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:
- Appraisal and attitudes toward individual with FEP, i.e., self-report, attitude score
- Psychological distress, i.e., burden score, emotional distress level, stigma score
- 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.
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 databaseshttp://www.journallink.or.th/. 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 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 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.
1. McGorry PD, Yung AR, Phillips LJ, Yuen HP, Francey S, Cosgrave EM, et al. Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis
in a clinical sample with subthreshold symptoms. Arch Gen Psychiatry. 2002. 59:921-8.
2. McWilliams S, Egan, D, Jackson, D, Renwick, L, Foley, S, Behan, C, et al. Caregiver psychoeducation for first-episode psychosis
. Eur Psychiatry. 2010. 25:33-8.
3. Weiden PJ, Buckley PF, Grody M. Understanding and treating first-episode schizophrenia. Psychiatr Clin North Am. 2007. 30:481-510.
4. Chiliza B, Oosthuizen P, Emsley R. First-episode psychosis
: an update. SAJP. 2008. 14(1):14-9.
5. Subramaniam M, Pek E, Verma S, Chan YH, Chong SA. Diagnostic stability 2 years after treatment initiation in the Early Psychosis Intervention Programme in Singapore. Aust N Z J Psychiatry. 2008. 41:495-500.
6. Mullen A, Murray L, Happell B. Multiple family group interventions in first episode psychosis: enhancing knowledge and understanding. Int J Ment Health Nurs. 2002. 11:225-32.
7. Etheridge K, Yarrow L, Peet M. Pathway to care in first episode psychosis. J Psychiatr Ment Health Nurs. 2004. 11:125-8.
8. Compton M, Esterberg M, Druss B, Walker E, Kaslow N. A descriptive study of pathways to care among hospitalized urban African American first-episode schizophrenia-spectrum patients. Soc Psychiatry Psychiatr Epidemiol. 2006. 41:566-73.
9. Proctor SE, Mitford E, Paxton R. First episode psychosis: a novel methodology reveals higher than expected incidence; a reality-based population profile in Northumberland, UK. J Eval Clin Pract. 2004. 10(4):539-47.
10. Amminger GP, Harris MG, Conus P, Lambert M, Elkins KS, Yuen HP, et al. Treated incidences of first-episode psychosis
in the catchment area of EPPIC between 1997 and 2000. Acta Psychiatr Scand. 2006. 114:337-45.
11. Coid, JW, Kirkbride, JB, Barker, D, Cowden, F, Stamps, R, Yang, M, et al. Raised incidence rates of all psychoses among migrant group. Arch Gen Psychiatry. 2008. 65(11):1250-8.
12. Kirkbride, JB, Barker, D, Cowden, F, Stamps, R, Yang, M, Jones, PB, et al. Psychoses, ethnicity and socio-economic status. Br J Psychiatry. 2008. 193:18-24.
13. Garety P, Jolley S. Early intervention in psychosis. The Psychiatrist. 2000. 24:321-3.
14. Malla, A, Norman, R, Schmitz, N, Manchanda, R, Bechard-Evans, L, Takhar, J, et al. Predictors of rate and time to remission in first-episode psychosis
: a two-year outcome study. Psychol Med. 2006. 36:649-58.
15. Lenior ME, Dingemans PMAJ, Linszen DH, Haan LD, Schene AH. Social functioning and the course of early-onset schizophrenia: five-year follow-up of a psychosocial intervention. Br J Psychiatry. 2004. 179:53-8.
16. Röpcke B, Eggers C. Early-onset schizophrenia: a 15-year follow-up. Eur Child Adolesc Psychiatry. 2005. 14:341-50.
17. Milev P, Ho BC, Arndt S, Andreasen NC. Predictive values of neurocognition and negative symptoms on functional outcome in schizophrenia: a longitudinal first-episode study with 7-year follow-up. Am J Psychiatry. 2005. 162:495-506.
18. Macdonald E, Sauer K, Howie L, Albiston D. What happens to social relationships in early psychosis? a phenomenological study of young people's experiences. Journal of Mental Health. 2005. 14(2):129-34.
19. Penn D, Waldheter EJ, Perkins DO, Mueser KT, Lieberman JA. Psychosocial treatment for first-episode psychosis
: a research update. Am J Psychiatry. 2005. 162:2220-32.
20. Power PJR, Bell RJ, Herrman-Doig T, Davern M, Henry L, McGorry PD. Suicide prevention in first episode psychosis: the development of a randomized controlled trial of cognitive therapy for acutely suicidal patient with early psychosis. Aust N Z J Psychiatry. 2003. 37:414-20.
21. Crumlish N, Whitty P, Kamali M, Clarke M, Browne S, McTigue O, et al. Early insight predicts depression and attempted suicide after 4 years in first-episode schizophrenia and schizophreniform disorder. Acta Psychiatr Scand. 2005. 112:449-55.
22. Robinson J, Cotton S, Conus P, Schimmelmann G, McGorry P, Lambert M. Prevalence and predictors of suicide attempt in an incidence cohort of 661 young people with first-episode psychosis
. Aust N Z J Psychiatry. 2009. 43:149-57.
23. Large M, Andrews D, Babidge N, Hume F, Nielssen O. Self-inflicted eye injuries in first-episode and previously treated psychosis. Aust N Z J Psychiatry. 2008. 42:183-91.
24. Large M, Babidge N, Andrews D, Storey D, Neilssen O. Major self-mutilation in the first episode of psychosis. Schizophr Bull. 2009. 35(5):1011-21.
25. Harris AWF, Large MM, Redoblado-Hodge A, Neilssen O, Anderson J, Brennan J. Clinical and cognitive associations with aggression in the first episode of psychosis. Aust N Z J Psychiatry. 2010. 44:85-93.
26. Neilssen O, Large M. Rates of homicide during the first episode of psychosis and after treatment: a systematic review and meta-analysis. Schizophr Bull. 2010. 36(4):702-12.
27. Addington J, Addington D. Pattern S. Predictors and impact of substance use in early psychosis: a longitudinal study. Acta Psychiatr Scand. 2007. 115:304-9.
28. Addington J, Collins A, McCleery A, Addington D. The role of family work in early psychosis. Schizophr Res. 2005. 79(1):77-83.
29. Tennakoon L, Fannon D, Doku V, O'Ceallaigh S, Soni W, Santamaria M, et al. Experience of caregiving: relatives of people experiencing a first episode of psychosis. Br J Psychiatry. 2000. 177:529-33.
30. Mo FYM, Chung WS, Wong SW, Chun DYY, Wong KS, Chan SSM. Experience of Caregiving in Caregivers
of Patients with First-episode Psychosis
. East Asian Archives of Psychiatry. 2008. 18(3):101-6.
31. Reed SI. First-episode psychosis
: a literature review. Int J Ment Health Nurs. 2008. 17:85-91.
32. Penny E, Newton E, Larkin M. Whispering on the water: British Pakistani families’ experiences of support from an early intervention service for first-episode psychosis
. Journal of Cross-Cultural Psychology. 2009. 40(6):969-87.
33. McCann TV, Lubman DI, Clark E. First-time primary caregivers
’ experience of caring for young adults with first-episode psychosis
. Schizophr Bull. 2011 Mar. 37(2):381-8.
34. Sin J, Moone N, Harris P. Siblings of individuals with first-episode psychosis
: understanding their experiences and needs. J Psychosoc NursMent Health Serv. 2008. 46(6):33-40.
35. Sin J, Moone N, Wellman N. Developing services for carers
of young adults with early-onset psychosis-listening to their experiences and needs. J Psychiatr Ment Health Nurs. 2005. 12:589-97.
36. Corcoran C, Gerson R, Sills-Shahar R, Nickou C, McGlashan T, Malaspina D, et al.Trajectory to first episode of psychosis: a qualitative research study with families. Early Intervention in Psychiatry. 2007. 1:308-15.
37. Cotton SM, McCann TV, Gleeson JF, Crisp K, Murphy BP, Lubman DI. Coping strategies in carers
of young people with a first episode of psychosis. Schizophr Res. 2013. 146(1):118-24.
38. Gerson R, Davidson L, Booty A, Wong C, McGlashan T. Families’ experience with seeking treatment for recent-onset psychosis. Psychiatr Serv. 2009. 60(6):812-6.
39. Bergner E, Leiner AS, Carter T, Franz L, Thompson NJ, Compton MT. The period of untreated psychosis before treatment initiation: a qualitative study of family members’ perspectives. Compr Psychiatry. 2008. 49(6):530-6.
40. Wong C, Davidson L, Anglin D. Stigma in families of individuals in early stages of psychotic illness: family stigma and early psychosis. Early Intervention in Psychiatry. 2009. 3:108-15.
41. McCann TV, Lubman DI, Clark E. Responding to stigma: first-time caregivers
of young people with first-episode psychosis
. Psychiatr Serv. 2011. 62(5):548-50.
42. Birchwood M, Fiorillo A. The critical period for early intervention. Psychiatric Rehabilitation Skills. 2000. 4(2):182-98.
43. Addington J, Addington D, Jones BT K. Family intervention in an early psychosis program. Psychiatric Rehabilitation Skills. 2001. 5(2):272-86.
44. Gleeson JF, Cotton SM, Alvarez-Jimenez M, Wade D, Crisp K, Newman B, et al. Family outcomes from a randomized control trial of relapse prevention therapy in first-episode psychosis
. J Clin Psychiatry. 2010 Apr. 71(4):475-83.
45. Lenior ME, Dingemans PMAJ, Linszen DH, Haan LD, Schene AH. Social functioning and the course of early-onset schizophrenia: five-year follow-up of a psychosocial intervention. Br J Psychiatry. 2001. 179:53-8.
46. Breitborde NJ, Moreno FA, Mai-Dixon N, Peterson R, Durst L, Bernstein B, et al. Multifamily group psychoeducation and cognitive remediation for first-episode psychosis
: a randomized controlled trial. BMC Psychiatry. 2011. 11(9):1-7.
47. Addington J, McCleery A, Addington D. Three-year outcome of family work in an early psychosis program. Schizophr Res. 2005. 79(1):107-16.
48. Jeppensen P, Petersen L, Thorup, A, Abel MB, Oehlenschlaeger, J, Christensen, R, et al. Integrated treatment of first-episode psychosis
: effect of treatment on family burden: OPUS trail. Br J Psychiatry. 2005. 187(suppl.48):s85-s90.
49. Calbral RRF, Chaves AC. Multi-Family group intervention in a program for patients with first-episode psychosis
: a Brazilian experience. Int J Soc Psychiatry. 2010. 56(5):527-32.
50. González-Blanch C, Martín-Mu-oz V, Pardo-García G, Martínez-García O, Alvarez-Jiménez M, Rodríguez-Sánchez JM, et al. Effects of family psychoeducation on expressed emotion and burden of care in first-episode psychosis
: a prospective observational study. Span J Psychol. 2010 May. 13(1):389-95.
51. Pickett-Schenk S, Cook JA, Steigman P, Lippincott F, Bennette C, Grey, D. Psychological well-being and relationship outcomes in a randomized study of family-led education. Arch Gen Psychiatry. 2006. 63:1043-50.
52. Nugter A, Dingemans P, Van der Does JW, Linszen D, Gersons B. Family treatment, expressed emotion and relapse in recent onset schizophrenia. Psychiatry Res. 1997. 72:23-31.
53. So HW, Chen EYH, Chan RCK, Wong CW, Hung SF, Chung, DWS, et al. Efficacy of a brief intervention for carers
of people with first-episode psychosis
: a waiting list controlled study. Hong Kong Journal of Psychiatry. 2006. 16(3):92-100.
54. O'Brien MP, Zinberg JL, Ho L, Rudd A, Kopelowicz A, Daley M, et al. Family problem solving interactions and 6-month symptomatic and functional outcomes in youth at ultra-high risk for psychosis and with recent onset psychotic symptoms: a longitudinal study. Schizophr Res. 2009. 107:198-205.
55. Otero S, Moreno-Iniguez M, Payá B, Castro-Fornieles J, Gonzalez-Pinto A, Baeza I, et al. Twelve-month follow-up family communication and psychopathology in children and adolescents with a first psychotic episode (CAFEPS study). Psychiatry Res. 2011. 185:72-7.
56. Lowenstein JA, Butler DW, Ashcroft K. The efficacy of a cognitively orientated carers
group in an early intervention in psychosis service-a pilot study. J Psychiatr Ment Health Nurs. 2010 Sep. 17(7):628-35.
57. McCann TV, Lubman DI, Cotton SM, Murphy B, Crisp K, Catania L, et al. A randomized controlled trial of bibliotherapy for carers
of young people with first-episode psychosis
. Schizophr Bull. 2013. 39(6):1307-17.
58. Bird V, Premkumar P, Kendall T, Whittington C, Mitchell J, Kuipers E. Early intervention services, cognitive-behavioral therapy and family intervention in early psychosis: systematic review. Br J Psychiatry. 2010. 197:350-6.
Appendix I: Appraisal instruments
MAStARI appraisal instrument
Appendix II: Data extraction instruments
MAStARI data extraction instrument