The Necessity of Family Type Interventions During First-Episode Psychosis in Schizophrenia

Members of families where someone has been diagnosed with schizophrenia may feel burdened by their role as “caretakers”, they may not be able to deal with the stress of having to care for a person with a pathology with such a serious prognosis, they may have massive personal costs or may not be able to look after the patient for long periods of time, which might have repercussions on their personal lives, on their capacity to help the patient, and on the evolution of the disease [1].


Introduction
Members of families where someone has been diagnosed with schizophrenia may feel burdened by their role as "caretakers", they may not be able to deal with the stress of having to care for a person with a pathology with such a serious prognosis, they may have massive personal costs or may not be able to look after the patient for long periods of time, which might have repercussions on their personal lives, on their capacity to help the patient, and on the evolution of the disease [1].
Antipsychotic medical treatment is the elective therapeutic intervention in first -episode psychosis in schizophrenia [2]. The same clinical manifestations produce different reactions in families, with repercussions on the evolution of schizophrenia. Various studies have tried to correlate certain family characteristics (level of expressed emotions, burden, attributing the cause of the disease, disease coping mechanisms, family member resources) with the evolution of the disease, and thus to support the obligativity of family type interventions in the patient's recovery process.
Chakrabarti and Kulhara [3] have shown that families of patients suffering from schizophrenia present higher burdening than families with affective or anxiety disorders.
The burdening and distress felt by family members are in accordance with the way the patient's problems are evaluated (the way the family members attach meaning to them) and with the identified personal resources [4,5].
There have been studies [6,7] that aimed at determining the correlation between the type of symptoms and the level of burden felt by the family. Their results are not consequent that positive symptoms. It seems impact the entire family, but mostly the negative ones, which unlike the positive ones, are present all the time.
Birchwood and Cochrane [8], Magliano et al. [9] presented that there was a link between the coping mechanisms and family burdening.
Barrowclough et al. [10] have shown that assigning by family members to the cause of the psychosis is a better predictor of relapse than the level of expressed emotion (EE).
Multiple studies have demonstrated that a high level of expressed emotions is associated with high burdening in members of families of the schizophrenia patient [11][12][13] as well as with high risk of relapse [14][15][16][17].
Fewer studies [18][19][20] have evaluated the correlation between the EE level and the first psychotic episode and they are contradictory as to the relation between a high level of EE and relapses. A high level of EE has been found both in patients with chronic psychosis and in those having a first psychotic episode, and that it represents a valuable indicator of relapse [21][22][23][24]. According to other studies, EE is less pronounced in the early stages of psychosis, and criticism and hostility develop quickly during the first years of disease [25], in contrast with results of studies carried out in 12 countries for 40 years which signal a high level of criticism and rejection in families with chronic schizophrenia [26,27].
Early intervention is a desiderate in treating psychotic disorders, presently existing more than 200 centres all over the world [28] that offer specialised services addressed to the first psychotic episode. Some programmes addressed to the first psychotic episode Early Psychosis Prevention and Intervention Centre (EPPIC), Australia, The Early Treatment and Intervention of Psychosis (TIPS), Norway, Calgary Early Psychosis Program (EPP), Canada, The Recognition and Prevention of Psychological Problems (RAP), USA) also incorporate family intervention (family psychotherapy, psycho-educational multifamily group treatment) [28].
The research study published by Penn et al. [29], a meta-analysis of the papers published between 1983 and 2004, regarding the efficiency of psychosocial interventions during the first psychotic episode, concluded that significant differences were noticed with respect to frequency of hospitalisation, number of hospitalisation days, a drop in positive symptoms, the amelioration of social functioning for the benefit of those who also took part in family therapy.
Following the analysis of 32 research studies which included 2429 subjects, the NICE (National Institute for Health and Clinical Excellence) guide for schizophrenia (2010) reached the conclusion that there is clear evidence of family type intervention efficiency in relapse risk, rate of hospitalisation, and symptom seriousness.
There have been concordant results between many studies [30][31][32][33] which discovered a rate of transition of the people with a very high risk of developing psychosis at a first psychotic episode of 40% within one year from being included in the risk group.
Until now, there are very few research studies [34,35] with modest results on the efficiency of antipsychotics on postponing the occurrence of the first psychotic episode and which necessitate reconfirmation.
The results of the family type interventions on the first psychotic episode represent a recommendation for initiating comparative studies with other types of psychotherapy (cognitive-behavioural therapy) [36] to confirm their efficiency for people with a very high risk of developing psychosis.
From the data presented, it is clear that further comparative research is needed on the efficiency of family type psychotherapy as opposed to other types of psychotherapy, to prove the necessity of compulsory introduction of family therapy in the management of the first schizophrenic episode, together with the consequences of this recommendation, namely the reorganisation of mental health policies and services.