Soc Psychiatry Psychiatr Epidemiol (2003) 38 : 69–75
DOI 10.1007/s00127-003-0601-z
ORIGINAL PAPER
Mao-Sheng Ran · Meng-Ze Xiang · Cecilia Lai-Wan Chan · Julian Leff · Peggy Simpson · Ming-Sheng Huang · You-He Shan · Si-Gan Li
Effectiveness of psychoeducational intervention for rural Chinese families experiencing schizophrenia A randomised controlled trial Received: 16 April 2002 / Accepted: 29 August 2002
■ Abstract Background The aim of this study was to explore the characteristics and efficacy of psychoeducational family intervention for persons with schizophrenia in rural China. Methods A cluster randomised controlled trial of psychoeducational family intervention for families experiencing schizophrenia (three groups, 326 cases) was conducted in Xinjin County, Chengdu. Treatment groups consisted of family intervention and medication, medication alone, and a control. Results The results showed a gain in knowledge, a change in the relatives’caring attitudes towards the patients,and an increase in treatment compliance in the psychoeducational family intervention group (p < 0.05, 0.001). Most importantly, the relapse rate over 9 months in this group (16.3 %) was half that of the drug-only group (37.8 %),
and just over one-quarter of that of the control group (61.5 %) (p < 0.05). Antipsychotic drug treatment and families’attitudes towards patients after the 9-month follow-up were significantly associated with clinical outcome (p < 0.05). Conclusions In rural China, family intervention should focus on improving the relatives’ recognition of illness, the caring attitude towards the patients,treatment compliance,relapse prevention,and the training of the patients’social functioning.This trial,one of the largest in the literature, has shown that psychoeducational family intervention is effective and suitable for psychiatric rehabilitation in Chinese rural communities.
M.-S. Ran · M.-Z. Xiang · M.-S. Huang · Y.-H. Shan Institute of Mental Health West China Hospital West China University of Medical Sciences Chengdu, China
Introduction
C. L.-W. Chan Department of Social Work and Social Administration University of Hong Kong Hong Kong J. Leff Section of Social Psychiatry Institute of Psychiatry London, UK P. Simpson Department of Nursing Studies University of Hong Kong Hong Kong S.-G. Li Xinjin Mental Hospital Chengdu, China
According to the prevalence rate of schizophrenia,which stands at 6.55 per 1,000 population aged 15 years and over (Chen et al. 1998), there are about 5.3 million persons with schizophrenia in Mainland China, 4.3 million of whom live in the rural areas. Traditionally, more than 90 % of mental patients in China, including persons with schizophrenia, are cared for by their family members at home (Zhang and Yan 1993). Families have to face especially taxing difficulties, burdens, and levels of stress when caring for individuals with schizophrenia (Li et al. 1998). Moreover, the lack of a correct recognition of mental illness is a serious problem for relatives of persons with schizophrenia in rural areas. They usually believe in witchcraft, and accept the notion that mental illness cannot be cured and that medication has no effect on the illness and only wastes family money. Thus, patients cannot usually receive treatment unless they show severely destructive behaviour. Therefore, providing treatment and improving the prognosis of persons with schizophrenia is a crucial problem in rural China. Much evidence suggests that 30–40 % of schizophrenic patients still relapse when on medication (Lam
SPPE 601
Mao-Sheng Ran, M. D., Ph. D. () Department of Social Work and Social Administration and Center of Suicide Research and Prevention The University of Hong Kong Pokfulam Road Hong Kong E-Mail:
[email protected]
■ Key words schizophrenia – community mental health – family – psychoeducation
70
1991). Substantial evidence also indicates that family intervention is a very effective method of improving the illness outcome and decreasing the relapse of the illness (Hogarty et al. 1986; Leff et al. 1990; Klingberg et al. 1999; Chen et al. 2000; Dixon et al. 2000), but there has been little work demonstrating the effectiveness of interventions in rural community settings. The benefits of family intervention and how psychoeducational family intervention in particular influences the prognosis of illness is still not completely clear. The aim of this study is to explore the characteristics and efficacy of a psychoeducational family intervention in a Chinese context. This research, based on a previous pilot study (Xiang et al. 1994), was conducted using larger samples in a Chinese rural community of Xinjin County, Chengdu, China.
management of the illness including relapse prevention and social functioning rehabilitation. 2. Multiple family workshops were held once every 3 months. During the workshop, general questions were discussed, and relatives shared the experiences of caring for patients. 3. Crisis intervention conducted when necessary (e. g. for attempted suicide, aggressive and destructive behaviour). The local village broadcast network was also employed for health education during the first 2 months. Trained psychiatrists and village doctors conducted all these above-family interventions. Village doctors did not get the same training as psychiatrists, but assisted with the interventions.
Subjects and methods
■ Measurement
■ Study subjects The present study is a cluster randomised controlled trial of persons with schizophrenia. First, an epidemiological investigation of schizophrenia was carried out in six townships of Xinle, Huaqiao, Anxi, Taiping, Xinyi and Longma in Xinjin county of Chengdu in October 1994 (Ran et al. 1998). A random numbers table achieved block randomisation using townships as units. Xinle and Huaqiao were randomly selected into the family intervention group (drug treatment plus psychoeducational family intervention), Anxi and Taiping townships into the drug treatment group (drug treatment only), and Xinyi and Longma townships into the control group (no intervention). In the control group, medication was neither encouraged nor discouraged. The samples might go to see the other doctors in local area and then take medication by themselves. Schizophrenia was diagnosed according to ICD-10 (WHO 1992) and Chinese Classification and Diagnostic Criteria of Mental Disorder (CCMD-2-R) (Yang 1989). Patients with schizoaffective psychoses, with comorbid substance, or without relatives were excluded from the study. All the samples included both recent-onset and chronic patients and were followed up for 9 months in the community. ■ Psychoeducational family intervention The psychoeducational family intervention was modified to take account of the characteristics of Chinese rural areas, such as dispersed residences and a generally low level of education. Building on the psychoeducational family approach (Anderson et al. 1986) and the vulnerability-stress model (Lalonde 1995), an interactive psychoeducational family intervention model was developed for this study.A basic premise is that an effective psychoeducational family intervention should accentuate the families’ impact (e. g. belief, attitude) as well as many other aspects of the illness as possible, at all relevant system levels (Ran 2002). The main components of the intervention were as follows: 1. Family education conducted once per month for 9 months. The purpose was to provide specific advice, support and information to the family. During each visit, which lasted 1.5–3 h, patients’ relatives were taught basic knowledge of mental diseases, treatment and rehabilitation. Advice and information were given according to the patient’s specific condition, such as the stage of illness, recent onset or chronic. The patient was encouraged to join the meeting. The major content of the family education component included: a) definitions of a schizophrenic disorder; b) a description of the various symptoms; c) comprehensive basis of the illness; d) general prognosis of the illness; e) treatment recommendations concerning pharmacotherapy; and f) long-term
■ Drug treatment The drug treatment consisted of long-term injection of haloperidol decanoate (50–125 mg/month) and/or an oral depot. There was no significant difference of drug dose between the family intervention group and the drug treatment group.
Outcome measures included medication compliance, the recognition of mental disease, the caring attitude towards the patient, the relapse rate, the patient’s working ability, and the rate of mental disability. Medication compliance was defined as the therapist’s dichotomous rating (based on all available information) of the extent to which the patient takes his/her neuroleptic medication consistently. Relapse was defined as either a change from a normal or no schizophrenic state to a state of schizophrenia defined by PSE-derived criteria, or a marked worsening of schizophrenic symptoms. This is the definition used by Falloon’s group and Leff ’s group. Hence the relapse rates recorded in this study can be directly compared with those in the family intervention trials of these two groups. Mental disability referred to those whose mental illness had lasted for more than one year and had to some extent had an impact on their family and/or social functioning (Ran et al. 1992). Instruments used in this study included medical records, the Present State Examination (PSE–9, Chinese translation), the General Psychiatric Interview Schedule and Summary Form, the Social Disability Screening Schedule (SDSS) (Shen and Wang 1985; Cooper and Sartorius 1996), and the Relatives Investigation Scale and the Relatives’ Beliefs Scale (Ran et al. 2001) determining the relatives’ characteristics and beliefs about mental illness. Fifteen independent researchers, each of whom conducted assessments in all six townships, conducted the assessment. Even though it is very difficult to ensure blindness with psychological treatment, these assessors were blind to the study design and demonstrated good inter-rater reliability on these scales. Holding rater training sessions before each measurement ensured the inter-rater reliability. The mean percentage agreement of all the above instruments on the ratings for ten patients ranged from 80.5 to 99.0%, and Kappa values between pairs of raters ranged from 0.71 to 1.00. Data were recorded at the baseline, as well as at 9-month treatment phases, and Data were entered into the SPSS package for analysis. Nonparametric statistical test (χ2) was used. Otherwise, analysis of variance, ANOVA, Pearson’s correlation coefficient and multiple regression were used.
Results ■ Subjects A total of 357 persons with schizophrenia from the six townships met the inclusion criteria. Among these patients, 31 cases (8.7 %) refused to participate in this study because they had no family caregivers (24 cases, 77.4 %) or were afraid of social discrimination in their
71
local community (7 cases, 22.6 %). Therefore, 326 persons with schizophrenia who completed the full evaluations in Xinjin County were included. All patients meeting the inclusion criteria were assessed using related instruments. Fig. 1 shows the flow of participants through each stage of this cluster randomised trial. Of the remaining 326 persons with schizophrenia who completed the study, the majority were female (60.7 %) (Table 1). One of the reasons for higher female participation was the exclusion of more male patients (15.2 %) because they had no relatives or their relatives did not want to take care of them. Only 3.9 % of female patients were not included in the study (χ2 = 14.2, df = 1, p < 0.001). This also might indicate indirectly that families in this Chinese rural area would be more willing to help female patients. There were 126 cases in the family intervention group, 103 cases in the drug group, and 97 cases in the control group. There were no significant differences of demographics and clinical condition among the three groups before intervention (p > 0.05) (Table 1). Furthermore, there were no significant differences in the socioeconomic level of each household among the three groups. In the family intervention group, 4.8 % were Fig. 1 Study design with details of follow-up
high (higher than the average level), 45.2 % were middle (the average level) and 50 % were low (lower than the average level); in the drug group, 9.7 % were high, 38.8 % were middle and 51.5 % were low; and in the control group, 9.3 % were high, 33 % were middle and 57.7 % were low. This indicated that most patients were from a poor family background. Moreover, there were also no significant differences of demographics for the main carers among the three groups (p > 0.05) (Table 2).
■ The effectiveness of family intervention and drug treatment After 9-month intervention, treatment compliance in the family intervention group was significantly higher than that in the drug treatment and the control groups (p < 0.001). The percentages of irregular/discontinued treatment and never-treated/refused treatment in the drug treatment group were also significantly lower than those in the control group (p < 0.001). The results indicated that treatment compliance could be enhanced by family intervention and/or effective drug treatment.
72 Table 1 Demographic and clinical characteristics of patients before intervention Sex Male Female Mean age Education Illiteracy Primary school Middle school ≥ High school Marriage Unmarried Married Divorce/bereaved Age of onset Duration of illness (year) Witchcraft treatment Clinical status Improvement Severe symptom/deterioration
Intervention group (n = 126)
Drug group (n = 103)
Control group (n = 97)
p
44 (34.9) 82 (65.1) 43.5±14.3
48 (46.6) 55 (53.4) 42.4±14.7
36 (37.1) 61 (62.9) 44.8±13.8
> 0.05 > 0.05*
21 (16.6) 66 (52.4) 34 (27.0) 5 (4.0)
17 (16.5) 56 (54.4) 23 (22.3) 7 (6.8)
19 (19.6) 51 (52.6) 23 (23.7) 4 (4.1)
> 0.05
16 (12.7) 91 (72.2) 19 (15.1) 31.5±11.9 11.6±9.5 75 (59.5)
20 (19.4) 68 (66.0) 15 (14.6) 29.7±11.1 10.6±9.6 58 (56.3)
19 (19.6) 72 (74.2) 6 (6.2) 29.6±11.2 12.3±8.4 57 (58.8)
> 0.05 > 0.05* > 0.05* > 0.05
61 (48.4) 65 (51.6)
47 (45.6) 56 (54.4)
46 (47.4) 51 (52.6)
> 0.05
(%), * ANOVA, all other is χ2 test
■ The impact of family intervention on relatives
Table 2 The characteristics of relatives in three groups
Sex Male Female Mean age Relation Parent Spouse Other Type of family Nuclear Middle Extended Members in the family
Intervention group (n = 126)
Drug group (n = 103)
Control group (n = 97)
p
76 (60.3) 50 (39.7) 47.1±13.2
57 (55.3) 46 (44.7) 45.1±13.1
61 (62.9) 36 (37.1) 49.2±15.3
> 0.05 > 0.05*
37 (29.4) 69 (54.7) 20 (15.9)
31 (30.1) 53 (51.5) 19 (18.4)
29 (29.9) 53 (54.6) 15 (15.5)
> 0.05
76 (60.3) 31 (24.6) 19 (15.1) 3.7±1.2
61 (59.2) 20 (19.4) 22 (21.4) 3.7±1.4
68 (70.1) 12 (12.4) 17 (17.5) 3.6±1.5
> 0.05 > 0.05*
(%), * ANOVA, all other is χ2 test
There was no significant difference of clinical outcome between the family intervention group and the drug treatment group (p > 0.05), while the percentage of full recovery and significant improvement in the above groups was significantly higher than that in the control group (p < 0.05). The relapse rate in the family intervention group was less than half that in the drug treatment group and was significantly lower, while the relapse rate in the drug treatment group was significantly lower than that in the control group (p < 0.05). However, no significant differences in work ability and level of mental disability could be found among these three groups (p > 0.05) (Table 3).
Before intervention, the percentages of insufficient care and maltreatment were 19.8 %, 27.2 % and 24.7 % in the family intervention, drug treatment and control groups, respectively (p > 0.05). The item of ‘insufficient care and maltreatment’ was assessed according to the relative’s attitude and caring situation. After intervention, the percentage of insufficient care and maltreatment in the family intervention group (11.1 %) was significantly lower than that in the drug treatment (26.7 %) and control groups (21.7 %) (p < 0.05). No difference could be found between the drug treatment and control groups (p > 0.05). This indicateds that relatives’ attitudes could be changed through family intervention. Meanwhile, the results of beliefs about mental illness in the family intervention group (93 cases) and the drug treatment group (75 cases) showed that the level of relatives’ knowledge or belief in mental illness was higher in the family intervention group than in the drug treatment group (p < 0.05 or 0.01). This indicated that relatives’ knowledge or belief in mental illness were changed by family intervention. However, there was no significant difference between the two groups in regard to the beliefs that the illness was worth being treated and that relapse could be prevented by decreasing stress (p > 0.05) (Table 4). The item of ‘to repulse the psychotic patient’ means these peasants agree with these statements. To analyse the factors which most influenced clinical outcome, two multiple regression analyses were performed, with clinical outcome as dependent variable (see Table 5). The only variable to independently and consistently explain a significant amount of varying clinical outcome was disability level score, and this was significant for the analysis of clinical outcome before in-
73 Table 3 The effectiveness of patients after intervention (9 months) Treatment compliance Maintained regular treatment Irregular/discontinued treatment Never or refused treatment Clinical status Full recovery Significant improvement Severe symptom/deterioration Relapse rate (%) Ability to work Full-time Part-time No ability Mental disability Mild Moderate Serious Most serious
Intervention group (n = 126)
Drug group (n = 103)
Control group (n = 97)
p
44 (34.9) 79 (62.7) 3 (2.4)
33 (32.0) 42 (40.8) 28 (27.2)
5 (5.2) 44 (45.3) 48 (49.5)
53 (42.1) 40 (31.7) 33 (26.2) 16.3
38 (36.9) 27 (26.2) 38 (36.9) 37.8
22 (22.7) 23 (23.7) 52 (53.6) 61.5
< 0.05 < 0.05
73 (57.9) 41 (32.6) 12 (9.5)
65 (63.1) 30 (29.1) 8 (7.8)
53 (54.6) 29 (29.9) 15 (15.5)
> 0.05
23 (18.3) 10 (7.9) 15 (11.9) 25 (19.8)
17 (16.5) 4 (3.9) 10 (9.7) 21 (20.4)
20 (20.6) 14 (14.4) 9 (9.3) 15 (15.5)
> 0.05
< 0.001
(%), all is χ2 test
tervention and after the 9-month follow-up (R2 = 42 %). The only other significant variables were antipsychotic drug treatment and families’ attitudes towards patients after the 9-month follow-up (R2 = 45 %). Table 4 The change of relatives’ beliefs on illness after intervention
Mental illness is a thought problem Mental illness is caused by ghost This illness can be treated Illness is worth being treated Long-term treatment is necessary Knowing drug side effect Relapse can be prevented by decreasing stress To repulse the psychotic patient
Intervention group (n = 93)
Drug group (n = 75)
p
54 (58.1) 14 (15.0) 81 (87.1) 57 (61.3) 65 (69.9) 48 (51.6) 69 (74.2)
57 (76.0) 26 (34.7) 44 (58.7) 41 (54.7) 40 (53.3) 20 (26.7) 49 (65.3)
< 0.05 < 0.01 < 0.01 > 0.05 < 0.05 < 0.01 > 0.05
48 (51.6)
52 (69.3)
< 0.05
(%), all is χ2 test
Discussion Solving the treatment compliance problem is one of the most important steps when conducting rural community mental health services in China. The results of this study showed that psychoeducational family intervention could improve the level of relatives’ recognition of mental illness, which was consistent with the results of some previous studies (Leff et al. 1990; Barrowclough et al. 1999). In addition, the results showed that family intervention could enhance treatment compliance, which was consistent with the results of our pilot study (Xiang et al. 1994; Ran and Xiang 1995). The favourable compliance might be related to higher improvement rates of psychopathologic symptoms (Klingberg et al. 1999). The reason for the increase in compliance may be: [1] the change in relatives’ beliefs about illness and their attitudes towards the patient; [2] the out-reaching method of going to the patients’ homes – as the psychotic patients in the Chinese rural community reside dispersed-
Table 5 Multiple regression analyses of clinical outcome
Clinical outcome (before intervention)
Clinical outcome (9-month follow-up)
Variable
Coefficient (B)
Significance level
Coefficient (B)
Significance level
Age Age of onset Duration of illness Education level score Family economic level Antipsychotic drug treatment Families’ attitude toward patients Disability level scale
0.13 –0.11 –0.05 –0.03 0.04 0.07 0.01 0.61
0.162 0.20 0.46 0.60 0.35 0.15 0.83 0.0001*
0.07 –0.02 –0.04 –0.02 0.02 0.10 0.11 0.62
0.60 0.86 0.69 0.75 0.69 0.047* 0.014* 0.0001*
* Significant results
74
ly and have different individual problems, they need more specifically tailored intervention methods conducted in their homes; and [3] the simple and effective drug treatment (long-term depot). Some studies (Hogarty et al. 1986; Glick et al. 1991) have demonstrated that the effects of drug therapy and family therapy can be additive. The results of this study also support the notion that psychoeducational family intervention is effective in improving clinical status and preventing schizophrenic relapse after 9 months (Lam 1991; Hahlweg and Wiedemann 1999). The relapse rate in the combined drug and family intervention group is comparable with those achieved by the pioneering studies in western countries. The relapse rate in the drugonly group is slightly lower than those found in most western studies, which may be explained by the fact that many of our patients were not in an acute episode at entry into the study.While the clinical gains resulting from this intervention tend to be modest (Penn and Mueser 1996), they represent an important gain for the families caring for the patients. Why, though, is this study effective in reducing the relapse rate compared with the study by Hogarty and his colleagues (Hogarty et al. 1997)? The first reason may be the great differences between the three groups, such as there being no intervention in the control group. The second reason may be associated with the lower level of knowledge among relatives about mental illness before intervention. For example, before intervention, more than 83.5 % of the relatives had only had primary school education or less, and these relatives had not accepted the knowledge they had previously been taught about mental illness. Thus, for these relatives, it might be one reason that the change of relatives’ beliefs and/or attitudes was great after intervention. The third reason may be associated with the poor treatment conditions before intervention. A lot of patients in these three groups had not accepted regular treatment before intervention, and 22.7 % of them had refused treatment altogether. The fourth reason may be that the model of intervention can offer varying combinations of information about mental illness, practical and emotional support, development of problem-solving skills, and crisis management. This also indicates that the qualitative nature of the intervention should be tailored somewhat for regular versus irregular or no treatment patients. However, it seemed as if the existing family intervention served only to delay rather than to prevent relapse in the long term (Lam 1991; Penn and Mueser 1996; Tarrier et al. 1989). The short-term improvement of clinical status may be better than the long-term prognosis of clinical status. This study could not indicate the longterm effectiveness as there were only 9 months for the follow-up. The efficacy of long-term family intervention should be studied further. How does the psychoeducational family intervention impact the patients’ illnesses? One possible answer is that it may have an impact on relatives’ beliefs and attitudes, enhancing their confidence in the treatment of ill-
ness. This would then influence both relatives’ and patients’ treatment compliance or relatives’ expectations and tolerance of patients; thus, the progression of the illness may be changed. There was evidence indicating that relatives’ causal attribution and expressed emotion might influence the relapse of the schizophrenic illness (Barrowclough et al. 1994; Wearden et al. 2000). Moreover, a different prognosis of illness may still influence relatives’ beliefs about illness and their attitudes towards the patients. However, this study still cannot answer the question of whether ‘contact’ alone, without any particular therapeutic bias, is the critical ingredient for reducing relapse (Lauriello et al. 2000). Although family psychoeducation may improve a patient’s social functioning, either directly or by fostering the development of skills and so delaying disruptive relapse (Tarrier et al. 1989; Falloon and Pederson 1985), the results of this study did not indicate such. The reasons for this may be: 1) as most respondents in this study have a long-term illness, the current short-term family intervention cannot significantly improve their social functioning or level of disability; 2) patients’ relatives are busy working and so have little time to train the patients’ social functioning; and [3] the psychiatrists and village doctors in this study did not provide the necessary amount of education and training to cause significant changes. This also indicates that it is necessary to note how to control the quality of intervention in such a large sample from the community. Although there are studies that have shown that brief family education is effective on some domain of the patient’s illness, the evidence to date tends to caution against the organisation of short education packages without other intervention components (Lam 1991; Dixon et al. 2000). Moreover, individual as-needed consultation models may work better in communities where mental health is less professionalised (Shankar 1994; Susser et al. 1996). Thus, the authors also suggest that specific family intervention should be combined with other rehabilitation packages in conducting community mental health care, and that the highly trained village doctors should be suitable for conducting family intervention in Chinese rural communities. The effectiveness and feasibility of this method should be studied further. ■ Acknowledgements This study was supported by a grant from the China Medical Board of New York, Inc. (CMB, Grant No: 92–557).
References 1. Anderson CM, Reiss DJ, Hogarty GE (1986) Schizophrenia in the family: a practitioner’s guide to psychoeducation and management. Guilford Press, New York 2. Barrowclough C, Johnston M, Tarrier N (1994) Attributions, expressed emotion and patient relapse: an attributional model of relatives’ response to schizophrenic illness. Behaviour Therapy 25:67–88
75 3. Barrowclough C, Tarrier N, Lewis S, et al. (1999) Randomized controlled effectiveness trial of need-based psychosocial intervention services for carers of people with schizophrenia. British Journal of Psychiatry 174:505–511 4. Chen CH, Shen YC, Zhang WX, et al. (1998) Epidemiological survey on schizophrenia in seven areas of China. Chinese Journal of Psychiatry 31 (2):72–74 5. Chen YF, Gong YZ, Jiang XQ, et al. (2000) The influence of psycho-rehabilitation on effects of antipsychotic drug for schizophrenic patients: a 4.5 year follow-up study. Chinese Journal of Psychiatry 33 (3):175–178 6. Cooper JE, Sartorius N (1996) Mental disorders in China: results of the National Epidemiological Survey in 12 areas. Bell and Bain, Thornliebank, Glasgow, pp 1–112 7. Dixon L, Adams C, Lucksted A (2000) Update on family psychoeducation for schizophrenia. Schizophrenia Bulletin 26 (1):5–20 8. Falloon IRH, Pederson J (1985) Family management in the prevention of morbidity of schizophrenia: the adjustment of family unit. British Journal of Psychiatry 147:156–163 9. Glick ID, Clarkin JF, Haas GL, et al. (1991) A randomized clinical trial of inpatient family intervention: VI. Mediating variables and outcome. Fam Proc 30:85–99 10. Hahlweg K, Wiedemann G (1999) Principles and results of family therapy in schizophrenia. Eur Arch Psychiatry Clin Neurosci 249 (Suppl. 4):IV108–IV115 11. Hogarty GE, Anderson CM, Reiss DJ, et al. (1986) Family psychoeducation, social skills training and maintenance chemotherapy in the aftercare treatment of schizophrenia: I. One-year effects of a controlled study on relapse and expressed emotion. Archives of General Psychiatry 43:633–642 12. Hogarty GE, Kornblith SJ, Greenwald D, et al. (1997) Three-year trials of personal therapy among schizophrenic patients living with or independent of family: I. Description of study and effects on relapse rates. American Journal of Psychiatry 154:1504–1513 13. Klingberg S, Buchkremer G, Holle R, et al. (1999) Differential therapy effects of psychoeducational psychotherapy for schizophrenic patients – results of a 2-year follow-up. Eur Arch Psychiatry Clin Neurosci 249:66–72 14. Lalonde P (1995) Individualizing psychiatric rehabilitation in schizophrenia. In: Shriqui CL, Nasrallah HA (eds) Contemporary issues in the treatment of schizophrenia. American Psychiatric Press, Inc, Washington, DC, pp 785–798 15. Lam DH (1991) Psychosocial family intervention in schizophrenia: a review of empirical studies. Psychological Medicine 21:423–441 16. Lauriello J, Bustillo J, Keith SJ (2000) Commentary: Can intensive psychosocial treatments make a difference in a time of atypical antipsychotics and managed care? Schizophrenia Bulletin 26 (1):141–144 17. Leff JP, Berkowitz R, Shavit N, et al. (1990) A trial of family therapy versus a relatives’ group for schizophrenia. Two-year followup. British Journal of Psychiatry 157:571–577
18. Li J, Xiang MZ, Guo LT, et al. (1998) A comparative study of family burden between rural and urban area. West China Medical Journal 13 (1):4–6 19. Penn DL, Mueser KT (1996) Research update on the psychosocial treatment of schizophrenia. Am J Psychiatry 153:607–617 20. Ran MS, Xiang MZ, Jiang CF (1992) An epidemiological survey of mental disability in Sichuan, China. Medical Journal of Chinese Civil Administration 4 (3):123–126 21. Ran MS, Xiang MZ (1995) A study of schizophrenic patients’ treatment compliance in a rural community. Journal of Mental Health 1:85–89 22. Ran MS, Xiang MZ, Li SG, et al. (1998) An epidemiological study of schizophrenia in rural community of Xinjin County. Chinese Journal of Psychiatry 31 (2):123 23. Ran MS, Xiang MZ, Huang MS, et al. (2001) A controlled study of psychoeducational family intervention for relatives of schizophrenics in a Chinese rural community. Chinese Journal of Psychiatry 34 (2):98–101 (in Chinese) 24. Ran MS (2002) Community mental health in China – a randomized controlled trial of psychoeducational family intervention for carers of persons with schizophrenia in a rural area in Chengdu. Unpublished PhD Thesis, The University of Hong Kong 25. Shankar R (1994) Interventions with families of people with schizophrenia in India. New Directions for Mental Health Services 62:79–88 26. Shen YC, Wang CH (1985) A handbook of epidemiological investigation of mental illness. Renmin Health Press, Beijing 27. Susser E, Collins P, Schanzer B, et al. (1996) Can we learn from the care of persons with mental illness in developing countries? American Journal of Public Health 86:926–928 28. Tarrier N, Barrowclough C, Vaughn C, et al. (1989) Community management of schizophrenia: a two-year follow-up of a behavioural intervention with families. British Journal of Psychiatry 154:625–628 29. Wearden AJ, Tarrier N, Barrowclough C, Zastowny TR, Rahill AA (2000) A review of expressed emotion research in health care. Clinical Psychology Review 20:633–666 30. Xiang MZ, Ran MS, Li SG (1994) A controlled evaluation of psychoeducational family intervention in a rural Chinese community. British Journal of Psychiatry 165:544–548 31. Yang DS (1989) Chinese classification and diagnostic criteria of mental disorder and cases. The University of Hunan Press, Changsha, pp 502–578 32. Zhang MY, Yan HQ (1993) Effectiveness of psychoeducation of relatives of schizophrenic patients: a prospective cohort study in five cities of China. International Journal of Mental Health 22 (1):47
