Abstract
Psychotic-spectrum illnesses (PSIs) are a significant cause of relational dysfunction and vocational disability, and result in substantial economic costs to society. The impact of family process, particularly “expressed emotion,” on influencing the relapse rate of PSIs is now well documented. Over the last two decades, evidence has emerged supporting family-based treatments that decrease family stress (e.g., psychoeducation, training in problem solving, and improved communication), reduce the relapse rate, and improve medication adherence and social functioning among patients with PSIs. Family interventions are now included in the Expert Consensus Guidelines and the Agency for Health Care Policy and Research/National Institute of Mental Health (AHCPR/NIMH) Schizophrenia Patient Outcomes Research Team (PORT) recommendations for the treatment of schizophrenia. Nevertheless, family-based treatments are underused in the care of PSI patients. Building upon a case example, this article explores the barriers to implementing family interventions in the acute and outpatient treatment of these patients. The case discussion highlights the convergence of problems in the mental health care system with clinicians' typical capacities and practices, difficulties intrinsic to the nature of PSI itself, and the burden and stigmatization of families of the severely mentally ill. Taken together, these factors undercut the implementation of evidence-based family interventions.
Notes
*In this article, the term psychotic-spectrum illness (PSI) has been chosen instead of schizophrenia-spectrum illness or schizophrenia because PSI better characterizes the heterogeneous clinical realities of working with patients with psychosis, who frequently have comorbid mood and substance use disorders and do not strictly conform to the DSM-IV criteria for the schizophrenia subtypes. Additionally, the impact of family process variables and family interventions (as discussed in this article) is applicable to a broader range of patients with psychotic illnesses than those falling under the narrow diagnostic range connoted by schizophrenia.
†It is estimated that in patients with schizophrenia, for example, the rate of clinical relapse during the first year after a psychiatric hospitalization is in the range of 40% while patients are taking antipsychotic medications but increases to 60% to 80% if those medications are discontinued. However, when psychosocial treatments such as family interventions are added to 12 months of adherence with antipsychotic medication, the percentage of patients undergoing a relapse during their first year post-hospitalization decreases from 40% to 16% or lower.