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The effectiveness of family interventions on psychological distress and expressed emotion in family members of individuals diagnosed with first-episode psychosis: a systematic review protocol

Napa, Wilai RN; Tungpunkom, Patraporn RN, PhD; McCann, Terence V RN, PhD

Author Information
JBI Database of Systematic Reviews and Implementation Reports: April 2014 - Volume 12 - Issue 4 - p 3-16
doi: 10.11124/jbisrir-2014-662
  • Free


Inclusion criteria

Types of participants

This review will consider studies that target family members of individuals diagnosed with FEP aged 15-30 years. An individual with FEP is defined as a person who presents for the first time with psychotic features to an emergency department, psychiatric hospital or psychiatric outpatients’ department and is diagnosed according to criteria based on the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders Third Edition Revised (DSM-III-R), the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV), the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV TR), or the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD-10). Studies investigating caregivers or siblings of those with schizophrenia spectrum disorders, including schizophrenia, schizophreniform disorders and undifferentiated schizophrenia, who have experienced symptoms for no more than two years, will also be included. Studies focusing on caregivers or siblings of persons with affective psychosis or affective disorders will be excluded because this group are different in terms of treatment and interventions.

Types of intervention(s)/phenomena of interest

For the purpose of this review, a family intervention is defined as relevant education, psychoeducation, communication and coping skills training, problem-solving skills training and CBT provided to family members who care for a person with FEP. These interventions will be compared with usual care such as receiving medical treatment and advice from clinicians and nurses.

Types of outcomes

The review will consider studies that measure outcomes related to psychological distress and expressed emotion of family caregivers of individuals with FEP. This includes but is not restricted to:

  1. Appraisal and attitudes toward individual with FEP, i.e., self-report, attitude score
  2. Psychological distress, i.e., burden score, emotional distress level, stigma score
  3. Expressed emotion, i.e., expressed emotion score, pattern of expressed emotion

Types of studies

The review will consider randomized controlled trials, quasi-experimental studies, cohort studies and case-control studies of family interventions for caregivers or siblings who care for persons with FEP. The review will include studies conducted in any community and hospital setting, published in English and Thai from 1997 onwards, because family intervention programs were first evaluated in 1997.

Search strategy

A three-step search strategy will be developed for this review:

1) An initial limited search of journals indexed in MEDLINE and CINAHL will be undertaken, followed by an analysis of text words contained in the title, abstract and subject descriptors/ MeSH terms of relevant articles in order to identify additional key words.

2) All identified key words and their synonyms will be used for the extensive search of electronic databases. Individual search strategies will be developed for each database, adopting the different terminology of index thesauri, if applicable. The databases to be searched include ProQuest Dissertations & Theses, ScienceDirect, Scopus, and PsychInfo.

3) Reference lists and bibliographies of retrieved articles will be searched for additional relevant articles. In order to avoid publication bias, hand-searching will also be undertaken in journals not listed on databases but known to contain literature on the topic of investigation to ensure all relevant materials are captured. Reviewers will extract relevant articles from ThaiLIS in Thailand, National Research Council of Thailand database and Journal Link in Thailand union databases For articles published only with an abstract in English that meet the inclusion criteria, the reviewers will contact JBI entities to retrieve the full papers. In the event of any limitations of searching, such as database restrictions, the reviewers will seek collaborative agreements with JBI entities to retrieve the article of interest in order to obtain access to a wider range of databases.

Assessment of methodological quality

Prior to inclusion in the review, retrieved papers will be assessed by two independent reviewers for methodological validity using the standardized JBI critical appraisal instrument for Meta-Analysis Assessment and Review (JBI-MAStARI) (Appendix I). Disagreements between reviewers will be resolved through discussion, or with a third reviewer.

Data collection

Data will be extracted from papers for inclusion in the review using the standard JBI-MAStARI data extraction instrument (Appendix II). The extracted data will include details of interventions, population, study method and outcomes of significance to the review question and specific objectives. All results will be subjected to double data entry. For dichotomous data, the exposure (n) and total sample (N) will be extracted, whereas for continuous data, standard deviation (SD), mean and sample size will be extracted. In the event that some included studies are unclear in terms of population, intervention, and results, one of the reviewers will contact the author(s) to clarify the data.

Data synthesis

Data will be pooled in statistical meta-analysis using JBI-MAStARI. Odds ratios (for categorical data) and weight mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. In the event that statistical pooling is not possible, the findings will be presented in narrative form.

Conflicts of interest

There is no conflict of interest regarding this systematic review.


Our sincere thanks to the Thailand Center for Evidence Based Nursing and Midwifery for providing workshop training for conducting reviews.


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                                                                                                                      Appendix I: Appraisal instruments

                                                                                                                      MAStARI appraisal instrument

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                                                                                                                      Appendix II: Data extraction instruments

                                                                                                                      MAStARI data extraction instrument

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                                                                                                                      English words; family interventions; psychoeducation; education; communication training; coping skills training; problem-solving skills training; cognitive intervention; cognitive behavioral therapy; caregivers; carers; parents; first-episode psychosis; recent onset psychosis; schizophrenia spectrum disorders.; Thai words: poo pen roak jit krung rak; kan doo lae krobkrua; kan doo lae poo doo lae; sook ka parb jit suk sa; karn sue san; kan pa chern pun ha; kan bum bud tang kwaumkid; kan bum bud tang kra buan kwaumkid lae prued ti kum

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