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Family psychoeducation: is this a major step forward in relapse prevention for depression?

There was a pretty startling paper published in last month's British Journal of Psychiatry:

Shimazu, K., S. Shimodera, et al. (2011). "Family psychoeducation for major depression: randomised controlled trial." British Journal of Psychiatry 198(5): 385-390.  Background The value of family psychoeducation for schizophrenia has been well established, and indications for its use have recently expanded to include bipolar affective disorder. However, no study to date has adequately examined its use in depression. Aims To examine family psychoeducation in the maintenance treatment of depression and to investigate the influence of the family's expressed emotion (EE) on its effectiveness. Method Of 103 patients diagnosed with major depression and their primary family members, 57 pairs provided written informed consent. The pairs were randomly allocated to the intervention (n = 25) or control (n = 32). One family in the intervention group and two in the control group withdrew their consent after randomisation. The intervention group underwent four psychoeducation sessions consisting of didactic lectures about depression and group problem-solving focusing on how to cope in high-EE situations. Patients did not attend these sessions. Patients in both the intervention and control groups received treatment as usual. The families' EE levels were evaluated through Five-Minute Speech Samples. The primary outcome was relapse. Results Time to relapse was statistically significantly longer in the psychoeducation group than in the control group (Kaplan-Meier survival analysis, P = 0.002). The relapse rates up to the 9-month follow-up were 8% and 50% respectively (risk ratio 0.17, 95% CI 0.04-0.66; number needed to treat 2.4, 95% CI 1.6-4.9). In Cox proportional hazard analysis, baseline EE did not moderate the effectiveness of the intervention. Conclusions Family psychoeducation is effective in the prevention of relapse in adult patients with major depression.

Yes, you read it correctly "The relapse rates up to the 9-month follow-up were 8% and 50% respectively".  This is a really impressive treatment effect ... and for a four session group intervention.  Wow!  Wouldn't it be fascinating to compare this approach with other relapse prevention methods like continuation antidepressants, continuation psychotherapy, and mindfulness-based cognitive therapy.  And how about combining family psychoeducation with these already established methods?  And would family psychoeducation be helpful for other recurring psychological problems ... how about anxiety disorders, or eating disorders, or other difficulties?  

What did the intervention involve?  The authors write:  "Family psychoeducation took the form of courses attended by up to five family members, without the participation of the patients.  Only one family member per patient attended.  Sessions took place once every 2 weeks, and the full course comprised four sessions: ‘Epidemiology and causes', ‘Symptoms', ‘Treatment and course' and ‘Coping with the patient'.  Each session lasted 90-120 min: the first 30 min were devoted to providing information regarding depression and its treatment, and the subsequent 60-90 min were devoted to group discussion and problem-solving for high-EE ("expressed emotion") situations experienced by the participating families.  A videotape and a textbook explaining depression and its treatment were prepared for this study and were used as teaching materials.  In the group problem-solving exercises, family members were asked to collaborate on compiling a list of possible solutions, discussing their advantages and disadvantages, and arriving at the best possible coping solution in response to high-EE situations suggested by family members.  The therapists tried to minimise their intervention in order to respect the families' autonomy and to empower them maximally.  The number of participants was limited to five to encourage them to contribute to the group discussion".

Interestingly although the treatment seemed so effective there is a big question whether it worked by changing family EE (expressed emotion).  In this research EE was measured using Five-Minute Speech Samples (FMSS) and the Family Attitude Scale (FAS).  The authors commented "In the intervention group, neither EE status according to FMSS nor FAS score decreased significantly from baseline to follow-up. Nor did EE status or FAS scores at 9-month follow-up differ significantly between the intervention and control groups when controlled for respective baseline values".  There are a whole series of pathways that can link family psychoeducaton to patient outcomes - see, for example, the recent paper "Emerging models for mobilizing family support for chronic disease management: a structured review".  Assuming the benefits of psychoeducation are replicated, it will be interesting and important to understand better how it works (partly as this may suggest ways the treatment can be made even more effective).  The paper ends with the words:  "It must also be emphasised that our family psychoeducation - consisting of four sessions and using videotapes and booklets specifically prepared for this programme - was brief and easy to disseminate.  Given the great number of people affected by depression - both patients and their families - we believe that our study has paved a new way to their effective care.  A replication study with a larger sample is warranted in order to confirm its effectiveness and to elucidate its mechanisms".  Spot on ...

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