A systematic review of randomized controlled trials of psychoeducation interventions for patients diagnosed with schizophrenia

Abstract

Background:

Schizophrenia is one of the most complicated psychiatric disorders, and, although medication therapy continues to be the core treatment for schizophrenia, there is a need for psychotherapy that helps in providing patients comprehensive mental health care. Psychoeducation is one of the most recognized psychosocial interventions specific to schizophrenia. Further knowledge about the impact of this type of intervention on patients diagnosed with schizophrenia needs to be acquired.

Aim:

This review aimed to explore the effects of psychoeducational interventions on improving outcome measures for patients diagnosed with schizophrenia.

Methods:

The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline was used in this systematic review. Two reviewers were involved in screening articles for inclusion and in the data extraction process. The selected studies were assessed for quality using the ‘Consolidated Standards of Reporting Trial (CONSORT)’ checklist. Out of the 441 records identified, 11 papers were considered for full review (from 2000 to 2018).

Results:

The psychoeducational interventions showed a consistent improvement in many outcome measures. Most of the reviewed studies focused on outpatients and the method of delivering the psychoeducational interventions was mostly in lecture format.

Conclusion:

This systematic review of randomized controlled trial studies emphasizes the positive impact of psychoeducational interventions for patients diagnosed with schizophrenia concerning various outcome measures. The findings of this review have important implications for both nursing practice and research, as the information presented can be used by the administrators and stakeholders of mental health facilities to increase their understanding and awareness of the importance of integrating psychoeducational interventions in the routine care of patients diagnosed with schizophrenia.

Keywords

Schizophrenia systematic review randomized controlled trial psycho-education

Introduction

Patients diagnosed with schizophrenia (PDwS) are not treated by medication alone. Although this approach continues to be the core treatment for the management of schizophrenia, there is a need for psychosocial interventions that help in providing the biopsychosocial approach for PDwS (Rami et al., 2018; World Health Organization, 2017).

Psychosocial interventions in the management of schizophrenia have expanded robustly during the past three decades. For that reason, psychoeducation interventions (PEIs) are one of the oldest and better known psychosocial interventions that are useful in treating schizophrenia (Chądzyńska & Charzyńska, 2011; Kryshtal et al., 2017). Psychoeducation is described as the education of a patient with a mental illness concerning the psychiatric symptoms, treatment management, and prognosis of that mental illness (Tabeleão et al., 2018; Zhao et al., 2015). It not only provides information to patients but is a training method that focuses on encouraging insight and offering forms to control, adapt, and live with a mental illness (Motlova et al., 2017; Zhao et al., 2015).

Over the past 10 years, psychoeducation has become an important treatment of choice for PDwS (Hasan et al., 2015; Rotondi et al., 2010; Wu et al., 2019). Using PEIs with PDwS tends to have positive outcomes, such as improved medication compliance (Choe et al., 2015; George et al., 2016), increased level of knowledge of the disease (Aho-Mustonen et al., 2010; Hasan et al., 2015), better patients’ social and coping skills (Chien & Thompson, 2014), reduced number of relapses (Hasan et al., 2015; Srivastava & Panday, 2016), reduced severity of psychiatric symptoms (Soliman et al., 2018), internalized stigma (Uchino et al., 2012; Von Maffei et al., 2015) and improved patients’ quality of life (Soliman et al., 2018).

To date, systematic reviews of randomized controlled trials (RCTs) that explored the effectiveness of PEIs for PDwS are limited. Hence, this review is significant because it will add a primary addition to the body of knowledge, using a robust appraisal of evidence from the literature that explores the positive impact of such interventions on a variety of outcome measures targeting PDwS. The purpose of the systematic review of the RCT was to explore the effects of PEIs for PDwS on improving outcome measures, level of knowledge about schizophrenia, medication compliance, and for reducing psychiatric symptoms, internalized stigma and relapse rate.

Methods

The review protocol comprised two phases: the first phase included database searches, while the second phase involved recalling and checking all the related articles identified from the first phase to ensure rigour and trustworthiness of this systematic review. Cited references in these related articles were also recalled from the relevant articles. The guideline of ‘The Preferred Reporting Items for Systematic Review and Meta-Analysis protocols (PRISMA)’ was applied (Moher et al., 2009) (see Supplementary File 1). This systematic review was registered in the PROSPERO under the number CRD42019121254.

Search strategy

This literature review managed RCT studies that applied PEIs for PDwS. The first step in our search strategy was to break down the review questions to guide the development of our search terms. Using the Population, Intervention, Comparators, and Outcomes (PICO) method, the search used the subsequent related terms: Population – PDwS; Interventions – any method of delivering PEIs (lecture based, online, etc.); Comparators – usual treatment, or standard care, which is mainly medication treatment; Outcomes – level of knowledge about schizophrenia, psychiatric symptoms, patient’s internalized stigma, relapse rate and medication compliance.

Data sources and screening process

A thorough literature search from the year 2000 to 2018 was performed to define the pertinent RCT studies utilizing the subsequent electronic databases: Science Direct, PubMed, Web of Knowledge, EBSCO host and Springer Link. The reason for selecting this time duration was because this period marks the publication of almost all the articles on evidence-based practice regarding PEIs. Our search keywords were ‘psychoeducation’, ‘patient education’, ‘psychoeducation intervention’, ‘psychoeducation programme’, ‘nursing psychoeducation’, ‘patients with schizophrenia’, ‘family intervention’, ‘psychosis’ and ‘randomized control trial’. All the relevant records with the title and abstract were retrieved. To improve the research strategy, we combined the medical subject headings (MeSH terms), their synonyms and keywords through utilizing operators, such as truncation, wildcard and Boolean. In this review, only RCT studies for PDwS in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Mental Disorder (ICD) were considered (see Supplementary File 2: Electronic search strategy).

This review included studies for both in- and outpatient care settings. However, we excluded studies that recruited patients with a history of a learning disability, a known organic mental disorder and/or substance abuse. Our final search strategy was peer-reviewed to check for any errors and possibly missed searches, which helped in reducing the recall of papers. In addition, we searched all the reference lists for papers in a search for more studies to include in this review. The inclusion and exclusion criteria of the studies in this review are summarized in Table 1.

Table 1.

Inclusion and exclusion criteria of the studies in the literature review.

	Inclusion	Exclusion
Participants	Patients diagnosed with schizophrenia	Patients diagnosed with other mental disorders
Study criteria	Quantitative experimental study (RCT)	Non-experimental study. Any other study design
Intervention	Studies that used a PEI, as a form of psychosocial intervention	Psychosocial interventions other than psychoeducation (e.g. social skill training and group therapy)
Outcomes	Relapse rate, level of knowledge about schizophrenia, psychiatric symptoms, internalized stigma and medication adherence	Other outcomes from that stated in the selected outcomes
Language	English	Any other language
Place	No restriction on place	–
Time	2000 or after	Before 2000

RCT: randomized controlled trial; PEI: psychoeducation intervention.

Data extraction

The primary checking of the abstracts produced 441 studies addressing schizophrenia, of which 169 studies were not included after checking their titles or found to be replicated from various databases (n = 46). The abstracts were then checked and other studies were not included (n = 120) because they did not meet the inclusion criteria, such as psychosocial interventions other than psychoeducation for PDwS (i.e. social skills training and group therapy) (n = 45), or PEIs for other mental disorders (n = 10), non-RCT studies (n = 35), issued in a language other than English (n = 20) or published before the time duration considered for this review (i.e. before 2000) (n = 10). The full text of 106 articles was examined based on the title first for suitability, and then the abstract of the studies was reviewed after which 95 articles were not included for different reasons. Some studies focused on PEIs for family caregivers only (n = 1), outcomes measured were other than those stated in the inclusion criteria (n = 38), PEIs for other mental disorders (n = 19), using PEIs together with other methods of psychosocial interventions – as the interventions (n = 2), systematic articles (n = 8) and conference abstracts (n = 10). Thus, 11 studies were considered in the review. The data extraction procedure was established using the step-by-step guideline by the PRISMA guidelines (Moher et al., 2009). Figure 1 shows the selection of studies.

Figure 1.

Study selection based on the PRISMA protocol.

Quality assessment

Titles and/or abstracts of studies restored applying the search strategy were checked by two reviewers (M.M.B.A. and K.L.A.) to recognize studies that potentially meet the inclusion criteria outlined above. The full text of these possibly eligible studies was restored and evaluated by two of the authors (M.M.B.A. and K.L.A.). Any discrepancies over the eligibility of a study were resolved through discussion with a third reviewer (T.L.Y.). Although research studies reporting checklists have been recognized in the literature to assess the quality of these studies, there is no evidence of a good research reporting checklist tool to assess the quality of RCTs. In this study, data extraction was performed using the Consolidated Standards of Reporting Trial (CONSORT) checklist (see Supplementary File 3) to evaluate the quality of the RCTs (CONSORT, 2010). This checklist involves 25 items to evaluate the methodological quality of an RCT study and to determine the level to which a study has managed the chance of bias in its design and analysis. A point was given to each study if there was a positive and clear explanation of every single item; consequently, the CONSORT score for the methodological quality of RCT ranged from 0 (low quality) to 25 (high quality).

The extracted data comprised specific descriptions about the interventions, settings, populations, study methods and outcome measures. Two authors (M.M.B.A. and K.L.A.) extracted data independently and any disagreement or uncertainty was resolved through discussion with the third author (T.L.Y.). The study authors were contacted through email for more clarification about their studies, where data were not clear or missing.

Results

Qualitative appraisal for selected papers

The aim of this systematic review was to explore the outcomes of PEIs on the PDwS. Table 2 illustrates the study characteristics: content of PEIs, outcome measures, methods of delivery and results of the articles reviewed. A total of 11 RCT studies were included for the final review.

Table 2.

Summary of the studies reviewed.

No	StudySetting	Sample size	Interventions	Outcome measures/methods of delivery	Results
1	Li and Arthur (2005) China	101 in-PDwS	Intervention group (n = 46) participated in 8 hours of PEI for the PDwS, while the family received 32 hours, followed by 6 hours for 3 months (2 hours/month) after discharge from the hospital for the patient and family together. Content: not specified. Control group (n = 55) received UT including asking for information from staff, and educational booklets, whenever needed by patient and family.	1. KASI 2. BPRS 3. Medication compliance (stops taking medication >1 week) 4. Relapse rate (readmission or symptom severity). Measured at admission, discharge, 3 and 9 months after discharge Seminar (lectured based).	Knowledge of schizophrenia level was significantly improved post-intervention and at 3- and 9-month follow-up in the intervention group. Psychiatric symptoms improved at 9-month follow-up, but only in the intervention group. No significant differences in compliance level between the intervention and control groups at any time measured in the study. Relapse rate decreased at 9-month follow-up, but only in the intervention group.
2	Bäuml et al. (2007) Germany	101 in-PDwS	Intervention group (n = 51) received 4-hour weekly sessions of PEI, followed by four sessions monthly for PDwS; in addition, the family member received eight sessions (biweekly) separately. Content: coping skills, medication and crisis management. Control group (n = 50) received UT, which is medication only.	1. Rehospitalization rate 2. Duration of hospitalization 3. The mean of consuming chlorpromazine 4. Psychiatric symptoms measured by BPRS Outcomes assessed at baseline, 2- and 7-year follow-ups. Individual session supported with booklet.	Hospitalization rate and duration were lower in the experimental group compared to the control group. Also, there was a significant increase in the mean number who consumed chlorpromazine in the intervention group. No significant difference was found in the psychiatric symptoms between the intervention and the control group.
3	Hasan et al. (2015) Jordan	121 out-PDwS	Intervention group (n = 58) received six booklets/12 weeks (two booklets/2 weeks). Followed by phone calls. Content: diagnosis of schizophrenia, causes of schizophrenia, side effects of medications, relapse prevention strategies, problem-solving and stress management. TAU (control, n = 63)	1. Knowledge measured by KASQ 2. Symptoms measured by PANSS 3. Relapse rate measured by number of admissions. Measured at baseline, post-intervention and 3-month follow-up. Educational booklets.	PDwS in the intervention group experienced a greater improvement in knowledge scores and reduced symptom severity. Relapse rate with hospitalization was reduced in the intervention group, while relapse with medication was increased in this group compared to the control group.
4	Rotondi et al. (2010) USA	31 out-PDwS	Intervention group (n = 16) for PDwS participated in online PEI for 4 hours. Content: targeting the communication and problem-solving skills. Control group (n = 15, 11) received UT, which is not specified.	1. SAPS (measured at pre-test and 12-month follow-up) 2. KASI (measured at pre-test and 6-month follow-up). Online method.	Knowledge level was significantly improved at 6-month follow-up and symptoms were reduced at 12-month follow-up.
5	Kulhara et al. (2009) India	76 out-PDwS	Eleven sessions (40–60 minutes) as PEI were given to the intervention group (n = 38) over a 9-month period. Content: sessions focused on aetiology, symptoms, treatment and prognosis, medication, communication skills, problem-solving skills, relapse prevention and employment opportunities. Control group (n = 38) received UT, which included medication and counselling therapy.	1. Symptoms measured by PANSS 2. Psychiatry disability measured by World Health Organization (WHO) disability scale 3. Relapse (symptom exacerbation or readmission) Reported at pre-test and immediately after intervention. Seminar (lecture based plus booklet).	Psychiatric symptoms and disability scores were reduced significantly after intervention in the experimental group. No significant difference was observed in the relapse rate between the intervention and the control post-intervention.
6	Aguglia et al. (2007) Italy	135 out-PDwS	Intervention group (n = 69), PDwS and their families enrolled separately in eight sessions of PEI (60 minutes). Content: introduction of the PEI, definition of schizophrenia, cause, treatment methods, relapse warning signs and family role. Control group (n = 66) received traditional psychosocial interventions, in addition to their medication treatment, as their TAU.	1. Symptoms measured by BPRS, SAP and SANS 2. Medication compliance measured by ROMI. Measured at baseline, after 3, 6, 9 and 12 months. Group seminar (lecture based).	Psychiatric symptoms as measured by BPRS reduced significantly in the intervention group at all times measured. Positive symptom scores were reduced at all times measured (at baseline to 12-month follow-up) in the experimental group and no significant reduction in the control group. Experimental group showed a significant improvement in medication compliance from baseline to 12-month follow-up, while the control group revealed no significant difference. Relapse rate was significantly decreased in the intervention group over follow-up times, compared to no significant differences in the control group.
7	Barrio and Yamada (2010) USA	59 out-PDwS	Intervention group (n = 26) received 16 sessions (2 hours) as PEI every 2 weeks. Content: not stated in the study. Control group (n = 33) received UT, which was not specified.	1. Symptom severity 2. QoL 3. Treatment compliance. Measures not specified. Assessed at baseline, immediately post-intervention and 3-month follow-up. Multi-group seminar (lecture based).	Symptom severity was significantly decreased in the intervention group at 3-month follow-up. In addition, QoL and treatment adherence were improved in the intervention group at 3-month follow-up.
8	Ran et al. (2015) China	238 out-PDwS	Experimental group (n = 92), PEI and medication treatment. Content: basic knowledge about schizophrenia, treatment and rehabilitation. (n = 73) in the medication group. (n = 73) participants in the control group (no intervention)	1. Patients’ follow-up schedule 2. Symptoms measured by PANSS 3. Global Assessment of Functioning (GAF) 4. Help-seeking behaviour (rate of antipsychotic medication) and work ability level measured by structured questions. Measured at 14-year follow-up. Seminar (lecture based).	Positive and negative symptoms’ mean scores and general mental health total scores measured by GAF showed no significant differences among the three groups (experimental, medication and control group) at 14-year follow-up. The experimental group showed a higher rate of antipsychotic medication–seeking behaviour and a higher work ability level than the medication and control groups at 14-year follow-up.
9	Ngoc et al. (2016) Vietnam	59 in-PDwS	Intervention (n = 30) received three sessions of approximately 1.5 hours over a period of a week and a half. Content: introduction about schizophrenia, family support and reintegration into community. Control (n = 29) received TAU, which consisted of psychotropic medication.	1. QoL measured by QoL Enjoyment and Satisfaction Questionnaire 2. Stigma measured by Stigma Towards Schizophrenia scale 3. Medication non-compliance measured by Medication Compliance Inventory 4. Consumer satisfaction measured by the developed scale for this study. Measured at baseline and 6 months after intervention. Seminar (lecture based)	There were significant effects for the intervention group on (1) QoL, (2) stigma and (3) medication compliance.
10	Rami et al. (2018) Egypt	60 out-PDwS	Intervention group (n = 30) received 14 sessions of culturally adapted programme, 1 hour/week, and their medication treatment. Content: Patients learned about the signs, symptoms, aetiology and relapse signs of schizophrenia, communication skills and problem-solving skills. Control group (n = 30) received medication treatment and medical consultation and advice.	1. Symptoms measured by PANSS 2. Social functions measured by SFQ 3. QoL measured by QLS 4. Attitudes towards medication measured by DAI. Measured at baseline and 6-month follow-up. Seminar (lecture based).	The intervention group showed a significant reduction in the symptom scores and enhancement of the social function level, QoL and attitude towards medication at 6-month follow-up compared to the control group.
11	Ran et al. (2003) China	326 out-PDwS	PDwS and their family together (n = 126) in the experimental group participated in nine sessions of PEI for 9 months (one session/month) with their medication treatment. Content: schizophrenia definition, symptoms, prognosis, treatment management, relapse prevention and social functioning rehabilitation. Medication group (n = 103). Control group (n = 97)/intervention was neither encouraged nor discouraged.	1. Medication compliance measured by to what extent PDwS takes his/her antipsychotic medication 2. Relapse rate (symptom worsening) 3. Social support measured by Social Disability Screening Schedule. Measured at the baseline, as well as at 9-month follow-up. Seminar (lecture based).	Medication compliance post-intervention was higher in the experimental group, in contrast to the two other groups (medication and control groups). At 9-month follow-up, experimental group showed a significant reduction in the relapse rate compared to the other two groups, while social support improved in the experimental and medication groups at the follow-up time measured.

PDwS: patient diagnosed with schizophrenia; PEI: psychoeducation intervention; UT: usual treatment; KASI: Knowledge About Schizophrenia Inventory; BPRS: Brief Psychiatric Rating Scale; KASQ: Knowledge About Schizophrenia Questionnaire; PANSS: Positive and Negative Symptoms Scale; SAPS: Scale for Assessment of Positive Symptoms; SANS: Scale for the Assessment of Negative Symptoms; ROMI: Rating of Medication Influences; QoL: quality of life; SFQ: Social Function Questionnaire; QLS: Quality of Life Scale; DAI: Drug Attitude Inventory; TAU: Treatment As Usual.

Most of the selected studies focused on outpatients, while only three studies focused on inpatients who were diagnosed with schizophrenia. The most prominent outcome measures of the reviewed studies were knowledge about schizophrenia, psychiatric symptoms, relapse rate and medication compliance. In addition, the mode of delivery for the psychoeducational interventions was in lecture format. This assessment was done by the primary author (M.M.B.A.) and confirmed by the secondary authors (K.L.A., T.L.Y., L.A. and M.D.). Any discrepancies were discussed and resolved by consensus.

This resulted in one study rated as high quality (Hasan et al., 2015) and the studies by Aguglia et al. (2007), Barrio and Yamada (2010) and Ngoc et al. (2016) rated as low quality. Moreover, the other selected studies (n = 7) were rated as moderate quality (n = 3) and low–moderate quality (n = 4). According to the methodological quality on the criteria listed in the CONSORT checklist, no paper was excluded (Table 3).

Table 3.

Quality of RCT studies in which PEIs were directed based on CONSORT checklist.

Items	Li and Arthur	Bäuml et al.	Hasan et al.	Rotondi et al.	Kulhar et al.	Aguglia et al.	Barrio and Yamada	Ran and Chan	Ngoc et al.	Rami et al.	Ran et al.
Title and abstract	Yes	Yes	Yes	No	Yes	No	No	Yes	No	No	Yes
Background and objective	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	No	Yes	Yes
Methods
Trial design	Yes	Yes	Yes	No	NA	No	Yes	Yes	No	Yes	Yes
Participants	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Intervention	Yes	Yes	Yes	Yes	Yes	No	Yes	No	Yes	Yes	Yes
Outcomes	Yes	Yes	Yes	NA	No	No	No	Yes	Yes	Yes	Yes
Sample size	Yes	NA	No	No	No	No	No	No	No	No	No
Randomization
Sequence generation	Yes	Yes	Yes	No	No	No	NA	No	No	Yes	Yes
Allocation concealment mechanism	Yes	No	Yes	No	No	No	No	No	No	Yes	Yes
Implementation	Yes	Yes	Yes	NA	No	No	No	No	No	Yes	No
Blinding	No	Yes	Yes	Yes	Yes	No	No	No	No	Yes	No
Statistical methods	No	Yes	Yes	Yes	Yes	Yes	No	Yes	No	Yes	No
Results
Participant flow	Yes	Yes	Yes	No	Yes	No	No	Yes	Yes	Yes	Yes
Recruitment	No	No	No	Yes	Yes	No	No	No	No	No	No
Baseline data	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes	Yes	Yes
Numbered analysed	No	No	Yes	Yes	Yes	No	No	Yes	Yes	Yes	Yes
Outcomes and estimation	No	No	Yes	Yes	No	NA	Yes	No	NA	No	Yes
Ancillary analyses	No	No	NA	No	No	No	No	NA	No	NA	NA
Harms	No	No	No	No	No	No	No	No	No	No	No
Discussion
Limitation	Yes	No	Yes	Yes	No	No	NA	Yes	Yes	Yes	No
Generalizability	NA	NA	Yes	NA	NA	Yes	Yes	Yes	No	No	Yes
Interpretation	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Other information
Registration	No	No	Yes	No	No	No	No	No	No	No	No
Protocol	No	No	No	No	No	Yes	No	No	No	No	No
Funding	No	No	No	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes
Overall quality	M (14)	L.M (13)	H (22)	L.M (12)	L.M (11)	L (5)	L (8)	L.M (13)	L (9)	M (16)	M (15)

RCT: randomized controlled trial; PEI: psychoeducation intervention; CONSORT: Consolidated Standards of Reporting Trial.

More than 18, high quality (H); 14–18, moderate quality (M); 10–13, low–moderate quality (L.M); less than 10, low quality (L).

‘Yes’ in all domains would place a study at ‘low risk of bias’; ‘No’ in any of the domains would place a study at ‘high risk of bias’; ‘Unclear/NA’ in any of the domains would place the study at ‘unclear risk of bias’.

Effectiveness of psychoeducation

All the reviewed studies revealed that the PEIs for the PDwS identified many primary and secondary outcomes. In common with many studies, the patient’s level of knowledge about schizophrenia was a main outcome in some studies. In addition, psychiatric symptoms/relapse rate and medication compliance were also identified as primary outcomes. On the other hand, secondary outcomes were the stigma of mental illness and quality of life for PDwS. Consequently, most of the reviewed studies showed that PEIs show a vigorous role in promoting the outcomes for PDwS. This will be discussed in the following sections in more detail.

Effect of psychoeducation on knowledge level of patients diagnosed with schizophrenia

Schizophrenia is a complex chronic illness and acquiring knowledge about it could have a favourable effect on patients (Daltio et al., 2015). Unfortunately, many PDwS experience a lack of knowledge and skills that could help them adapt to this serious mental disorder (Gümüş, 2008). Patients perceived gaining knowledge about their illness during PEIs as being a major motivation that enables them to control their mental illness effectively (Hasan et al., 2015; Li & Arthur, 2005).

Three studies assessed the level of knowledge after applying PEIs (Hasan et al., 2015; Li & Arthur, 2005; Rotondi et al., 2010) using questionnaire. The results revealed a positive impact of PEIs on the knowledge level for all times measured (post-intervention and follow-up). Hasan et al. (2015) found a large effect (0.52) (p < .001) of their PEIs on the level of knowledge after intervention and 3-month follow-up although there were no significant differences in the level of knowledge between the intervention and the control group pre-intervention. In addition, Li and Arthur (2005) found a significant difference for the intervention group in terms of the total score of the knowledge levels between the three time points (post-intervention (M = 14.8, p = .001), 3-month (M = 15.3, p < .001), and 9-month (M = 15.9, p < .001) follow-up). Meanwhile, the control group showed no significant differences within the three time points. Moreover, Rotondi et al. (2010) found a large improvement (p = .028, d = 0.88) in knowledge level at 6-month follow-up after applied PEIs among PDwS.

Psychoeducation effect on psychiatric symptoms

Most PDwS manifest both positive and negative psychiatric symptoms. Nine of the reviewed studies explored the effectiveness of the PEIs directed for PDwS on psychiatric symptoms. These studies used several scales to evaluate the psychiatric symptoms: four studies used a positive and negative symptom scale (Hasan et al., 2015; Kulhara et al., 2009; Rami et al., 2018; Ran et al., 2015), while three of the studies (Aguglia et al., 2007; Bäuml et al., 2007; Li & Arthur, 2005) used a brief psychiatric rating scale. In addition, the scale of assessment of the positive symptoms was used by Aguglia et al. (2007) and Rotondi et al. (2010) with one study using the scale of assessment of negative symptoms (Aguglia et al., 2007). Only one study did not specify the measure used for psychiatric symptoms (Barrio & Yamada, 2010).

The PEIs showed various effects on the psychiatric symptoms, ranging from positive effect to no effect at any time point (after the intervention and follow-up). Nearly half of the reviewed studies found a positive effect of PEIs on psychiatric symptoms for all time points (Aguglia et al., 2007; Barrio & Yamada, 2010; Hasan et al., 2015; Kulhara et al., 2009; Rami et al., 2018). Li and Arthur (2005) and Rotondi et al. (2010) reported an improvement in psychiatric symptoms, but only at 9 and 12 months, respectively. On the other hand, two studies found that there was no change among PDwS regardless of their psychiatric symptoms between the intervention and control groups (Bäuml et al., 2007; Ran et al., 2015).

Psychoeducation effect on medication compliance/adherence

Six of the selected studies in the review (Aguglia et al., 2007; Barrio & Yamada, 2010; Li & Arthur, 2005; Ngoc et al., 2016; Rami et al., 2018; Ran et al., 2003) evaluated the impact of PEIs on medication compliance/adherence for PDwS. These studies used different types of scales to measure patient medication compliance/adherence. Two studies used a medication inventory (Ngoc et al., 2016; Rami et al., 2018), while the study by Aguglia et al. (2007) used the rating of medication influence scale. In addition, two studies used qualitative questions to assess the medication compliance/adherence for PDwS (Li & Arthur, 2005; Ran et al., 2003); on the other hand, in the study by Barrio and Yamada (2010), the instrument was not specified. Of these, all of them, except Li and Arthur (2005), showed a positive impact of PEIs on medication compliance/adherence directly post-intervention and at the 3 and 12-month follow-ups. In 2005, Li and Arthur found no significant effect of their PEIs in terms of the compliance level at any of the time points between the intervention and the control group.

Psychoeducation effect on relapse prevention

Two RCTs (Aguglia et al., 2007; Ran et al., 2003) showed that outpatients who enrolled in the PEIs reported a lower relapse rate (readmission rate and/or psychiatric symptom severity), at all the time points – including post-intervention and follow-up – while only one study showed a lower relapse rate at the 9-month follow-up (Li & Arthur, 2005) when compared to the control group, which only received their usual treatment – antipsychotic drugs. Moreover, Hasan and his team (2015) found a lower relapse rate with hospitalization, which was measured by the number of admissions, in the intervention group at all time points, compared to a higher relapse rate with medication which was measured by the number and dosage of antipsychotics in the intervention group. However, Kulhara et al. (2009) found no significant difference in the relapse rate between the intervention and the control group after intervention. Relapse prevention is a major challenge for the patient, family and mental health service providers (Sariah et al., 2014); 52% of PDwS after discharge experienced at least one relapse episode within a year (Matsuda & Kohno, 2016). Of them, 30%–40% frequently suffered from relapse, even if they adhered to their medication treatment (Sariah et al., 2014; Spaniel et al., 2016).

Psychoeducation effect on other outcomes

Only a few of the patients’ outcome measures were described in the PEIs’ studies, which included the stigma of mental illness and the quality of life. PDwS experience feelings of stigmatization and discrimination more than other patients with mental illness (Karakaş et al., 2016), in which the feeling of stigmatization influences their functions (Pellet et al., 2019; Sharaf et al., 2012). It has been reported that the PEIs showed a positive effect in terms of reducing the feeling of stigma for the PDwS (Ngoc et al., 2016). Moreover, three from reviewed studies (Barrio & Yamada, 2010; Ngoc et al., 2016; Rami et al., 2018) reported a significant improvement in their quality of life for the intervention group. This type of PEIs helps PDwS to focus on the factors that can help them develop strategies to improve their quality of life (Khalil et al., 2018).

Psychoeducation: methods of delivery

Psychoeducation is a flexible intervention, which can be delivered by means of a variety of different methods for PDwS in individual and group format. This includes seminars or lecture based (Aguglia et al., 2007; Barrio & Yamada, 2010; Kulhara et al., 2009; Li & Arthur, 2005; Ngoc et al., 2016; Rami et al., 2018; Ran et al., 2003, 2015), educational booklets (Hasan et al., 2015), seminars or lecture based with booklets (Bäuml et al., 2007) and online methods (Rotondi et al., 2010). Rotondi et al. (2010) conducted a longitudinal experimental study of PDwS in which they applied online (website with home computers) PEIs. Patients (n = 31) were randomly assigned to online PEIs or usual treatment. Data were obtained at 3, 6 and 12 months after the PEIs, in which the participants in both groups (intervention and control) completed an interviewer-administered assessment of the scales of positive symptoms and the knowledge about the schizophrenia instrument. Similar to the face-to-face method (seminars or lecture-based sessions), the patients reported a large and significant reduction in the psychiatric symptoms and an increase in the level of knowledge about the illness compared to the control group.

Therefore, we can conclude from the previous studies that no simple psychoeducational method fits each patient and that there is no confirmation that one psychoeducation method is better than the other methods. Thus, in the first place, any type of PEIs should consider the patient’s needs.

Discussion

Schizophrenia is one of the most sophisticated psychiatric disorders and has a chronic phase. Most of the PDwS are not treated by psychotropic medications alone, although biological care continues to be the core treatment for schizophrenia. There is a need for psychotherapy that helps in providing the comprehensive mental health care for PDwS through applying a biopsychosocial approach. Psychoeducation is one of the most recognized psychotherapies specific to schizophrenia.

This review examined the effects of PEIs for PDwS in terms of improving the outcome measures. Most of the studies included in this review reported the content for their PEI contents on topics that are related to schizophrenia (definition, symptom management, treatment modalities and relapse prevention strategies). However, some studies focused on a specific topic for their PEI contents, such as medication compliance/adherence (Rotondi et al., 2010), problem-solving skills and communication skills (Rami et al., 2018). Two studies did not specify their psychoeducation content (Barrio & Yamada, 2010; Li & Arthur, 2005). The number of sessions, duration and frequency differed from one study to another, starting from one session weekly, lasting 17–90 minutes (Aguglia et al., 2007; Bäuml et al., 2007; Kulhara et al., 2009; Ngoc et al., 2016; Rami et al., 2018), to one session monthly (Li & Arthur, 2005).

Knowledge about schizophrenia, psychiatric symptoms, medication compliance/adherence and relapse rate were the most common outcomes for these reviewed articles that examined the effects of PEIs for PDwS. The less common outcomes that were used in some studies included the stigma of mental illness (Ngoc et al., 2016) and the quality of life (Barrio & Yamada, 2010; Ngoc et al., 2016; Rami et al., 2018). Consequently, PEIs showed a positive impact on these outcomes that targeted PDwS. In addition, three of the reviewed studies considered the small sample size to be a major limitation of their studies (Aguglia et al., 2007; Barrio & Yamada, 2010; Li & Arthur, 2005).

PEIs can also be applied to the family caregiver who is responsible for caring for PDwS. Most of the reviewed studies included family caregivers when they explored the effects of PEIs for PDwS (dyad), as having a family member with schizophrenia can negatively affect the whole family. So considering family caregivers in PEIs broadens the post-intercession effects of the patient and family caregiver at the same time.

Psychoeducation treatment is a flexible intervention that is able to be delivered by many mental health professions for the PDwS. In particular, psychiatric nursing plays a promising role in applying PEIs for patients with mental illness, specifically PDwS (Aguglia et al., 2007; Hasan et al., 2015; Li & Arthur, 2005). Psychiatric nurses should focus on their therapeutic communication skills, active listening skills and education skills as the major elements of patient education. These skills will help them in conducting the PEIs more efficiently.

Limitation

This study has some limitations. First, different methods of delivering PEIs were reviewed, which makes differentiation between these findings difficult. Second, this review excluded non-RCT and qualitative studies and only included RCT studies. Consequently, there is a requirement for an integrative systematic review to assess the viability of PEIs and their effects.

Conclusion

PEIs are gaining more recognition compared to other types of psychosocial intervention, such as social skills training and cognitive therapy when delivering to PDwS, as this intervention can be applied in a variety of psychiatric clinical settings (community, inpatient and outpatient setting). This review identified a common gap in that most of the literature focused on the effects of PEIs for out-PDwS. Only three studies targeted in-PDwS (Bäuml et al., 2007; Li & Arthur, 2005; Ngoc et al., 2016), while the rest of the reviewed studies focused on outpatients. There is a need for more studies that assess the effects of PEIs for in-PDwS. This review adds to the knowledge and makes a primary effort to evaluate the quality of this type of treatment approach in conjunction with the pharmacological therapy provided for PDwS. This information is crucial to establish better strategies for integrating psychoeducation programmes into regular treatment for this population and for improving the provision of psychosocial interventions according to the biopsychosocial approach for PDwS.

Supplemental Material

Supplementary_file.2.doc – Supplemental material for A systematic review of randomized controlled trials of psychoeducation interventions for patients diagnosed with schizophrenia

Supplemental material, Supplementary_file.2.doc for A systematic review of randomized controlled trials of psychoeducation interventions for patients diagnosed with schizophrenia by Majdi MB Alhadidi, Khatijah Lim Abdullah, Tang Li Yoong, Lourance Al Hadid and Mahmoud Danaee in International Journal of Social Psychiatry

Supplemental Material

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Supplemental material, Supplementary_File3_CONSORT for A systematic review of randomized controlled trials of psychoeducation interventions for patients diagnosed with schizophrenia by Majdi MB Alhadidi, Khatijah Lim Abdullah, Tang Li Yoong, Lourance Al Hadid and Mahmoud Danaee in International Journal of Social Psychiatry

Supplemental Material

Supplementary_file_1.PRISMA.doc – Supplemental material for A systematic review of randomized controlled trials of psychoeducation interventions for patients diagnosed with schizophrenia

Supplemental material, Supplementary_file_1.PRISMA.doc for A systematic review of randomized controlled trials of psychoeducation interventions for patients diagnosed with schizophrenia by Majdi MB Alhadidi, Khatijah Lim Abdullah, Tang Li Yoong, Lourance Al Hadid and Mahmoud Danaee in International Journal of Social Psychiatry

Footnotes

Author contributions

The authors have read and approved the final manuscript.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Majdi MB Alhadidi

Khatijah Lim Abdullah

Supplemental material

Supplemental material for this article is available online.

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