Psychoeducation for siblings of people with severe mental illness

Jacqueline Sin, Cheryl D Jordan, Elizabeth A Barley, Claire Henderson, Ian Norman

Many people with severe mental illness (SMI) have siblings. Siblings are often both natural agents to promote service users' recovery and vulnerable to mental ill health due to the negative impact of psychosis within the family. Despite a wealth of research evidence supporting the effectiveness of psychoeducation for service users with SMI and their family members, in reducing relapse and promoting compliance with treatment, siblings remain relatively invisible in clinical service settings as well as in research studies. If psychoeducational interventions target siblings and improve siblings' knowledge, coping with caring and overall wellbeing, they could potentially provide a cost-effective option for supporting siblings with resulting benefits for service users' outcomes. To assess the effectiveness of psychoeducation compared with usual care or any other intervention in promoting wellbeing and reducing distress of siblings of people affected by SMI.The secondary objective was, if possible, to determine which type of psychoeducation is most effective. We searched the Cochrane Schizophrenia Group Trials Register and screened the reference lists of relevant reports and reviews (12th November 2013). We contacted trial authors for unpublished and specific data on siblings' outcomes. All relevant randomised controlled trials focusing on psychoeducational interventions targeting siblings of all ages (on their own or amongst other family members including service users) of individuals with SMI, using any means and formats of delivery, i.e. individual (family), groups, computer-based. Two review authors independently screened the abstracts and extracted data and two other authors independently checked the screening and extraction process. We contacted authors of trials to ascertain siblings' participation in the trials and seek sibling-specific data in those studies where siblings' data were grouped together with other participants' (most commonly other family members'/carers') outcomes. We calculated the risk difference (RD), its 95% confidence interval (CI) on an intention-to-treat basis. We presented continuous data using the mean difference statistic (MD) and 95% CIs. We assessed risk of bias for the included study and rated quality of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). We found 14 studies that included siblings amongst other family members in receipt of psychoeducational interventions. However, we were only able to include one small trial with relevant and available data (n = 9 siblings out of n = 84 family member/carer-participants) comparing psychoeducational intervention with standard care in a community care setting, over a duration of 21 months. There was insufficient evidence to determine the effects of psychoeducational interventions compared with standard care on 'siblings' quality of life' (n = 9, MD score 3.80 95% CI -0.26 to 7.86, low quality of evidence), coping with (family) burden (n = 9, MD -8.80 95% CI -15.22 to -2.34, low quality of evidence). No sibling left the study early by one year (n = 9, RD 0.00 CI -0.34 to 0.34, low quality of evidence). Low quality and insufficient evidence meant we were unable to determine the effects of psychoeducational interventions compared with standard care on service users' global mental state (n = 9, MD -0.60 CI -3.54 to 2.38, low quality of evidence), their frequency of re-hospitalisation (n = 9, MD -0.70 CI -2.46 to 1.06, low quality of evidence) or duration of inpatient stay (n = 9, MD -2.60 CI -6.34 to 1.14, low quality of evidence), whether their siblings received psychoeducation or not. No study data were available to address the other primary outcomes: 'siblings' psychosocial wellbeing', 'siblings' distress' and adverse effects. Most studies evaluating psychoeducational interventions recruited siblings along with other family members. However, the proportion of siblings in these studies was low and outcomes for siblings were not reported independently from those of other types of family members. Indeed, only data from one study with nine siblings were available for the review. The limited study data we obtained provides no clear good quality evidence to indicate psychoeducation is beneficial for siblings' wellbeing or for clinical outcomes of people affected by SMI. More randomised studies are justified and needed to understand the role of psychoeducation in addressing siblings' needs for information and support.