Abstract
Background: Attitudes of patients, their relatives and caregivers toward psychosocial interventions have been identified through different studies. However, the attitudes of psychiatrists have not been documented in Greece. Aim: (i) To document the attitudes of psychiatrists toward psychosocial interventions for patients with schizophrenia. (ii) To identify their knowledge regarding ongoing programs, as well as their opinion on the availability of organized support structures. Materials and Methods: A two-phase qualitative study was carried-out in representative regions of Greece. A questionnaire was administered to 26 randomly-selected psychiatrists in private practice in the context of an online survey about schizophrenia (PONTE). Results: All respondents considered the role of the family as being critical and the majority (80%) highlighted the efficacy of family counseling among the psychosocial therapeutic strategies. Half of the psychiatrists reported an ineffective information network on support programs, and most of the respondents (73%) considered the available psychosocial support programs to be insufficient. Conclusion: An insufficient network of organized support structures for patients with schizophrenia is reported by Greek psychiatrists. There is consensus for the need to involve family members during psychosocial treatment.
Psychosocial interventions in schizophrenia aim at minimizing adverse effects of disease burden, as well as managing patient's functional deficits. To achieve this, medication is combined with re-inforcement of patients' existing capacities, social skills training and development of multi-lateral social support interventions (1). The organization of psychiatric services, factors related to medication, and the extent of psychosocial education of patients and their relatives considerably affect compliance (2). Therapies with psychoeducational components can focus on improving adherence to medication and reducing relapse and re-hospitalization (3, 4).
Several studies have been conducted to identify attitudes of patients, their relatives and caregivers toward illness and medication (5-9), as well as their joint conceptions of relapse (10), and doctors' attitudes regarding the treatment and prevention of relapse (2). The vital role of the family or other social support is emphasized in different settings (9). The prejudice of relatives against medication may have an effect on patient compliance with maintenance therapy and thereafter, on their relapse rate (11). It is important to take subjective attitudes and concerns of patients with respect to their illness and medication seriously (4, 5). It is suggested that patients and, if possible, their relatives, be included in the treatment decision process in order to enhance medication compliance (5).
Awareness of mental illness by the family members is indicated at the initial stage of diagnosis to reduce fears and prevent stigmatization. Long-term family therapy can focus on implementing strategies to reduce stress, help overcome this situation and lead the family to support the gradual re-integration of the patients in their activities. Long-term collaboration with the family can be supportive, behavioral, or of systemic type (1).
A patient's perspective of participating in psychoeducation is related to their willingness to obtain more information about their illness in order to improve their quality of life (12). Positive effects on coping, activation and social interaction have been reported and the integration of quality of life topics has been appreciated (13). However, no qualitative study has been conducted in Greece to document doctors' attitudes toward supportive psychosocial therapies for patients with schizophrenia.
The present study aimed to identify the attitudes of psychiatrists regarding psychosocial interventions, their knowledge about ongoing programs, as well as their opinion about the availability of organized support structures for patients with schizophrenia in Greece.
Materials and Methods
Out of a total of 423 doctors in private practice on the initial list, 174 were randomly selected and were invited via telephone to participate (81 refused). The final number of participants was set at 26, with an initial criterion to be a representative sample of the entire territory. The study sample comprised of 26 psychiatrists, according to the final randomization list, who filled in a structured electronic questionnaire in the context of an online opinion survey about schizophrenia for the PONTE program (Program of specialists' mutual convergence for the management of neuropsychiatric disorders), based on the Delphi Method (14, 15).
The questionnaire contained 34 questions and all responses were elicited in a scale form. Different topics related to schizophrenia were approached, including patient's characteristics, parameters influencing the progression of schizophrenia and psychosocial interventions in support of the illness. This questionnaire included questions about patients' demographic features (age, sex, marital status), as well as the main causes of non-compliance during treatment. Respondents were asked their opinion about the participation of family members during patient's psychosocial treatment and the role of the family as far as the progression of the illness is concerned. Likewise, they were asked about psychosocial support programs for family members and patients with schizophrenia in their region. They were also asked about the adequacy of the information network about support programs for patients with schizophrenia, the main sources of such information, and forms of psychosocial interventions. Respondents had to note the form of psychosocial intervention they would consider essential for their patients, the satisfaction rate regarding the availability of psychosocial support programs and the network of organized support structures for patients with chronic illness.
The respondents in private practice were randomly selected from 6 different representative regions of Greece, in order to present different populations in a representative way (Athens, Thessaloniki, Crete and islands, Central Greece, Peloponnese, Northern Greece). Five groups were formed according to their duration of practice as a psychiatrist: group 1, up to 5 years; group 2, 5-10 years; group 3, 10-15 years; group 4, 15-20 years; and group 5, more than 20 years. Respondents were also asked about their adequacy of access to sources of scientific information. In a second approach, participants were given a repeat questionnaire. All responses were taken into account and there was not any statistical analysis except percentages and frequencies of the responses, according to the Delphi Method (14, 15).
Results
The respondents (n=26) were psychiatrists, and half of them had worked as a psychiatrist for up to 10 years (19% up to five years, 31% 5-10 years). More than half of the respondents (58%) were working in regions with more than 200,000 habitants. The majority (81%) reported adequate and easily-accessible sources of scientific information in their region, mainly via internet access (38%) and scientific congresses (35%).
Most of the patients with schizophrenia who visited a private psychiatrist for the first time were aged 20-30 years (73%). The average social profile of patients with schizophrenia in Greece is male (59,6%), single (83%), living with his parents (63%), without children. Despite the high level of acceptance of treatment initially, denial of the illness (79%) and disbelief (70%) were the main causes of non-compliance with treatment. The subjects in this study showed consensus for the need to involve family members during psychosocial treatment, considering the role of the family as being critical in improving the progression of the illness (100%).
Respondents were asked about psychosocial support programs for family members in their region: 27% of them reported insufficient ongoing programs and a further 24% had no information. When asked if they were adequately informed about support programs for patients with schizophrenia offered by healthcare Institutions and hospitals, half of the psychiatrists reported the information network in their region to be ineffective. The main sources of information about programs of psychosocial intervention were public mental health centers (65%) and hospitals (54%).
A total of 23% of the respondents had no information regarding psychosocial support programs of their region for patients with schizophrenia and 15% reported insufficient psychosocial interventions.
Respondents were also asked about the forms of psychosocial interventions currently being carried out; the answers included social skills training in 81%, supportive psychotherapy in 75%, family counseling in 69%, psychoeducation in 31% and cognitive-behavioral therapy in 25% of the respondents. The majority of the respondents (80%) considered family counseling as being more effective for their patients, 73% supportive psychotherapy and 62% social skills training.
Overall, the majority of psychiatrists (73%) regarded the available psychosocial support programs of their region as being insufficient. A poor network of organized support structures for patients with chronic illness was reported and the family (65%) had assumed this role while the patient was in remission.
Discussion
Attitudes of mental health private practitioners toward psychosocial interventions for patients with schizophrenia were determined through a qualitative study. An ineffective network of organized support structures as well as inadequate information network were reported, and the need to involve the patient's family during psychosocial treatment was emphasized.
Adjunctive psychosocial therapies have been used to help alleviate residual symptoms and to improve social functioning and quality of life in patients with schizophrenia, amplifying the benefits of pharmacotherapy and enhancing functioning in psychotic disorders (3, 16). Therapies with psychoeducational components for patients and their families have been considered to be the most promising during recent decades. The total effectiveness of psychoeducational interventions has been demonstrated by a great amount of research in this field (17) and improvements in parameters such as reduction of relapse, increase of quality of life and adherence to medication have been confirmed (17-22).
Demographic variables have not been consistently reported to correlate with compliance in schizophrenia. The severity of the disorder has been found to correlate with compliance (7). Patients' subjective reasons for non-compliance with treatment have been reported in different studies and include side-effects (6-8), lack of acceptance of the necessity for medication and lack of insight into the disease (6, 7). The perception of benefit and a subjective sensation of well-being seem to have been more consistently correlated with compliance (7, 8). In our study, denial of the illness and disbelief were the main causes of non-compliance during treatment.
A positive therapeutic alliance and a positive attitude of significant others toward neuroleptic treatment seem to contribute to patients' medication compliance (6, 7). Initiatives aiming at improving treatment adherence have been proposed, involving family/key persons in care (4). Doctors in this study were convinced of the need to involve family in psychosocial intervention for patients with schizophrenia, assuming family members are able to participate. The role of the family is unanimously (100%) considered crucial for the course of the illness. These findings are in concordance with previous data supporting the efficacy of family psychoeducation (23) and having demonstrated reduced relapse rates, improved outcomes and improved family well-being among participants (24-27), suggesting that long-term family interventions are particularly helpful (28).
Despite the agreement of these assessments, psychosocial support programs for family members were deemed insufficient in our study. More than half of the psychiatrists asked, reported on a scarcity of ongoing programs and related information.
An ineffective information network about specific support programs offered by healthcare Institutions and hospitals for patients with schizophrenia is indicated. One out of two doctors admited to not being adequately informed of such programs. Mental health Centers (65%) and hospitals (54%) are the main sources of such information in Greece. During this period of economic crisis in Greece, a drastic 30% reduction in government funding and an extraordinary delay in the provision of essential resources have evident consequences on the mental health of its citizens (29).
The conduct of psychosocial support programs for patients with schizophrenia was assessed as being insufficient, since a percentage of respondents in this study either had no information about psychosocial interventions in their region (23%), or found them to be inadequate (15%).
Previous studies on representative samples of psychiatric services have shown a low degree of effective rehabilitation interventions, probably due to the scarcity of mental health workers trained in social and work skills strategies and the absence of a structured framework to formulate rehabilitation practices (30). A survey to evaluate the actual availability of rehabilitation services in France was conducted by Leguay et al., and suggested that the majority of public service psychiatrists have access to hospital and ambulatory facilities for treatment, while psychiatrists who are private practitioners have less access to such arrangements for their patients (31).
The major psychosocial therapeutic strategies currently in use for patients with schizophrenia as documented by Greek private psychiatrists are: social skills training, supportive psychotherapy and family counseling, followed by psychoeducation and cognitive-behavioral therapy. Most of them (80%) highlight the efficacy of family counseling, considering supportive psychotherapy (73%) and social skills training (62%) indispensable.
In the international literature, findings pertaining to the efficacy of psychosocial interventions included cognitive-behavioral therapy, family intervention, social skills training and vocational rehabilitation, suggesting improvement in different parameters such as medication adherence, relapse prevention, skills and overall functioning (3, 32-34).
Despite limitations, recent findings regarding the efficacy of cognitive-behavioral therapy and family intervention in early psychosis are consistent with the evidence base found in the treatment of later psychotic episodes (35-37). Family intervention reduced relapse and hospital admission rates when compared with standard care, whereas cognitive-behavioral therapy reduced the severity of symptoms (35).
Doctors in the present study reported on a low degree of satisfaction regarding the availability of psychosocial support programs in their region. It is considered that due to an inadequate network of organized support structures for patients with chronic illness, the family has assumed this role in the majority of cases (65%).
Conclusion
The majority of Greek doctors surveyed find easy access to scientific information in their region, due to spread of the internet. Despite this, one out of two psychiatrists reported the information network about specific support programs offered by healthcare Institutions and hospitals for patients with schizophrenia to be inadequate. The main sources of such information are mental health Centers and hospitals. Assuming that private practitioners have less access to these arrangements for their patients, additional sources of information should be provided. Medical associations and local authorities could potentially undertake this.
Overall, our findings imply an insufficient network of organized support structures for patients with established schizophrenia. The role of the family in supporting these patients while in remission, therefore, becomes essential. Developing early intervention services consisting of community-based multi-disciplinary mental health teams is expected to have clinically important benefits over standard care. Programs of family interventions should be enhanced, taking into account evidence that such a type of intervention reduces hospital admission and relapse rates.
In order to increase the satisfaction regarding available psychosocial interventions, continuing educational programs for physicians are required to address the best management of patients with schizophrenia.
Acknowledgements
Sanofi had assigned the conduct of the program to the polling company “Hellenic Research House”.
- Received November 12, 2013.
- Revision received February 6, 2014.
- Accepted February 7, 2014.
- Copyright © 2014 The Author(s). Published by the International Institute of Anticancer Research.
References
In this issue
Jump to section
Related Articles
Cited By...
- No citing articles found.