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Schizophrenia Bulletin Advance Access originally published online on July 14, 2006
Schizophrenia Bulletin 2006 32(4):765-775; doi:10.1093/schbul/sbl006
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© The Author 2006. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oxfordjournals.org.

Psychoeducation in Schizophrenia—Results of a Survey of All Psychiatric Institutions in Germany, Austria, and Switzerland

Christine Rummel-Kluge1, Gabriele Pitschel-Walz, Josef Bäuml and Werner Kissling
Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar der Technischen Universität München, Möhlstrasse 26, 81675 München, Germany


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Appendix. Example Question
 References
 
Introduction: Psychoeducation can reduce rehospitalization rates and mental health costs in schizophrenia. The aims of this study were to investigate the percentage of patients and family members participating in psychoeducation in the year 2003 and to evaluate how psychoeducation was conducted. Methods: Part I of a 2-part postal survey was sent to the heads of all psychiatric institutions in Germany, Austria, and Switzerland; part II was sent directly to the moderators of psychoeducational groups. Responses were analyzed using descriptive statistics. Results: Psychoeducation was offered in 86% of the responding institutions and in 84% of these for schizophrenia (response quotas: part I, 54%; part II, 55%). A mean of 21% of the patients with schizophrenia and 2% of their family members had taken part in psychoeducation in the responding institutions in the year 2003. Discussion: Many readmissions and thus significant costs to the health system and substantial human suffering could be avoided if more patients and their family members participated in psychoeducation. New approaches to offering more psychoeducation would consist in integration of the entire psychiatric team into psychoeducation and peer-to-peer strategies.

Keywords: psychoeducation / schizophrenia / survey


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Appendix. Example Question
 References
 
Rehospitalization rates within the first year of patients with schizophrenia on oral antipsychotic medication average 42%.1 More than 50% of these rehospitalizations may be attributable to noncompliance with antipsychotics.2 Noncompliance can be related to subjective attitudes concerning the illness and the medication, the stigma of taking medication, or adverse drug reactions.3 One strategy for enhancing compliance with antipsychotics is psychoeducation.4

Psychoeducation is defined as systematic, structured, didactic information on the illness and its treatment and which includes integrating emotional aspects in order to enable the participants—patients as well as family members—to cope with the illness.5–7 Modern treatment guidelines recommend education about schizophrenia as part of the treatment.8 Psychoeducation for patients with schizophrenia improves the understanding of mental illness, increases the quality of life, and can reduce relapse rates.9–11 Family psychoeducation as well has become a strongly supported evidence-based practice in the treatment of schizophrenia.12–14 Psychoeducation in families of patients with schizophrenia can reduce the relapse rates of these patients ,15,16 positively influence the course of the patient's illness,17 and help the families and patients to better cope with the mental illness.18–22

So far, however, publications assessing to what extent psychoeducation is actually provided for patients with schizophrenia and their families are lacking. Therefore, a postal survey of the distribution, frequency, type of psychoeducation, and the percentage of participants was conducted which addressed all psychiatric departments in Germany, Austria, and Switzerland. This article focuses on the findings on psychoeducation in schizophrenia.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Appendix. Example Question
 References
 
Questionnaire Design and Definition of Psychoeducation
A 2-part questionnaire was designed and piloted within the German expert group "Psychoeducational interventions for schizophrenic disorders." This expert group was founded in Hamburg, Germany, in 19965 with the aim of arriving at a consensus about psychoeducational concepts, developing implementation strategies, and planning further studies on psychoeducation. Regular meetings have been held twice a year since 1996. Participants in the group are local teams who are engaged in psychoeducation research and are experienced in conducting psychoeducational interventions for patients with schizophrenia and their families.

A small survey on the implementation of psychoeducational groups in Southern Germany had been performed in 1995 by our local team.23 Those questions which had proved to be of importance were then considered for this survey. In addition, we generated further items via brainstorming as we were not able to identify a similar comparable survey in the literature. The questionnaires for this survey consisted of multiple-choice questions with room for adding one's own possible answers, purely multiple-choice questions, and some open-ended questions. A sample question is shown in the Appendix. The full questionnaires are available upon request from the first author.

The definition of psychoeducation supplied in the cover letters was that of our expert group, namely: "Psychoeducation is defined as systematic, structured, didactic information on the illness and its treatment, and which includes integrating emotional aspects in order to enable the participants to cope with the illness."5 In addition, following this definition, we explicitly excluded several interventions which might have been mistaken by the respondents for psychoeducation: "Pure psychotherapeutic groups are not considered psychoeducation; similarly inpatient groups where everyday routine activities are discussed, concentration groups, muscle relaxation groups or newspaper groups are not what this survey is concerned about; routine information dialogues between patients or family members and the treating physician or psychologist are also not considered psychoeducation."

In the survey question about the conduction of psychoeducational groups, we referred to the definition in the cover letter (see the example question in the Appendix).

Part I of the questionnaire was constructed as a self-completion/self-report questionnaire addressing the head of a psychiatric department in order to determine

  • whether psychoeducation had taken place in this institution in the year 2003,
  • for which diagnoses psychoeducation had been conducted,
  • contact persons for psychoeducation in specific diagnoses,
  • reasons for not offering psychoeducation and
  • the characteristics of the institution.

Part II of the questionnaire was constructed as a self-completion/self-report questionnaire with 23 questions for specific diagnoses. These questions sought to obtain specific information directly from those who were conducting psychoeducational groups in 2003 for the purpose of

  • determining the percentage of patients and family members having received psychoeducation in 2003 and
  • assessing how psychoeducation was conducted for specific diagnoses.

Survey Method
A 2-part postal survey was conducted between December 2003 and July 2004. Part I, consisting of a 2-page postal questionnaire and a cover letter, was sent to the heads of the departments of all psychiatric hospitals and departments in Germany, Austria, and Switzerland (N = 622). The mailing list used was obtained from the "German hospital association" (Deutsche Krankenhaus Gesellschaft). The addressed physicians were requested to return the 2-page questionnaire by fax. The questionnaire was again sent with a reminder letter to all nonresponders after 2 months.24

Part II, a more detailed questionnaire, was sent directly to those named by the respondents of part I as being responsible for conducting psychoeducational groups in the specific diagnosis.

In both parts, respondents were asked to state their name, profession, address, and telephone number in order to facilitate contacting them in case of missing or unclear data in their responses as anonymity has not shown consistent effects on the quality or rate of response.24

A random sample of 10% of the nonresponding survey population of part I was selected 4 months after the reminder letter for a telephone reminder in order to evaluate whether the nonresponding institutions were those which did not conduct psychoeducation.

Responses were analyzed using descriptive statistics. All calculations were done with SPSS for Windows, version 12.0.1.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Appendix. Example Question
 References
 
Replies to Questionnaire Part I
In all, 337 of the 622 part I questionnaires (response quota 54%) were returned after the initial letter or a reminder letter and the telephone reminder: 291 of the 507 (57%) in Germany, 23 of the 57 (40%) in Austria, and 23 of the 58 (40%) in Switzerland. Of those who were chosen at random for a telephone reminder, 29% did not reply to the questionnaire due to organizational reasons (not a psychiatric hospital; more than one contact person in the database, another had already answered), 43% did not answer and gave no reason, and 29% answered. All of these "late responders" reported conducting psychoeducation in their institutions.

Eighty-six percent (86%) of all respondents stated that psychoeducation as defined in the cover letter had generally been conducted in their institution in the year 2003—in particular, 88% of the German, 65% of the Austrian, and 70% of the Swiss respondents, showing statistically significant differences between Germany and Austria (Fisher's exact test P = .006) and between Germany and Switzerland (Fisher's exact test P = .019).

Of those who were conducting psychoeducation, 84% did so in schizophrenia—in particular, 84% of the German, 80% of the Austrian, and 88% of the Swiss institutions, with no statistically significant differences among the 3 countries (Fisher's exact tests: Germany-Austria P = .714, Germany-Switzerland P = 1.0, Austria-Switzerland P = .654).

On the whole, the importance of psychoeducation in general for patients in their institution was rated as "none" by 2%, "low" by 13%, "high" by 54%, and "very high" by 32% of the respondents; the importance of psychoeducation in general for family members was rated as "none" by 8%, "low" by 35%, "high" by 43%, and "very high" by 15% of the respondents.

Fourteen percent of the respondents stated that psychoeducation had not been conducted at all in their institution in 2003; the reasons for this are shown in table 1. When respondents who did not offer psychoeducation were asked what was necessary for starting to offer psychoeducational groups, the most frequent reply was "additional staff"; details are presented in table 2.


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  		Table 1 Reasons for Not Conducting Psychoeducational Groups (in %)a

 

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  		Table 2 Basic Conditions for Initiating Psychoeducational Groups (in %)a

 
Replies to Questionnaire Part II
In all, 131 of the 239 detailed part II questionnaires (response quota 55%) sent to those responsible for conducting psychoeducation in schizophrenia were returned: 118 of the 213 (55%) in Germany, 7 of the 12 (58%) in Austria, and 6 of the 14 (43%) in Switzerland. Altogether, most of the respondents were psychologists (37%), consultants (30%), or psychiatry residents (16%) and worked in a psychiatric department of a general hospital (37%), a psychiatric state hospital (34%), another psychiatric hospital (15%), or a university hospital (9%). Of the responding institutions offering psychoeducation, 33% offered psychoeducation for patients with schizophrenia and their family members (31% offered parallel groups for patients and relatives, 2% offered psychoeducation for patients and relatives in the same group), 1% offered groups for relatives only, and 66% offered psychoeducation for patients only.

Percentage of Psychoeducation for Patients With Schizophrenia in 2003
A mean of 41% of the patients (median 33%) had taken part in psychoeducation for schizophrenia in the year 2003 in the institutions which conducted psychoeducation for patients and replied to the questions about the number of treated patients with schizophrenia and the number of participants in psychoeducation (n = 100; 31 respondents did not supply these numbers). If those responding institutions who did not offer psychoeducation in schizophrenia according to part I (n = 94) are added to the basis of the above calculation, a mean of 21% of patients with schizophrenia took part in psychoeducation in 2003. Details are shown in table 3 and figure 1.


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  		Table 3 Participation of Patients With Schizophrenia in Psychoeducation in 2003

 

Figure 1
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  		Fig. 1 Percentages of patients with schizophrenia participating in psychoeducation in the responding institutions.

 
Percentage of Psychoeducation for Family Members in 2003
A mean of 13% (median 8%) of the family members of inpatients with schizophrenia (assuming one family member per patient) had participated in psychoeducation for schizophrenia in the year 2003 in those institutions which conducted psychoeducation for family members and replied to the questions about the number of treated patients with schizophrenia and the number of participants in family psychoeducation (n = 36).

If those responding institutions who did not offer psychoeducation in schizophrenia according to part I (n = 94) and those responding institutions who did not offer family psychoeducation in schizophrenia according to part II (n = 87) are added to the basis of the above calculation, the percentage decreases from 13% to only 2%. Details are shown in table 4 and figure 2.


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  		Table 4 Participation of Family Members in Psychoeducation in Schizophrenia in 2003

 

Figure 2
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  		Fig. 2 Percentages of family members participating in psychoeducation in schizophrenia in the responding institutions.

 
The following results refer only to those psychiatric institutions which replied to Parts I and II of the questionnaires.

Conducting Psychoeducation in Schizophrenia
Forty-nine percent (49%) of the responding institutions included only patients with schizophrenia in the groups. Of the remaining 51%, 64% additionally included patients with other psychotic disorders (ICD-10 F2-diagnoses), 23% with other psychotic and mood disorders (F2 + F3 diagnoses), 8% with other psychotic and mental and behavioral disorders due to psychoactive substance use (F2 + F1), and 5% with further diagnoses.

Sixty-five percent (65%) were conducting psychoeducation with participants from more than one ward, 32% only for single wards, and in 3% of the cases psychoeducation was offered outside of the institution. Sixty-four percent used published manuals for psychoeducation25–29 and 36% had their own scheme or did not use published manuals. Ninety percent (90%) of the respondents used prepared informational material, 53% transparencies, 50% prepared flip charts, 38% handouts, 25% films, and 25% workbooks. Twenty-eight percent (28%) offered one-to-one psychoeducational sessions for individual patients (eg, for first-episode patients, for patients who were not suitable for group psychoeducation, or if no group psychoeducation took place at that time).

Seventy-five percent (75%) considered psychoeducation to be part of the usual therapy program. Twenty-one percent (21%) advertised their patients' groups by "word of mouth," 18% through posters, 11% through outpatient practitioners, and 5% through consumer organizations.

The respondents were also asked how they publicized their family groups; due to multiple answering possibilities, results add up to more than 100%. In 84% of the institutions, family members were directly invited to participate in the groups, in 60% indirectly through the patients. Forty-seven percent announced their family groups through posters, 21% through self-help organizations, 21% through outpatient practitioners, 19% through advertisements, and 2% via the Internet.

Structure of Psychoeducation
Detailed information on the structure of psychoeducational groups and their moderators is given in tables 5, 6, and 7. Table 8 provides information on the informational topics and table 9 on emotional topics addressed in the groups. In addition to those topics shown in table 9, "anxiety in general," "emotional acceptance of schizophrenia," and "partnership/sexuality/longing to have children" were the self-reported emotional topics that were discussed in the groups.


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  		Table 5 Structure of Psychoeducational Groups for Patients With Schizophrenia (in %)a

 

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  		Table 6 Structure of Psychoeducational Groups for Family Members of Patients with Schizophrenia (in %)a

 

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  		Table 7 Moderators of Psychoeducation (in %)a

 

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  		Table 8 Frequency of Informational Topics Discussed in Psychoeducation in All 3 Countries; The Categories "Very Much" and "Much" Out of 4 Possible Categories ("very much," "much," "some," and "none") Were Added and Ranked According to Their Frequency (n varies from 119 to 131 due to missing data)

 

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  		Table 9 Frequency of Emotional Topics Discussed During Psychoeducation in the 3 Countries (N = 130)

 
Dropouts From Psychoeducational Groups
A mean of 25% of patients with schizophrenia receiving psychoeducation dropped out before the end of the group sessions. Reasons included discharge (with or against medical advice) in 63%, worsening of psychotic symptoms in 52%, and lack of motivation of patients in 25%.

In the family members' groups a mean of 15% dropped out. Reasons included lack of time, lack of interest, reluctance by the relative to accept the diagnosis of schizophrenia, and discharge of the patient.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Appendix. Example Question
 References
 
Psychoeducation was offered in 86% of the responding institutions and in 84% of these for schizophrenia. In general, statistically significantly more psychoeducation was conducted in Germany than in Austria and Switzerland. A possible reason for this might be that the above-mentioned German expert group on psychoeducation had made efforts in implementing psychoeducation in Germany since their foundation in 1996. However, no statistically significant differences in conducting psychoeducation for schizophrenia were found among the 3 countries, showing that if psychoeducation is done at all it is most probably done in schizophrenia.

Most of the responding institutions appear to be conducting psychoeducation according to the published recommendations, eg, regarding informational and emotional contents, moderators, participants, duration, or frequency of sessions. These recommendations were defined in a consensus paper by the above-mentioned German expert group.5 There were no substantial differences between the 3 countries: typically, in patients' groups, up to 10 participants met once a week for 50–60 min for 8–12 sessions, moderated by 2 moderators; family psychoeducation was conducted every 2 weeks for 6–15 participants for a mean duration of 87 min with a mean number of 7 sessions per group. The main informational topics were warning signs, pharmacotherapy, vulnerability-stress model, contingency plan, and relapse prevention; emotional topics frequently dealt with were stigmatization, isolation, and feelings of guilt and shame. Interestingly, whereas almost all respondents stated they were focusing on pharmacotherapy (93%), side effects (87%), and the vulnerability-stress model (93%), psychotherapeutic offerings were mentioned by only 47%. In addition, only 56% of the respondents reported frequently working with the topic "neurotransmitter system" and only 34% with the "dopamine hypothesis."

Our main finding, however, is that only 21% of the patients with schizophrenia and only 2% of their family members in all the responding institutions participated in psychoeducation in 2003. And even in the institutions which conducted psychoeducation, only 41% of the patients and 13% of the family members received psychoeducation. The respondents supplied the numbers of all treated patients with schizophrenia in their institutions and the numbers of all patients and family members having taken part in psychoeducation in that year. These numbers were based on hospital statistics and attendance lists as well as on estimates.

This brings up the first limitation of this study: the data evaluated in this survey are based upon the specifications and estimates of the respondents. The survey was done nonanonymously in order to be able to call up the respondent in the event of unclear responses and to limit the incorrect specification of numbers. The specifications concerning the conducting of, the structure of, or the topics of psychoeducation were to a great extent those one might expect in usual psychoeducation in schizophrenia. Specifications of the numbers concerning participation in psychoeducation may therefore be regarded as reliable as well, even though the endeavor to answer according to social desirability might have increased the above-mentioned numbers. The percentages obtained from them must therefore be regarded as an approximation, rather an upper limit for clinical reality.

However, the more detailed and specific part II of the questionnaire was answered by those who were actively conducting psychoeducation, primarily psychologists and physicians, whereas part I was answered mainly by the addressed heads of the departments.

Secondly, not all institutions replied, and it remains unclear how much psychoeducation in schizophrenia is being conducted in the nonreplying institutions. This lack may have caused a bias of the results, most probably an overestimation of the actual amount of psychoeducation given to patients with schizophrenia. Reporting positive results more often than negative ones is well known in the medical literature.30 Nevertheless, our findings provide a useful scope. In the PORT (Schizopnrenia Patient Outcomes Research Team) client survey, Dixon et al.31 showed similar results on psychoeducation for family members of patients with schizophrenia in 1999 in the United States of America: only 8% of the patients reported that their families had attended an educational or support program.

The response quota of 54% in part I and 55% in part II were comparable to or even greater than those of similar surveys of physicians.32–35

Should we try to integrate more patients into psychoeducational approaches? In a randomized controlled multicentre study (PIP-study) comparing a short-term psychoeducational intervention with routine treatment, patients in the intervention group were hospitalized in the following year for only 17 days compared with 30 days in the control group.11 Based on this study and data from the federal health monitoring system on hospitalization days of patients with schizophrenia in Germany in the year 1999, we did a model calculation: if it were possible to triple the number of patients receiving psychoeducation in schizophrenia from currently about 20% to 60%, it would be possible to save 13 hospital days each for about 48 000 patients, adding up to over 600 000 hospital days. Thus, at the rate of 250 Euros per hospital day, over 150 million Euros in direct costs could be saved in Germany alone by offering more patients a psychoeducational program.36

What can be done to achieve such an increase? As our survey shows, most of the moderators of psychoeducational groups are psychologists and physicians (table 5). "Additional staff" for the initiation of psychoeducational groups was considered necessary in those institutions which did not offer psychoeducation. It therefore appears necessary to integrate more moderators into psychoeducation than there are today. On the one hand, this can be done by integrating the entire psychiatric team, ie, physicians, psychologists, and especially the nursing staff, social workers, and ergotherapists into psychoeducation.29,37–39 A new approach to improving the availability of moderators for psychoeducation is the "peer-to-peer concept," in which recovered patients who are personally experienced with schizophrenia or their family members are trained to become group moderators themselves.40–43

Another way of reaching more patients with psychoeducation might be an adjustment of the frequency of the sessions. Most institutions offered one psychoeducational session per week for patients, but because the time that patients with schizophrenia spend in the hospital is constantly decreasing, conducting 2 sessions per week might allow more patients to participate and also limit the number of dropouts due to discharge.

On consideration of the evidence base for family psychoeducation in schizophrenia,12–16 our survey reveals that there still exists an enormous gap between scientific findings and clinical reality. "Detailed information on diagnosis," "advice on how to handle specific problems," and "help in regaining structure and routine" are among the topics where the lowest satisfaction scores in the current system were found in a survey of families of first-episode psychotic patients in 5 European family associations.44 Similar dissatisfaction with information received about the treatment, the disorder, and the services provided was found in a study on patients’ and relatives’ satisfaction with psychiatric services.45 This again emphasizes the need for structured information programs.

A number of different reasons might contribute to the current lack of family psychoeducation: family groups should take place in the evenings to allow working family members to participate, thus implying additional—often unpaid—work for professionals after their regular working hours. On the other hand, some family members are reluctant to take advantage of such offers.46–48 Therefore, therapists have to motivate and invite all family members consistently to attend psychoeducational groups. The therapist should take into consideration that many family members hesitate to come in contact with psychiatric institutions. But integrating family members of patients with schizophrenia into psychoeducational groups or family interventions reduces rehospitalization rates within 2 years by 20%,11 and thus, significant costs to the health system and substantial suffering of people with schizophrenia and their families could thereby be avoided. Considering this possible reduction of costs and human suffering, psychoeducation needs to be adequately paid for. Health insurance companies and hospitals need to find ways for coverage of the costs of these interventions.

As psychoeducation is conducted for only about one fifth of all hospitalized patients with schizophrenia and only for one family member of every 50th patient, it is still essential to attempt to offer psychoeducation for more patients with schizophrenia and their families than is the case today. Every patient with schizophrenia and his/her family members must be offered the possibility of attending psychoeducation in order to obtain information about schizophrenia, to receive support with coping strategies, and thus to be empowered for competent decision making concerning relapse prevention with antipsychotic medication. If this were accomplished, many readmissions, the resultant costs, and significant human suffering could be avoided.


   Appendix. Example Question
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix. Example Question
References
 
Formula


  Footnotes
 
1To whom correspondence should be addressed; tel: +49-89-4140-6676, fax: +49-89-4140-6688, e-mail: christine.rummel{at}lrz.tum.de.


   Acknowledgments
 
We wish to thank all respondents for their participation in this survey.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix. Example Question
 References
 

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