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Interventions to improve the experience of caring for people with severe mental illness: systematic review and meta-analysis

  • Amina Yesufu-Udechuku (a1), Bronwyn Harrison (a2), Evan Mayo-Wilson (a3), Norman Young (a4), Peter Woodhams (a5), David Shiers (a6), Elizabeth Kuipers (a7) and Tim Kendall (a2)...

Abstract

Background

Informal caregiving is an integral part of the care of people with severe mental illness, but the support needs of those providing such care are not often met.

Aims

To determine whether interventions provided to people caring for those with severe mental illness improve the experience of caring and reduce caregiver burden.

Method

We conducted a systematic review and meta-analyses of randomised controlled trials (RCTs) of interventions delivered by health and social care services to informal carers (i.e. family or friends who provide support to someone with severe mental illness).

Results

Twenty-one RCTs with 1589 carers were included in the review. There was evidence suggesting that the carers' experience of care was improved at the end of the intervention by psychoeducation (standardised mean difference −1.03, 95% CI −1.69 to −0.36) and support groups (SMD =–1.16, 95% CI −1.96 to −0.36). Psychoeducation had a benefit on psychological distress more than 6 months later (SMD =–1.79, 95% CI −3.01 to −0.56) but not immediately post-intervention. Support interventions had a beneficial effect on psychological distress at the end of the intervention (SMD =–0.99, 95% CI −1.48 to −0.49) as did problem-solving bibliotherapy (SMD =–1.57, 95% CI −1.79 to −1.35); these effects were maintained at follow-up. The quality of the evidence was mainly low and very low. Evidence for combining these interventions and for self-help and self-management was inconclusive.

Conclusions

Carer-focused interventions appear to improve the experience of caring and quality of life and reduce psychological distress of those caring for people with severe mental illness, and these benefits may be gained in first-episode psychosis. Interventions for carers should be considered as part of integrated services for people with severe mental health problems.

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Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives licence (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits noncommercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of Cambridge University Press must be obtained for commercial re-use or in order to create a derivative work.

Corresponding author

Tim Kendall, National Collaborating Centre for Mental Health, Royal College of Psychiatrists, 21 Prescot Street, London E1 8BB, UK. Email: tim.kendall@shsc.nhs.uk

Footnotes

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Joint last authors.

The National Collaborating Centre for Mental Health receives £1.4 million per year from the National Institute for Health and Care Excellence to develop guidelines for the treatment of mental health problems.

Declaration of interest

None.

Footnotes

References

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Interventions to improve the experience of caring for people with severe mental illness: systematic review and meta-analysis

  • Amina Yesufu-Udechuku (a1), Bronwyn Harrison (a2), Evan Mayo-Wilson (a3), Norman Young (a4), Peter Woodhams (a5), David Shiers (a6), Elizabeth Kuipers (a7) and Tim Kendall (a2)...
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eLetters

Caring for the carers: An effective way to help patients with mental ill health and their families

Rachel A Cichosz, Medical Student, Cardiff University
10 August 2015

Yesufu-Udechuku et al (2015) conducted a review into interventions for carers of those with mental illness and whether they should be considered as part of integrated services for those with mental health problems. They have raised an important issue and during medical school there is minimal teaching on the effect of mental ill health on family and care givers, despite evidence that this can impact on recovery for both patient and carer. Carers often spend a significant amount of time with the patient and so it is important that we help them develop effective coping strategies to stay (Kuipers et al, 2010) well in order to improve outcomes for all involved.

We should consider the biopsychosocial needs of patients, which includes the environment in which they live and so surely it is in the best interest of everyone involved to look after the family and carers. Many carers for the mentally ill report difficulty in coping, and caring can contribute directly to ill health and social problems (Awad and Voruganti, 2008). As Yesufu-Udechuku et al (2015) state, caregivers have an underlying need for help ‘not just as carers but as individuals’. The question is- where does the responsibility lie and what can we do about this gap in services?

There are clear benefits making this a key part of the medical school curriculum in order to equip us with the skills and experience to look after those involved closely with patients.

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Conflict of interest: None Declared

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Caring for relatives with schizophrenia: a role for stress reduction and CBT techniques training?

The recent meta-analysis reported in BJP (Yesufu-Udechuku et al. 2015) demonstrated a need for new directions in research. Basic CBT techniques aligned with personal stress reduction would appear to be a potential way forward. Carers are a substantially untapped resource for delivering improved outcomes. In particular carers spend more time in direct contact with the service user than any mental health professional. The development of a collaborative approach based on CBT would be likely to reduce high expressed emotion as agreed goals are worked towards. In a large scale highly powered pragmatic RCT, Turkington et al. (2002) demonstrated that carers with basic training could safely and effectively support psychiatric nurses delivering CBT techniques to service users with schizophrenia. Carers supporting therapists are in a perfect position to listen to audiotapes of therapy to reinforce CBT techniques and explain homework exercises. Subsequent to this, Turkington et al. (2014) found that teaching case managers without a mental health qualification (equivalent of the support worker role in the UK) CBT techniques for the treatment of schizophrenia, was safe and improved patient outcomes to a modest degree as long as telephone supervision was available. Therefore, there is now no reason not to begin to teach carers and family members these basic and safe techniques with access to supervision in order that caring might become CBT-informed. The first such ‘CBT techniques for the treatment of schizophrenia workshop’ was run for carers in York, UK, in the summer of 2014 with the help of Rethink.

Carers were taught the following techniques during this workshop: dealing with personal stress, communicating and normalising, helping with distressing voices and beliefs, improving coping skills, working with attitudes to antipsychotic medication to improve adherence and planning for ongoing wellness. Results were promising as the majority of carers reported all CBT techniques to be understandable and potentially helpful. In terms of the need to reduce personal stress a sub-group of carers had already recognised this and highlighted the importance of regular practice of a range of techniques for themselves including mindfulness, yoga, prayer, exercise, talking therapies and maintaining hobbies/ interests.

It would appear that an emphasis on personal stress reduction and the learning of CBT techniques could lead to improved outcomes. This combined approach should now be formally tested and, if appropriate, carer manuals and training schemes developed.



Latoyah Lebert, Research Assistant, Northumberland Tyne and Wear NHS Mental Health Foundation Trust, Academic Psychiatry, Centre for Ageing and Vitality, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne, UK. NE4 6BE. Email:toyah.lebert@ntw.nhs.uk

Helen Spencer, Doctoral Researcher, Northumberland Tyne and Wear NHS Mental Health Foundation Trust, Academic Psychiatry, Centre for Ageing and Vitality, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne, UK. NE4 6BE.

Douglas Turkington, Professor of Psychosocial Psychiatry, Newcastle University, Academic Psychiatry, Centre for Ageing and Vitality, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne, UK. NE4 6BE.

References

1.Yesufu-Udechuku A, Harrison B, Mayo-Wilson E, Young N, Woodhams P, Shiers D, Kuipers E, Kendall T. Interventions to improve the experience of caring for people with severe mental illness: systemic review and meta-analysis. Br J Psychiatry 2015; 206(4): 268-74.

2.Turkington D, Kingdon D, Turner, T. Effectiveness of a brief cognitive behavioural therapy intervention in the treatment of schizophrenia. Br J Psychiatry 2002; 180(6): 523-27.

3.Turkington D, Munetz M, Pelton J, Montesano V, Sivec H, Nausheen B, Kingdon D. High-Yield cognitive behavioural techniques for Psychosis delivered by case managers to their clients with persistent psychotic symptoms: An exploratory trial. J Nerv Ment Dis 2014; 202(1): 30-4

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