and postinterventional phases
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[Table 14] indicates that the caregiver respondents' pre- and postinterventional levels of EE did differ significantly with respect to their overall pre- and posttest FAS score (t = 25.20, P = 0.001 and P < 0.05, respectively), with the pretest mean value of 94.33 to the posttest mean value of 37.28, with the greater difference of 57.05. Further, the dimensions of FAS that are critical comments (P = 0.001), distancing (P = 0.001), and hostility (P = 0.001) also had been significantly differed when compared with mean values of pretest scoring. | Table 14: Results of t-test of Family Attitude Scale score and its dimensions in pre- and postinterventional phases
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| Discussion | | |
The present study findings are consistent with the following similar studies conducted on BPAD. A study was done by Nusslock et al.[11] on psycho-socio-demographic and clinical profiles of patients with bipolar. They focused on longitudinal course factors such as age, gender, age at onset, episode duration, and frequency, comorbidities, family loading of bipolarity, affective temperament, frequent job changes, marital discord, and hospitalization rates, all of which were found to be significantly higher. Another study of sociodemographic and clinical variables in BPAD in the present scenario found that bipolar disorder affected both genders, with a slightly higher occurrence in females. The majority of them were from the age group of 39–48 years old, illiterate, married, belonged to a low socioeconomic class, and had a rural background.[12] Yet another study done by Romans and McPherson found that BPAD patients have impoverished social relationships and increased rates of marital failure. All these demographic factors greatly impact the quality of life of patients with BPAD.[13] Similar findings regarding sociodemographic profiles of the persons with BPAD were found in the current study. Mental illness affects marital life; on the other hand, marital conditions are one of the major factors that determine the prognosis of the illness. The present study found that the illness affected the marital life of the individuals, only 16% of the married patients stayed with their life partners, whereas the remaining were either separated or widowed, and even unmarried. Illness being one of the reasons for separation, not getting married. The sociodemographic details of the caregivers show that, the major primary social support system of the patients with BPAD were either parents or spouses, or siblings. The statistical significance was observed during analysis of posttest FAS score and its dimensions as compared with pretest FAS scores among respondents, and the effectiveness of family-focused psycho-education on EEs among caregivers of persons with BPAD was measured based on the findings of posttest FAS scores. The pre- and postinterventional levels of EEs did differ significantly with respect to their overall pre- and posttest FAS score (t = 25.20, P = 0.001 and P < 0.05, respectively), with the pretest mean value of 94.33 to the posttest mean value of 37.28, with the greater difference of 57.05. Further, pre- and postinterventional level of EEs did differ significantly with respect to the dimensions of FAS that is critical comments (P = 0.001), distancing (0.001), and hostility (0.001). This means the family-focused psycho-education is effective on EEs among primary caregivers of persons with BPAD. A study conducted by Nusslock et al.[11] concluded that, in bipolar disorder, family psycho-education, couple, and parent psycho-education programs have significantly improved the nonverbal interactions, caregiver knowledge of the disorder, patient understanding of the illness, positive family interactions, caregiver distress, coping, attributions, patient functioning, and patient medication adherence. Another study conducted by Honig et al.[14] reported a significant change in EE for a treatment group compared to a control group: results of a six-session multifamily psycho-educational intervention showed that 31% of relatives of patients with bipolar disorder in the treatment group changed from high EE to low EE. The findings of the present study indicate that family-focused therapy reduces symptoms by raising awareness of disease-coping methods and lower levels of familial EE, which thereby can improve the treatment outcome of patients with BPAD.
This study showed that the Barcelona psycho-educational intervention strategy has been effective in reducing caregivers' EE in BPAD. Thus, family psycho-education is an important part of comprehensive care for patients with BPAD and is applicable in clinical settings. Long-term follow-up data of the intervention may be proposed. A future multisite study in several settings may increase sample size and enhance the generalizability of the results.
| Conclusion | | |
This study aimed to investigate the effectiveness of the group psycho-education on the EE in families of the patients with BPAD. The study has shown that the family-focused psycho-education is effective in reducing high/negative EE among caregivers of patients with BPAD. The study has a strong implication in the management of BPAD.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14]
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