Family Environment Important in Early
Psychosis Outcomes

Liam Davenport

July 07, 2020

Family environment may influence subsequent functional outcomes in patients with first-episode psychosis (FEP), new research suggests.

A study of more than 300 patients with FEP showed that although family environment was not associated with functioning at initial presentation, an interaction developed over time that could have "important implications for early interventions for both patients and caregivers," investigators report.

The results highlight the need for intervention in patients with FEP as well as their families, study co-investigator Norma Verdolini, MD, PhD, Bipolar and Depressive Disorders Unit, Hospital Clinic Barcelona, University of Barcelona, Spain, told Medscape Medical News

The findings were scheduled to be presented at the Congress of the Schizophrenia International Research Society (SIRS) 2020, but the meeting was canceled because of the coronavirus pandemic.

FAST Measures

Previous research has shown that family environment influences the development of psychotic symptoms, with negative family environmental factors associated with poor prognoses.

Conversely, one study indicated that a positive family environment is linked to greater improvement in negative and disorganized symptoms in adolescents at imminent risk for psychosis onset.

However, the current investigators note that the impact of family environment on longitudinal functioning in individuals presenting with FEP is unclear.

To investigate further, they conducted an analysis as part of the PEPs study, which included 335 patients with FEP and 253 healthy controls.

Functioning was measured using the Functional Assessment Short Test (FAST), and family environmental styles were evaluated using the Family Environment Scale (FES), which assesses "emotional climate" of a family across 10 domains.

At baseline, the mean total FAST score was 27.8 in patients with FEP vs 3.5 in the healthy controls, indicating substantially worse functioning among the patients.

Linear regression analysis indicated that at baseline there was no significant association between aspects of family environment on the FES and functional  scores.

Patients were assessed again at 2 years, by which point 283 had been diagnosed with psychotic disorders and 52 with bipolar disorder. The mean total FAST scores were 20.98 among patients with psychotic disorders and 13.8 in those with bipolar disorder.

Family Conflict

Results showed that among those with bipolar disorder, worse functioning on FAST at 2 years was significantly associated with higher rates of open expression of conflict in the family (P = .004).

In patients with psychotic disorders, worse functioning was significantly associated with lower rates of participation in social activities (P = .006) and an achievement-oriented family environment (P = .039).

Worse functioning in patients with psychotic disorders was also significantly associated with higher rates of religious practice and values (P = .003).

Verdolini noted the reason family environment does not appear to have an impact at initial FEP presentation may be that the "first kick" is given by an individual's genetic liability for psychiatric disorders in combination with the family environment.

She pointed out that, in reality, the two are intertwined, especially when considering what it means to a family to have one member with a psychiatric disorder, which "will have an impact on the family environment."

Verdolini added, "This is not actually the objective family environment" but the perceived family environment.

"So maybe in the following 2 years the patient who experiences a first episode of psychosis may change their idea of the family environment itself," she noted. She added that at her institution psychoeducation is offered to FEP patients' families.

"Interesting" Findings

Commenting on the study for Medscape Medical News, Nicole Kozloff, MD, from the Child, Youth, and Emerging Adult Program at the Centre for Addiction and Mental Health in Toronto, Canada, said one limitation of the study is that it's not clear what care patients received — or who in the family completed the FES.

It is also important to note that "measures of association do not necessarily imply that one factor caused the other factor," said Kozloff, who was not involved in the research.

"For example, it may be that among people with bipolar disorder, open expression of conflict in the family can lead to worse functioning, or that worse functioning can lead to more conflict in the family," she said.

Nevertheless, Kozloff described the finding of an emerging association between the family environment and functioning over time as "interesting."

When young people with FEP enter treatment, "they have reached a crisis point and are functioning poorly," she noted.

"It could be that there is less to differentiate among levels of functioning at treatment entry but, after 2 years, the individuals have separated into those who have been responsive to treatment and are functioning well, and those who continue to have functional challenges. And this is where we start to see a relationship with family environment emerge," Kozloff said.

She also agreed with Verdolini's take on the findings, and that family psychoeducation "can reduce relapse rates in schizophrenia and the emotional burden on the family."

"We also know that having family involvement in care is one of the most robust predictors that young people with psychosis will remain engaged in mental health services," she said.

Teaching families about psychosis and its treatment, about problem-solving and communication skills, and providing support to ensure that family members know how to get help in a crisis, "is a key part of comprehensive early psychosis intervention," Kozloff said.

"It is good for the patient and good for the family, and allows the clinicians to provide better care," she added.

Articulates Clinical Practice Findings

Also commenting on the results, Brian O'Donoghue, MD, PhD, senior clinical research fellow at Orygen, The National Centre of Excellence in Youth Mental Health in Melbourne, Australia, described the research as important, adding that the study highlights the need for sufficient follow-up.

"It makes sense that the involvement of family over time has a strong impact upon outcome and functioning," he told Medscape Medical News.

"These research findings articulate what we see in clinical practice, so it is good to see that it is captured," added O'Donoghue, who was not associated with the study.

He noted that it is common for family involvement to influence outcome, especially if the family is positively involved. "It is invaluable toward their recovery," he said.

"However, conversely, if there are ongoing family stressors, then this can be a trigger for relapse or lack of improvement," he added.

Overall, the results "really emphasize that the family needs to be involved in care."

The Early Psychosis Prevention and Intervention Centre where O'Donoghue is a consultant psychiatrist offers a psychoeducational course "to inform families about psychosis, treatment, and how they can support their family members," he reported.

"We also have family peer support workers and family therapists, which are essential to the service and for the young person's recovery," O'Donoghue said.

The investigators and O'Donoghue have disclosed no relevant financial relationships. Kozloff reports having received research funding from the CAMH Foundation, Brain & Behavior Research Foundation, Canadian Institutes of Health Research, and AFP Innovation Fund; honoraria from Humber River Hospital, the University of Calgary, and the Canadian Consortium for Early Intervention in Psychosis; and salary support from Inner City Health Associates.

Congress of the Schizophrenia International Research Society (SIRS) 2020: Abstract S229.

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