r e v c o l o m b p s i q u i a t .

2 0 1 7;4 6(1):2–11

www.elsevier.es/rcp

Original article

Expressed emotions, burden and family

functioning in schizophrenic and bipolar I patients
of a multimodal intervention programme: PRISMA夽

Alexandra Ramírez a , Juan David Palacio a , Cristian Vargas a , Ana María Díaz-Zuluaga a ,
Kelly Duica a , Yuli Agudelo Berruecos b , Sigifredo Ospina b , Carlos López-Jaramillo a,∗
a Grupo de Investigación en Psiquiatría (GIPSI), Departamento de Psiquiatría, Facultad de Medicina, Universidad de Antioquia, Medellín,
Colombia
b Grupo de Epidemiología Hospitalaria, Hospital Universitario de San Vicente Fundación, Medellín, Colombia

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Bipolar disorder and schizophrenia are causes of major suffering in patients.
Received 30 July 2015 Nevertheless, they also affect family and caregiver functioning. This is important because
Accepted 28 February 2016 the participation and involvement of families and caregivers is essential to achieve an
Available online 4 April 2017 optimal treatment.
Objective: To describe the level of expressed emotions, burden, and family functioning of
Keywords: bipolar and schizophrenic patients and, to evaluate the efficacy of the multimodal inter-
Expressed emotions vention (MI) versus traditional intervention (TI) in family functioning and its perception by
Family functioning patients and caregivers.
Multimodal intervention Material and methods: A prospective, longitudinal, therapeutic-comparative study was con-
Schizophrenia ducted with 302 patients (104 schizophrenic and 198 bipolar patients) who were randomly
Bipolar disorder assigned to a MI or TI groups of a multimodal intervention programme PRISMA. MI group
received care from psychiatry, general medicine, neuropsychology, family therapy, and occu-
pational therapy. TI group received care from psychiatry and general medicine. Hamilton,
Young and SANS, SAPS scales were applied to bipolar and schizophrenic patients, respec-
tively. The EEAG, FEICS, FACES III and ECF were also applied at the initial and final time.
Results: There were statistically significant differences in socio-demographic and clinical
variables in schizophrenia vs bipolar group: 83% vs 32.2% were male, 37 vs 43 mean age,
96% vs 59% were single, 50% vs 20% unemployed, and 20% vs 40% had college studies. In
addition, 2 vs 2.5 numbers of hospitalisations, 18 vs 16 mean age of substance abuse onset

夽
Please cite this article as: Ramírez A, Palacio JD, Vargas C, Díaz-Zuluaga AM, Duica K, Agudelo Berruecos Y, et al. Emociones expresadas,
carga y funcionamiento familiar de pacientes con esquizofrenia y trastorno afectivo bipolar tipo I de un programa de intervención
multimodal: PRISMA. Rev Colomb Psiquiat. 2017;46:2–11.
∗
Corresponding author.
E-mail addresses: calberto.lopez@udea.edu.co, grupopsiquiatria@udea.edu.co (C. López-Jaramillo).
2530-3120/© 2016 Asociación Colombiana de Psiquiatrı́a. Published by Elsevier España, S.L.U. All rights reserved.
 r e v c o l o m b p s i q u i a t . 2 0 1 7;4 6(1):2–11 3

and, 55 vs 80 points in EEAG. There were no statistically significant differences in family

scales after conducting a multivariate analysis on thr initial and final time in both groups.
Conclusions: This study did not show changes in variables of burden and family functioning
between bipolar and schizophrenic groups that were under TI vs MI.
© 2016 Asociación Colombiana de Psiquiatrı́a. Published by Elsevier España, S.L.U. All
rights reserved.

Emociones expresadas, carga y funcionamiento familiar de pacientes con

esquizofrenia y trastorno afectivo bipolar tipo I de un programa de
intervención multimodal: PRISMA

r e s u m e n

Palabras clave: Introducción: El trastorno afectivo bipolar (TAB) y la esquizofrenia son causas importantes
Emociones expresadas de sufrimiento para los pacientes y sus familias, pues se afectan su funcionamiento y su
Funcionamiento familiar dinámica normal. Esto es importante, ya que la implicación de la familia es esencial para
Intervención multimodal un tratamiento óptimo del paciente.
Esquizofrenia Objetivo: Describir el nivel de emociones expresadas, la carga y el funcionamiento de las
Trastorno bipolar familias de los pacientes bipolares y esquizofrénicos y evaluar la eficacia de la intervención
multimodal (IM) en comparación con la intervención tradicional (IT) en el funcionamiento
familiar y en la percepción que de este tienen el paciente y sus cuidadores.
Material y métodos: Se realizó un estudio prospectivo, longitudinal, terapéutico-comparativo,
con una muestra de 302 pacientes (104 con diagnóstico de esquizofrenia y 198 con TAB)
aleatorizados a un grupo de IM y otro de IT dentro de un programa de salud mental con
énfasis en reducción de la carga, el daño y el gasto social de la enfermedad mental (PRISMA).
Los pacientes asignados a la IM recibían atención por psiquiatría, medicina general, neurop-
sicología, terapia de familia y terapia ocupacional, y los pacientes asignados a IT recibían
atención por psiquiatría y medicina general. Las escalas realizadas al inicio y al final de
las intervenciones fueron las de Hamilton y Young, SANS y SAPS, para pacientes bipolares
y esquizofrénicos respectivamente. A ambos grupos se aplicaron las escalas EEAG, FEICS,
FACES III y ECF.
Resultados: Se encontraron diferencias estadísticamente significativas en las variables
sociodemográficas y clínicas entre los grupos de pacientes con TAB y con esquizofrenia.
Tras hacer un análisis multivariable MANCOVA, no se observaron diferencias estadística-
mente significativas en los resultados entre los momentos inicial y final en los grupos de
pacientes con TAB y con esquizofrenia según las escalas FEICS, FACES III y ECF.
Conclusiones: Este estudio no evidencia un cambio en la carga y el funcionamiento familiar
entre los grupos sometidos a IM y a IT de pacientes bipolares y esquizofrénicos.
© 2016 Asociación Colombiana de Psiquiatrı́a. Publicado por Elsevier España, S.L.U.
Todos los derechos reservados.

and memory.2–5 Moreover, it is argued that lifestyle, person-

Introduction
ality characteristics and ways of coping with mental illness
also have an important influence on the demand for care from
Chronic mental disorders such as schizophrenia and bipo- emergency services, hospital admission and length of stay,
lar disorder are among the leading causes of disability and and adherence and response to treatment.6 The situation is
morbidity and admission to hospital in the local popula- similar in patients with schizophrenia, many of whom suf-
tion. Although they are treatable, and in recent decades fer from persistent residual positive and negative symptoms
advances in psychopharmacology have provided better ther- which are directly related to work-related, social and family
apeutic options and greater patient stability, these disorders disability.7,8
continue to occupy the top spots in global disability The knowledge accumulated up to now on bipolar disorder
statistics.1 and schizophrenia tells us that there are alterations in mul-
In bipolar disorder the disability is not only associated with tiple dimensions of the human being, and the complexity of
affective episodes and residual symptoms; studies show that, patients requires more comprehensive complementary strate-
even during periods of euthymia, patients have poor cognitive gies than those currently available. One answer to this need
performance in areas such as attention, executive function is to offer patients with bipolar disorder and schizophrenia a
4 r e v c o l o m b p s i q u i a t . 2 0 1 7;4 6(1):2–11

multidisciplinary intervention programme in which, in addi- random assignment, the groups were distributed as follows:
tion to pharmacological treatment, patients have adequate MI (50 patients with schizophrenia and 100 with bipolar
intervention in psychoeducation, psychology, neuropsycholo- disorder); and TI (54 patients with schizophrenia and 98 with
gical rehabilitation, occupational therapy, family therapy and bipolar disorder).
general medicine, with a treatment plan tailored to individ- Patients were selected from the Mood Disorders and Psy-
ual needs.9–11 Although many of these therapies have been chosis Clinic at Hospital Universitario San Vicente Fundación
evaluated separately and have proved useful in both dis- or those referred from other institutions by psychiatrists
orders, there is little information on the effectiveness of or health workers who knew the programme. Patients had
multimodal intervention (MI) programmes compared with tra- to have been previously diagnosed with bipolar disorder or
ditional intervention (TI) in the different therapeutic targets. schizophrenia. The initial assessment of patients began in Jan-
Family dynamics is one of the most important domains uary 2012; the programme was carried out for approximately
in the therapeutic approach and evaluation of patients with 2 years, and the final assessment ended in February 2015.
chronic mental illness,12 and it is known that there is a bidi- Patients who met the following inclusion criteria were
rectional interaction between patients and their families. The included: (a) patients diagnosed with bipolar I disorder
presence of a patient with schizophrenia or bipolar disorder and schizophrenia according to the Diagnostic Interview for
interferes with many aspects of family dynamics, generating Genetic Studies (DIGS)23 ; (b) age from 18 to 60 years; (c) having
a need for support, counselling and psychoeducation on the had schooling from the age of 5 to 16 years; (d) having agreed to
disease and treatment, as well as indications about how to participate in the study and signed the informed consent form
relate to the patient.13–16 The role of the family is essential, previously explained by the healthcare professional; and (e) be
since the lived experience and the proximity with the patient in good health, sufficient to apply the tests.
can provide the information necessary to define a work plan Among the exclusion criteria were having comorbidities
and talk about the relationships that exist within the family.17 such as other neurological or psychiatric disorders, men-
Studies of patients’ family environments have focused tal retardation, classic autism or personality disorder. Also
on expressed emotion (EE), that is, individual attitudes or excluded were subjects with a history of electroconvulsive
predispositions that facilitate or interfere with interpersonal therapy in the past 6 months or severe head injury.
relationships and constitute a relational process between The expected primary outcomes were improvement in the
patients and their relatives.18,19 Important aspects of EE level of expressed emotion (criticism and over-involvement),
are criticism and emotional over-involvement. Criticism is burden and family functioning in patients with bipolar dis-
defined as a negative filter that distorts how people see order and schizophrenia exposed to two interventions to be
themselves and others, and over-involvement is the lack of compared, traditional vs multimodal.
appropriate emotional boundaries between the members of a Informed consent was obtained from all patients after an
family. These emotions are highly correlated with the wors- explanation and resolution of doubts by the healthcare pro-
ening of symptoms and the need for hospitalisation.20–22 The fessional. The research project was approved by the respective
investigation of new strategies with which to address these bioethics committees.
critical points is necessary in order to help improve patients’
functionality and prognosis. Instruments
The mental health programme focusing on reducing the
burden, suffering and social spending in mental illness Patients were diagnosed with bipolar I disorder and
(PRISMA) was designed with several objectives, one of which schizophrenia using the DIGS, translated and validated for
is the aim to describe the level of expressed emotion (criticism Colombia,23 according to the criteria of the Diagnostic and
and over-involvement), burden and functioning in a popula- Statistical Manual of Mental Disorders, Fourth Edition (Text
tion of patients with bipolar disorder and schizophrenia, and Revision) (DSM-IV-TR).24 The 17-item Hamilton Rating Scale
to assess the efficacy of an MI compared with a TI in terms for Depression (HRSD)25 and the Young Mania Rating Scale
of family functioning and how it is perceived by patients and (YMRS),26 both validated in Spanish, were used for patients
their carers. with bipolar I disorder, and the Scale for the Assessment of
Negative Symptoms (SANS) and the Scale for the Assessment
of Positive Symptoms (SAPS)27 were applied to subjects with
Material and methods schizophrenia. In addition, both groups of patients were eval-
uated with the Global Assessment of Functioning (GAF) scale
Participants for the past month and at the worst point of the last episode.
For the evaluation of family variables, the following instru-
A prospective, open-label, longitudinal, therapeutic- ments were used:
comparative clinical trial was conducted with a total sample
of 302 patients (104 with schizophrenia and 198 bipolar 1. Family Emotional Involvement and Criticism Scale (FEICS).
disorder) who were randomly assigned to the MI or TI groups The FEICS consists of two subscales: criticism and involve-
within a mental health programme focusing on reducing ment; each consists of 7 items and they are intercalated
burden, suffering and social spending in mental illness: in the scale: the criticism-related items are the even num-
PRISMA. A professional outside the group with no contact bers and the involvement-related items are odd numbers.
with the patients or the intervention staff performed the Each item is evaluated according to an ordinal scale (from
randomisation using the Epidat 3.1 programme. After the almost never to almost always, with scores from 1 to 5), so
 r e v c o l o m b p s i q u i a t . 2 0 1 7;4 6(1):2–11 5

the total for each subscale can be from 7 to 35 points. The family information provided by the patient and to obtain
version of the FEICS used in this study was translated and the carer’s perspective in terms of needs or concerns for a
validated by the Department of Psychiatry of the University possible family therapy intervention. To avoid fatigue on the
of Antioquia.28 day of the evaluation, the day was divided into two blocks,
2. Family Adaptability and Cohesion Evaluation Scale (FACES with patients and relatives being offered refreshments and
III), a scale for evaluating family functioning. FACES III29 help with travelling expenses.
consists of 40 items, each with a Likert-type scale of five
options (almost always, very often, sometimes yes and Intervention
sometimes no, seldom, almost never), divided into two
parts: part 1, with 20 items, assesses the level of cohesion Multimodal intervention
and flexibility in the family as the subject perceives it at An outpatient MI was carried out for patients with bipo-
that moment (“actual family”), and part 2, with 20 items lar disorder and schizophrenia, which included care from
that assess the level of cohesion and flexibility that the sub- general medicine, psychiatry, psychology, family therapy, neu-
ject would like there to be in their family (“ideal family”). ropsychological rehabilitation, and occupational therapy. Each
This part includes the same items as the first, but the gen- patient was offered from 12 to 18 intervention sessions,
eral allocation of points is different. From the differences distributed according to a needs assessment performed by
between the “actual” and “ideal” scales, we can obtain the the therapeutic group in the initial evaluation. In addition,
satisfaction index that the person has with their family 10 weekly sessions of psychoeducation were offered for
functioning. patients with bipolar disorder and relatives with schizophre-
3. Self-applied Family Burden Scale (FBS). The FBS30 is an nia.
adaptation in the form of a self-applied scale from sections The MI programme consisted of periodic interventions by
of the psychosocial performance scale (Spanish adaptation general medicine to assess for other non-mental illnesses and
of the Social Behaviour Assessment Schedule).4 This is a initiate or adjust treatment for comorbidities. In addition, a
discriminative-type scale. The aspects assessed are objec- medical approach focused on promoting healthy lifestyles,
tive burden, attribution level and subjective burden. The in terms of sports, nutrition and hours and quality of sleep,
objective burden section evaluates changes in the daily among other areas. There were psychiatric evaluations, the
functioning of the people who form part of the patient’s aim of which was to assess and monitor the patient’s actual
environment. In cases where there is an objective burden clinical condition, apply clinical scales and adjust pharmaco-
(score other than 0), the level of attribution is evaluated, i.e. logical treatment. The intervention also included occupational
whether or not informants consider their problems to be therapy appointments for assessing each patient’s general,
related to the patient and to what extent (0 = not related; social, family and work functioning, as well as their occupa-
1 = possibly related; 2 = clearly related). Lastly, the subjec- tional capacity, in order to establish a therapeutic strategy.
tive burden section is an evaluation of the stress that all the Socio-occupational rehabilitation focused on increasing the
items corresponding to the subject’s behaviour, their per- patient’s functional independence, developing integration
formance of social roles and the adverse effects on others strategies and preventing disability, in order to encourage
cause in the informant. social interaction, decrease anxiety and stimulate cognitive
function.
Evaluation procedure Patients were also offered neuropsychological rehabilita-
tion sessions that were complemented by ecological strategies
At the start of the programme patients were selected and, from the Hospital Clínic de Barcelona Research Group’s
if they met the inclusion criteria, they were given appoint- Functional Remediation Programme. Before starting the inter-
ments to attend in groups. The first day the programme was vention programme, one of the therapists spent 3 months as
explained to them, and patients who agreed to participate a trainee observing and learning about the individual appli-
signed the consent form. An identification form was then filled cation of this programme. Patients also received individual
out, in which the patients were assigned a code within the pro- intervention with cognitive-behavioural psychology and fam-
gramme and they were referred to healthcare professionals ily therapy according to their particular needs identified at the
from each specialty to be evaluated using different instru- beginning of the programme.
ments. The evaluation of family therapy was done individually Psychoeducation was provided in group sessions and was
with patients and mixed (group-individual) with carers. designed to offer general knowledge about the disorder,
The evaluation of the patient lasted approximately 30 min symptoms, recognition of prodromal symptoms, stress man-
and consisted of a conversation aimed at collecting informa- agement, pharmacological treatment, adverse effects, healthy
tion from each patient’s genogram and identifying from their lifestyles and the rights and duties of the patient, among
perspective the difficulties or objectives of a possible fam- other topics. The coordinator of the psychoeducation groups
ily therapy intervention. The scales to be completed by the was an occupational therapist with experience in group psy-
patient (FEICS and FACES III) and the carer (FEICS, FACES III chotherapy, and the therapists in the programme participated
and FBS) were then explained. The patients were accompa- as co-therapists.
nied by a family therapist or co-therapist during the process
to explain any uncertainties about the instrument. Traditional intervention
After applying the scales, a conversation lasting approx- The TI consisted of assessments by general medicine and psy-
imately 15 min was held with each carer to supplement the chiatry, a total of 1–2 sessions of each during the follow-up
6 r e v c o l o m b p s i q u i a t . 2 0 1 7;4 6(1):2–11

period with the aim of achieving a level of care similar to that selection criteria were applied. Consequently, 302 subjects
currently offered by the health service. No psychoeducational were evaluated, 198 diagnosed with bipolar disorder and 104
groups were provided in the TI. schizophrenia. After allocating the subjects to the two arms,
the MI group consisted of 50 patients with schizophrenia and
100 with bipolar disorder and the TI group had 54 patients with
Statistical analysis
schizophrenia and 98 with bipolar disorder. Fig. 1 shows the
flow of patients during the study.
For the quantitative description of the socio-demographic and
During the follow-up and intervention period, some par-
clinical variables, measures of central tendency (arithmetic
ticipants were lost to follow-up and others withdrew, leaving
mean), measures of position (median) and measures of disper-
a final sample of 259 patients: 92 with schizophrenia and 167
sion (standard deviation and interquartile range) were used.
with bipolar disorder. This information is provided in detail in
In the qualitative variables report, absolute frequencies and
the patient flowchart (Fig. 1).
proportions were used. In the qualitative variables, normality
During the enrolment, follow-up and intervention period,
in the distribution was evaluated using the Shapiro–Wilk test,
there were no unintended injuries or effects in either of the
and independence (with respect to groups and subgroups) was
intervention groups.
measured by the 2 test and the log-likelihood ratio statistic.
For the comparison of quantitative variables between
groups and subgroups, a Student’s t test and the Socio-demographic characteristics of the patients with
Mann–Whitney U test were used, depending on the case. bipolar disorder and schizophrenia in the PRISMA
To compare the measurements of the first and second programme
moments, Student’s t-test was used for related samples and
After evaluating the socio-demographic variables of patients
the Wilcoxon test for paired observations. In the self-applied
with bipolar disorder and schizophrenia in the PRISMA pro-
family burden scale (FBS), the results of the two moments
gramme, a high proportion of patients with schizophrenia
were compared using the marginal homogeneity test. Lastly, a
were found to be male (83%) and among the patients with
multivariate analysis was performed with repeated measures
bipolar disorder, the majority were female (67.8%); mean age
for each scale (FBS, FACES III) using the multivariate analysis
was 37 among patients with schizophrenia and 43 among
of covariance (MANCOVA) model, where the dependent
patients with bipolar disorder. When marital status, occupa-
variables were the concepts evaluated within each scale and
tion and educational level were evaluated, 96% of the patients
the independent variables, socio-demographic and clinical
with schizophrenia were found to be single, 50% unemployed
characteristics.
and only 26% reported having higher education (technical,
technological or for a profession). Of the patients with bipo-
Results lar disorder, 59% were single, 20% unemployed and 40% had
completed higher education. There were statistically signifi-
Initially, 336 subjects with bipolar disorder and schizophre- cant differences in all four demographic variables (age, gender,
nia were recruited, with 34 of them being excluded once the marital status, occupation and education) (Table 1).

Table 1 – Socio-demographic variables of the patients with bipolar disorder and schizophrenia.
Variable Classification SCHZ (n = 104) BAD (n = 198) p

Gender Male 86 (83.5) 64 (32.2) <0.001

Marital status Married 2 (1.9) 48 (24.5) <0.001

Separated 2 (1.9) 22 (11.2)
Divorced 0 5 (2.6)
Widowed 0 4 (2.0)
Single 99 (96.1) 117 (59.7)

Occupation Unemployed 52 (50.5) 41 (20.7) <0.001

Working 4 (3.9) 16 (8.1)
Student 14 (13.6) 27 (13.6)
Independent 14 (13.6) 44 (22.2)
Household tasks 6 (5.8) 55 (27.8)
Retired 2 (1.9) 5 (2.5)
Other 11 (10.7) 10 (5.1)

Education Finished primary 32 (31.1) 57 (28.8) <0.051

Finished secondary 44 (42.7) 57 (28.8)
Higher education 27 (26.2) 80 (40.4)

Age (years) 37 [5.19] 43 [20] 0.001

BAD: bipolar affective disorder.

The values are expressed as n (%) or median [interquartile range].
 r e v c o l o m b p s i q u i a t . 2 0 1 7;4 6(1):2–11 7

Screened for selection, n=336

Excluded, n=34
Did not meet selection
criteria, n=17
Refused to take part, n=17

Randomised,
n=302

Traditional Multimodal
intervention intervention

SCHZ, BAD, SCHZ, BAD,

n=50 n=100 n=54 n=98

No-show, Could not be

n=3 Could not be Did not want to continue
contacted due
contacted due the process, n=2
to change of
telephone to change of Could not be contacted
number, n=3 telephone due to change of
number, n=4 telephone number, n=10
No-show, n=3

Completed Completed Completed

Completed the
the process, the process, the process,
process, n=86
n=94 n=47 n=50

Total number of patients who completed the process, n=227

Lost to follow-up, n=25

Fig. 1 – Study patient inclusion flowchart.

Differences in the clinical variables of patients with bipolar of 80; 29% had a history of suicide attempts and 26% a history
disorder and schizophrenia in the PRISMA programme of alcohol/substance/drug abuse.
Statistical differences between the two groups
The group of patients with schizophrenia reported an aver- (schizophrenia and bipolar disorder) were found in
age of 2 hospitalisations over the course of their lives, 15% the number of hospitalisations (p = 0.026), the age of
had a history of alcohol abuse and 31% had a history of onset of substance/psychoactive drug abuse (p = 0.004)
psychoactive substance abuse, with a mean age at onset and in the score on the GAF scale in the past month
of alcohol consumption of 18 and at onset of psychoactive (p = 0.001).
substance abuse of 16. The average SANS and SAPS scores There were no statistically significant differences between
were 45 and 9 respectively, with a GAF score in the previous the two groups in the following variables: alcohol abuse
month of 55. In the bipolar disorder group, the mean num- (p = 0.602); psychoactive substance abuse (p = 0.455); history of
ber of hospitalisations was 2.5, with an average of 2 episodes suicide attempts (p = 0.204); and age of onset of alcohol abuse
of mania/hypomania and a GAF score in the previous month (p = 0.86) (Table 2).
8 r e v c o l o m b p s i q u i a t . 2 0 1 7;4 6(1):2–11

Table 2 – Variables by disorder.

Variable Schizophrenia BAD p

No psychiatric admissions 2.0 [3.5] 2.5 [4.0] 0.026

No episodes of major depression 0 1 [2] <0.00
Age at onset of major depression (years) 19.5 [3.75] 22.5 [19.25] 0.508
No episodes of mania/hypomania 0 2 [4] <0.00
Age at onset of alcohol abuse (years) 18.0 [5.5] 18.5 [5.7] 0.866
Age at onset of substance/drug abuse (years) 16 [3] 18 [5] 0.004
Age at onset of active psychosis (years) 19.0 [5.6] 24.5 [14.0] <0.00
Young Scale – 0 [1] –
Hamilton Scale – 2 [8] –
SANS 45 [39.5] – –
SAPS 9 [28] – –
GAF at the worst point in the last episode 20 [6] 21 [10] <0.00
GAF in the past month 55 [5.23] 80 [23.0] <0.00
Alcohol abuse 16 (15.5) 37 (18.7) 0.602
Substance/drug abuse 32 (31.1) 52 (26.3) 0.455
Attempted suicide 23 (22.3) 59 (29.9) 0.204

BAD: bipolar affective disorder.

The values are expressed as n (%) or median [interquartile range].

Demographic and clinical characteristics of the subgroups When the FEICS domain of over-involvement was evalu-
of patients with bipolar disorder and schizophrenia ated, statistically significant differences were found between
assigned to multimodal intervention or traditional the scores of the relatives of patients with bipolar disorder
intervention and those of patients with schizophrenia (p = 0.030). Involve-
ment considered “high” was greater in the bipolar disorder
After comparing the demographic (gender, marital status, group (26%) than in the schizophrenia group (14.3%). The
occupation and educational level) and clinical characteris- patients’ scores for this domain showed a higher level of
tics of the subgroups of patients with bipolar disorder and over-involvement in the schizophrenia group than in the
schizophrenia assigned to MI and TI, statistically significant bipolar disorder group (p = 0.058). No statistically significant
differences were only found in the educational level of the differences were found between the two groups in the total
bipolar disorder group in the MI programme, where 50% of the involvement scores.
patients had some level of higher education compared with
29% of the TI group (p = 0.044). There were no statistically sig-
Cohesion and adaptability according to FACES III in
nificant differences between the subgroups of patients with
families of patients with schizophrenia compared with
bipolar disorder in the Hamilton and Young scale scores or
families of patients with bipolar disorder at baseline
between the subgroups of patients with schizophrenia in the
SAPS and SANS scores. There were no differences in the scores
A difference between the two groups was found in the total
for functionality in the past month between the MI and TI
family adaptability score on the scale completed by the
subgroups for patients with bipolar disorder or schizophrenia.
patient, with a higher median score in the schizophrenia
group (p = 0.051). No statistically significant differences were
found in the other total cohesion and adaptability scores or
Emotional involvement and criticism according to FEICS in
in the scores for these subdomains. In the adaptability scores
families of patients with schizophrenia or bipolar disorder
there was a tendency to find differences, but they were not
at the beginning
statistically significant (p = 0.092).

In the family criticism domain of the FEICS, 27% of patients

with schizophrenia and 21% of subjects with bipolar disor- Family burden for patients with schizophrenia compared
der gave their family a “high” criticism score. According to the with patients with bipolar disorder at baseline
family members’ ratings, the level of criticism in both groups
was lower than that reported by the patients. In the group with When the objective burden of the relatives was measured, 95%
bipolar disorder, 16% of the relatives rated the level of criticism of them (bipolar disorder and schizophrenia) reported “moder-
as “high” and 42% as “low”. There were no statistically signif- ate burden” or “severe burden”. One in every 4 of the patients’
icant differences in the FEICS criticism score level between relatives reported having “severe objective burden”. When
patients with bipolar disorder and patients with schizophre- assessing the attribution of the burden (emotional, work,
nia (p = 0.468), or between the families of each group (p = 0.508). leisure, relational, economic and at home) to the patient’s
It is important to point out that more than 40% of the relatives health status, only 15% of the relatives found a “clear relation-
classified the level of family criticism as “low”. No statistically ship”. Fifty-three percent (53%) of the relatives of patients with
significant differences were found between the two groups of bipolar disorder found “no relationship” between the burden
patients in total scores for family criticism. and the patient’s health status. When comparingthe scores for
 r e v c o l o m b p s i q u i a t . 2 0 1 7;4 6(1):2–11 9

this scale from the bipolar disorder and schizophrenia groups, schizophrenia group, although they did not persist after the
no statistically significant differences were found. multivariate analysis. In this research, the MI showed no ben-
efit over the TI in modifying the variables of carer burden,
Comparison between baseline and end of intervention of cohesion, adaptability, over-involvement and family criticism.
the FACES III and FEICS scores for patients with bipolar In view of the characteristics of the treatment, as the same
disorder and schizophrenia patient might receive several interventions by different thera-
pists within the same period of time, there was a possibility
When comparing the FACES III and FEICS between baseline of variables worsening, as the therapy exposes issues and sit-
and end of intervention for patients with bipolar disorder in uations which are highly emotionally charged. However, this
each of the intervention arms (MI vs TI), an improvement in phenomenon did not occur, i.e. the MI did not make family
the total family cohesion score was identified in the MI sub- dynamics worse.
group (p = 0.041) that was not observed in the TI group. No Among the possible explanations for not finding significant
statistically significant differences were found between the differences, the authors propose the following hypotheses: (a)
two subgroups in the adaptability domain or on the FEICS to see changes in family dynamics and therapeutic results
scale. The TI group showed significant changes in the variables from family therapy generally requires more extensive and
of adaptability (p = 0.024) and cohesion (p = 0.021) on the scale continuous processes, and in this MI patients had other inter-
applied to the relatives. However, these significant differences ventions included in their programme; more frequent and
were not identified after performing a MANCOVA. longer lasting interventions may be needed in this popula-
After comparing the patients with schizophrenia assigned tion to achieve better therapeutic effects; (b) the instrument
to the MI subgroup at baseline and at the end of the interven- used to measure the effect of the multimodal programme on
tion, an increase in family involvement score was observed family dynamics did not capture the variables in which there
(p = 0.017) that was not observed in the TI group. No changes might have been changes, and other psychometric instru-
were found in the criticism domain in either intervention arm. ments should therefore be explored in the future; and (c) this
In the TI group, a significant increase in the adaptability score study made predominantly quantitative measurements, but
was observed according to the scores recorded by the relatives a narrative and qualitative approach might have identified
(p = 0.023). These differences did not persist after the multi- significant changes in family dynamics that are difficult to
variate analysis. quantify with the tools used. It is important to emphasise this
last hypothesis, because strikingly, many of the patients and
relatives who participated in the programme showed a high
Discussion degree of satisfaction and recognised improvements in their
processes. This breakthrough was also recognised by the fam-
The results in this article form part of the report on a men- ily therapist who accompanied and assessed the patients and
tal health programme focusing on reducing burden, suffering their relatives throughout the process.
and social spending in mental illness (PRISMA) for patients The authors acknowledge that despite its strengths, such
with schizophrenia and bipolar disorder who were randomly as sample size, adequate randomisation, design of indivi-
assigned to an MI or TI. The primary objective of this part of dualised treatment programmes, management of a very sick
the research was to assess changes in family dynamics after population and the use of highly experienced therapists, this
treatment. The groups of patients with bipolar disorder and study also has its limitations. The most important limitations
schizophrenia assigned to each of the treatment arms (MI and include the absence of masking to therapists and evaluators,
TI) had similar demographic and clinical characteristics, and and the lack of control of other parallel interventions that
had adequate randomisation. might have positively or negatively affected the final outcome.
In the scores for the Caregiver Burden Scale (CBS), cohe- This was a population sample with heterogeneous pharma-
sion and adaptability (FACES III) and over-involvement and cotherapy and medical and psychiatric comorbidity, and high
criticism (FEICS) at the beginning of the programme, a higher consumption of psychoactive drugs, meaning that all patients
level of criticism was observed in patients with bipolar disor- had some other type of care in their healthcare system which
der than in patients with schizophrenia compared with their could not be eliminated from the study for economic and eth-
relatives; although the difference was large, it did not reach ical reasons.
statistical significance in the end. When assessing the carer’s
burden with the CBS scale, it was observed that 1 in 4 patients
with bipolar disorder and schizophrenia had “high objective
family burden” (emotional, work, leisure time, relational, eco- Conclusions
nomic and at home), but when that burden was correlated
with the patient’s condition, only 50% on average considered This study showed no differences in the variables of fam-
that there might be “some relationship” or “a clear relation- ily burden and family functioning in patients with bipolar
ship” between the burden and the patient’s illness. Close to disorder and schizophrenia who were in an MI programme
94% of the relatives reported having “some burden”. compared with patients in the TI programme. Future studies
Comparing the CBS, FACES III and FEICS scores at base- might include longer periods for remaining in the MI and more
line and at the end of the intervention in the group assigned frequent appointments and, additionally, they might explore
to the MI, we found some significant differences in family family dynamics with other instruments to achieve greater
cohesion in the bipolar disorder group and adaptability in the effects.
10 r e v c o l o m b p s i q u i a t . 2 0 1 7;4 6(1):2–11

mind in remitted patients with schizophrenia: effect of

Ethical disclosures residual symptoms. J Nerv Ment Dis. 2008;196:95–9.
8. Alptekin K, Erkoç S, Göğüş AK, Kültür S, Mete L, Uçok A, et al.
Protection of human and animal subjects. The authors Disability in schizophrenia: clinical correlates and prediction
declare that no experiments were performed on humans or over 1-year follow-up. Psychiatry Res. 2005;135:103–11.
animals for this study. 9. Gühne U, Weinmann S, Arnold K, Becker T, Riedel-Heller SG.
S3 guideline on psychosocial therapies in severe mental
illness: evidence and recommendations. Eur Arch Psychiatry
Confidentiality of data. The authors declare that they have fol-
Clin Neurosci. 2015;265:173–88.
lowed the protocols of their work centre on the publication of
10. Van der Voort TYG, Van Meijel B, Hoogendoorn AW, Goossens
patient data. PJJ, Beekman ATF, Kupka RW. Collaborative care for patients
with bipolar disorder: effects on functioning and quality of
Right to privacy and informed consent. The authors have life. J Affect Disord. 2015;179:14–22.
obtained the written informed consent of the patients or sub- 11. Van der Voort TYG, Van Meijel B, Goossens PJJ, Renes J,
jects mentioned in the article. The corresponding author is in Beekman ATF, Kupka RW. Collaborative care for patients with
bipolar disorder: a randomised controlled trial. BMC
possession of this document.
Psychiatry. 2011;11:133.
12. Gehart DR. The Mental Health Recovery Movement and
Funding Family Therapy, Part I: consumer-led reform of services to
persons diagnosed with severe mental illness. J Marital Fam
Ther. 2012;38:429–42.
This project was funded by COLCIENCIAS, CODI-Universidad 13. McCann TV, Bamberg J, McCann F. Family carers’ experience
de Antioquia and Hospital Universitario de San Vicente Fun- of caring for an older parent with severe and persistent
dación. mental illness. Int J Ment Health Nurs. 2015;24:203–12.
14. Carson VB, Yambor SL. Managing patients with bipolar
disorder at home: a family affair and a psychiatric challenge
Conflict of interests
in home healthcare. Home Health Nurse. 2012;30:280–91, quiz
291–3.
None. 15. Miklowitz DJ, Simoneau TL, George EL, Richards JA, Kalbag A,
Sachs-Ericsson N, et al. Family-focused treatment of bipolar
disorder: 1-year effects of a psychoeducational program in
Acknowledgements
conjunction with pharmacotherapy. Biol Psychiatry.
2000;48:582–92.
The authors would like to thank COLCIENCIAS, CODI- 16. Hsiao C-Y, Tsai Y-F. Factors of caregiver burden and family
Universidad de Antioquia, Hospital Universitario de San functioning among Taiwanese family caregivers living with
Vicente Fundación and PRISMA U.T. schizophrenia. J Clin Nurs. 2015;24:1546–56.
17. Aldersey HM, Whitley R. Family influence in recovery from
severe mental illness. Community Ment Health J.
references 2015;51:467–76.
18. Cechnicki A, Bielańska A, Hanuszkiewicz I, Daren A. The
predictive validity of expressed emotions (EE) in
1. Organización Mundial de la Salud. Invertir en salud mental. schizophrenia. A 20-year prospective study. J Psychiatr Res.
Ginebra: OMS; 2004. 2013;47:208–14.
2. Bourne C, Aydemir Ö, Balanzá-Martínez V, Bora E, Brissos S, 19. Wuerker A, Long J, Haas G, Bellack A. Interpersonal control,
Cavanagh JT, et al. Neuropsychological testing of cognitive expressed emotion, and change in symptoms in families of
impairment in euthymic bipolar disorder: an individual persons with schizophrenia. Schizophr Res. 2002;58:281–92.
patient data meta-analysis. Acta Psychiatr Scand. 20. Eisner LR, Johnson SL. An acceptance-based psychoeducation
2013;128:149–62. intervention to reduce expressed emotion in relatives of
3. Bearden CE, Shih VH, Green MF, Gitlin M, Sokolski KN, bipolar patients. Behav Ther. 2008;39:375–85.
Levander E, et al. The impact of neurocognitive impairment 21. Carrà G, Cazzullo CL, Clerici M. The association between
on occupational recovery of clinically stable patients with expressed emotion, illness severity and subjective burden of
bipolar disorder: a prospective study. Bipolar Disord. care in relatives of patients with schizophrenia. Findings
2011;13:323–33. from an Italian population. BMC Psychiatry. 2012;12:140.
4. Bora E, Yucel M, Pantelis C. Cognitive endophenotypes of 22. Van Humbeeck G, Van Audenhove C, De Hert M, Pieters G,
bipolar disorder: a meta-analysis of neuropsychological Storms G. Expressed emotion: a review of assessment
deficits in euthymic patients and their first-degree relatives. J instruments. Clin Psychol Rev. 2002;22:321–41.
Affect Disord. 2009;113:1–20. 23. Palacio CA, García J, Arbeláez MP, Sánchez R, Aguirre B, Garcés
5. Rosa AR, Reinares M, Michalak EE, Bonnin CM, Sole B, Franco IC, et al. Validación de la entrevista diagnóstica para estudios
C, et al. Functional impairment and disability across mood genéticos (DIGS) en Colombia. Biomedica. 2004;24:56–62.
states in bipolar disorder. Value Health. 2010;13: 24. American Psychiatric Association. Diagnostic and statistical
984–8. manual for mental disorders. Text revision. 4a ed. Arlington:
6. Tyrer P. Personality abnormality in severe mental illness and APA; 2000.
its influence on outcome of intensive and standard case 25. Williams JB. A structured interview guide for the Hamilton
management: a randomised controlled trial. Eur Psychiatry. Depression Rating Scale. Arch Gen Psychiatry. 1988;45:742–7.
2000;15:7–10. 26. Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for
7. Bora E, Gökçen S, Kayahan B, Veznedaroglu B. Deficits of mania: reliability, validity and sensitivity. Br J Psychiatry.
social-cognitive and social-perceptual aspects of theory of 1978;133:429–35.
 r e v c o l o m b p s i q u i a t . 2 0 1 7;4 6(1):2–11 11

27. Andreasen NC, Olsen S. Negative v positive schizophrenia. 29. Schmidt V, Barreyro JP, Maglio AL. Escala de evaluación del
Definition and validation. Arch Gen Psychiatry. funcionamiento familiar FACES III: ¿Modelo de dos o tres
1982;39:789–94. factores. Escritos Psicol. 2004;3:30–6.
28. Restrepo N, Hernández DL, Cardona LJ, Arango AM, 30. Sánchez Moreno J, Reinares M, Torrent C, Colom F, Vieta E,
González D, Puerta A, et al. Validación de la escala de Benabarre A, et al. Evaluación de la carga familiar: una
envolvimiento emocional y criticismo familiar (FEICS) en la propuesta de escala autoaplicada derivada de la escala de
población clínica psiquiátrica colombiana. Rev Colomb desempeño psicosocial. Rev Psiquiatr Fac Med Barc.
Psiquiatr. 2004;33:143–62. 2004;31:7–13.