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Psycho Education

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Psychoeducation for schizophrenia (Review)
Xia J, Merinder LB, Belgamwar MR

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2013, Issue 1 http://www.thecochranelibrary.com

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

TABLE OF CONTENTS

HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . . BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.1. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 1 Compliance: 1a. With medication - non-compliance. . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.2. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 2 Compliance: 1b. With medication - partial compliance. . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.4. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 4 Compliance: 2a. With follow up - loss to follow-up for any reason. . . . . . . . . . . . . . . . . . . . . Analysis 1.5. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 5 Compliance: 2b. With follow-up - received intervention but left the study early. . . . . . . . . . . . . . . . . Analysis 1.6. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 6 Compliance: 2c. With follow-up - allocated but never accepted treatment. . . . . . . . . . . . . . . . . . Analysis 1.7. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 7 Relapse: 1. Relapse for any reason. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.8. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 8 Relapse: 2. Relapse with readmission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.9. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 9 Knowledge: 1a. Average endpoint scale scores on various knowledge scales. . . . . . . . . . . . . . . . . . Analysis 1.11. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 11 Knowledge: 2. Average endpoint scores on various insight scales. . . . . . . . . . . . . . . . . . . . . . Analysis 1.12. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 12 Knowledge: 3. Average endpoint score on illness-related attitudes - 4 months (KK, high = high expressed). . . . . . . Analysis 1.13. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 13 Knowledge: 4. level of knowledge did not improve. . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.14. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 14 Behaviour: Average score (NOSIE-30, endpoint, high = poor). . . . . . . . . . . . . . . . . . . . . . Analysis 1.15. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 15 Social functioning: 1a. Average change scores on various scales - medium term (high = poor). . . . . . . . . . Analysis 1.16. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 16 Social functioning: 1b. Average endpoint scores on various scales (high = poor). . . . . . . . . . . . . . Analysis 1.18. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 18 Global functioning: 1. No clinically significant improvement. . . . . . . . . . . . . . . . . . . . . Analysis 1.19. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 19 Global functioning: 2. Average endpoint scale score. . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.20. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 20 Service utilisation: days in hospital. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

1 1 2 2 7 7 7 13 18 20 25 28 28 29 40 102 110 111 113 114 115 116 117 118 120 121 122 123 124 125 127 128 129 i Analysis 1.22. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 22 Global state: 1. Average endpoint score - medium term (CGI, high = poor). . . . . . . . . . . . . . . . Analysis 1.23. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 23 Global state: 2. Increased medication dose by 25%. . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.24. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 24 Global state: 3. Disability - long term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.25. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 25 Mental state: 1a. Global - continuous - average total endpoint scale scores (high = poor). . . . . . . . . . . . Analysis 1.26. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 26 Mental state: 1b. Global - continuous - average change scale scores - medium term (high = good). . . . . . . . Analysis 1.28. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 28 Mental state: 2a. Specific - binary - specific symptoms - short term. . . . . . . . . . . . . . . . . . . Analysis 1.29. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 29 Mental state: 2b. Specific - continuous - average endpoint PANSS scores (high = poor). . . . . . . . . . . . Analysis 1.30. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 30 Expressed emotion: Participants with high EE relatives (FQ). . . . . . . . . . . . . . . . . . . . . . Analysis 1.31. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 31 Quality of life: Average endpoint scores on various scales (high = favourable). . . . . . . . . . . . . . . . . Analysis 1.32. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 32 Quality of life: Average endpoint scores on various scales (high = poor). . . . . . . . . . . . . . . . . . . Analysis 1.33. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 33 Satisfaction with mental health services: 1. Short term - average change score (VSS, high = good). . . . . . . . . . Analysis 1.34. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 34 Satisfaction with mental health services: 2. Average change - at 1 year (VSS Scale, high = good). . . . . . . . . . . Analysis 1.35. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 35 Satisfaction with mental health services: 3. Binary outcome. . . . . . . . . . . . . . . . . . . . . . . Analysis 1.36. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 36 Adverse event: Death. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.1. Comparison 2 SUBGROUP ANALYSES 1. BRIEF PSYCHOEDUCATION/STANDARD PSYCHOEDUCATION vs STANDARD CARE, Outcome 1 Compliance: 1a. With medication - binary outcomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.2. Comparison 2 SUBGROUP ANALYSES 1. BRIEF PSYCHOEDUCATION/STANDARD PSYCHOEDUCATION vs STANDARD CARE, Outcome 2 Compliance: 2. With follow-up - loss to follow-up for any reason. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.3. Comparison 2 SUBGROUP ANALYSES 1. BRIEF PSYCHOEDUCATION/STANDARD PSYCHOEDUCATION vs STANDARD CARE, Outcome 3 Compliance: 2a. with follow-up - received intervention but left the study early. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.4. Comparison 2 SUBGROUP ANALYSES 1. BRIEF PSYCHOEDUCATION/STANDARD PSYCHOEDUCATION vs STANDARD CARE, Outcome 4 Relapse: Relapse for any reason. . . . . . . Analysis 3.1. Comparison 3 SUBGROUP ANALYSES 2. GROUP PSYCHOEDUCATION/INDIVIDUAL PSYCHOEDUCATION vs STANDARD CARE, Outcome 1 Compliance: 1a. With medication - binary outcomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 3.2. Comparison 3 SUBGROUP ANALYSES 2. GROUP PSYCHOEDUCATION/INDIVIDUAL PSYCHOEDUCATION vs STANDARD CARE, Outcome 2 Compliance: 2. With follow-up - leaving the study early/loss to follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 3.3. Comparison 3 SUBGROUP ANALYSES 2. GROUP PSYCHOEDUCATION/INDIVIDUAL PSYCHOEDUCATION vs STANDARD CARE, Outcome 3 Relapse: Relapse for any reason. . . . . . . Analysis 4.1. Comparison 4 SENSITIVITY ANALYSIS - Chinese studies vs non-Chinese studies, Outcome 1 Compliance: 1a. With medication - non-compliance. . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 4.2. Comparison 4 SENSITIVITY ANALYSIS - Chinese studies vs non-Chinese studies, Outcome 2 Compliance: 2a. With follow-up - loss to follow-up for any reason. . . . . . . . . . . . . . . . . . . . . Analysis 4.3. Comparison 4 SENSITIVITY ANALYSIS - Chinese studies vs non-Chinese studies, Outcome 3 Compliance: 2b. With follow-up - received intervention but left the study early. . . . . . . . . . . . . . . . .
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152 153 155 156 158 ii Analysis 4.4. Comparison 4 SENSITIVITY ANALYSIS - Chinese studies vs non-Chinese studies, Outcome 4 Relapse: 1. Relapse for any reason. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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[Intervention Review]

Psychoeducation for schizophrenia
Jun Xia1 , Lars Bertil Merinder2 , Madhvi R Belgamwar3
1 Cochrane

Schizophrenia Group, The University of Nottingham, Nottingham, UK. 2 Dept of Psychiatric Demography, Institute of Basic Psychiatric Research, University Hospital of Aarhus, Risskov, Denmark. 3 Radbourne Unit, Royal Derby Hospital, Derby, UK

Contact address: Jun Xia, Cochrane Schizophrenia Group, The University of Nottingham, Institute of Mental Health, Sir Colin Campbell Building„ University of Nottingham Innovation Park, Triumph Road„ Nottingham, NG7 2TU, UK. Jun.Xia@nottingham.ac.uk. Editorial group: Cochrane Schizophrenia Group. Publication status and date: Edited (no change to conclusions), published in Issue 1, 2013. Review content assessed as up-to-date: 19 April 2010. Citation: Xia J, Merinder LB, Belgamwar MR. Psychoeducation for schizophrenia. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD002831. DOI: 10.1002/14651858.CD002831.pub2. Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT Background Schizophrenia can be a severe and chronic illness characterised by lack of insight and poor compliance with treatment. Psychoeducational approaches have been developed to increase patients’ knowledge of, and insight into, their illness and its treatment. It is supposed that this increased knowledge and insight will enable people with schizophrenia to cope in a more effective way with their illness, thereby improving prognosis. Objectives To assess the effects of psychoeducational interventions compared with standard levels of knowledge provision. Search methods We searched the Cochrane Schizophrenia Group Trials Register (February 2010). We updated this search November 2012 and added 27 new trials to the awaiting assessment section. Selection criteria All relevant randomised controlled trials focusing on psychoeducation for schizophrenia and/or related serious mental illnesses involving individuals or groups. We excluded quasi-randomised trials. Data collection and analysis At least two review authors extracted data independently from included papers. We contacted authors of trials for additional and missing data. We calculated risk ratios (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data. We used a fixedeffects model for heterogeneous dichotomous data. Where possible we also calculated the numbers needed to treat (NNT), as well as weighted means for continuous data. Main results This review includes a total of 5142 participants (mostly inpatients) from 44 trials conducted between 1988 and 2009 (median study duration ~ 12 weeks, risk of bias - moderate). We found that incidences of non-compliance were lower in the psychoeducation group in the short term (n = 1400, RR 0.52 CI 0.40 to 0.67, NNT 11 CI 9 to 16). This finding holds for the medium and long term. Relapse appeared to be lower in psychoeducation group (n = 1214, RR 0.70 CI 0.61 to 0.81, NNT 9 CI 7 to 14) and this also
Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 1

applied to readmission (n = 206, RR 0.71 CI 0.56 to 0.89, NNT 5 CI 4 to 13). Scale-derived data also suggested that psychoeducation promotes better social and global functioning. In the medium term, treating four people with schizophrenia with psychoeducation instead of standard care resulted in one additional person showing a clinical improvement. Evidence suggests that participants receiving psychoeducation are more likely to be satisfied with mental health services (n = 236, RR 0.24 CI 0.12 to 0.50, NNT 5 CI 5 to 8) and have improved quality of life. Authors’ conclusions Psychoeducation does seem to reduce relapse, readmission and encourage medication compliance, as well as reduce the length of hospital stay in these hospital-based studies of limited quality. The true size of effect is likely to be less than demonstrated in this review - but, nevertheless, some sort of psychoeducation could be clinically effective and potentially cost beneficial. It is not difficult to justify better, more applicable, research in this area aimed at fully investigating the effects of this promising approach. Note: the 27 new citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.

PLAIN LANGUAGE SUMMARY Psychoeducation added to standard treatment for schizophrenia reduces relapse The purpose of patient education/teaching (or psychoeducation) is to increase patients’ knowledge and understanding of their illness and treatment. It is supposed that increased knowledge enables people with schizophrenia to cope more effectively with their illness. Psychoeducational interventions involve interaction between the information provider and the mentally ill person. This review compares the efficacy of psychoeducation added to standard care as a means of helping severely mentally ill people with that of standard care alone. The evidence shows a significant reduction of relapse or readmission rates. There seems to be some suggestion that psychoeducation may improve compliance with medication, but the extent of improvement remains unclear. The findings show a possibility that psychoeducation has a positive effect on a person’s well being and promotes better social function. In the medium term, treating four people with schizophrenia with psychoeducation instead of standard care resulted in one additional person showing a clinical improvement. The scarcity of studies made the comparison between the efficacy of different formats (programmes of 10 sessions or less or 11 or more, individual or group sessions) weak.

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]

ANY FORM OF PSYCHOEDUCATION compared with STANDARD CARE for schizophrenia

Patient or population: patients with schizophrenia Settings: in hospital Intervention: ANY FORM OF PSYCHOEDUCATION Comparison: STANDARD CARE Illustrative comparative risks* (95% CI) Relative effect (95% CI) No of participants (studies) Quality of the evidence (GRADE) Comments

Outcomes

Assumed risk STANDARD CARE ANY FORM OF PSYCHOEDUCATION RR 0.48 (0.31 to 0.75) 96 per 1000 (62 to 150) 282 (3 studies)

Corresponding risk

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Compliance: Not compli- Low risk population1 ant with medication 200 per 1000 Follow-up: 12 months

⊕ very low2,3,4

Medium risk population1 400 per 1000 192 per 1000 (124 to 300)

High risk population1 800 per 1000 384 per 1000 (248 to 600) RR 0.77 (0.48 to 1.23) 172 (2 studies) ⊕ very low2,3,4

Compliance: 2a. With Low risk population1 follow-up - loss to follow-up for any reason long term (by 5 years or more) Follow-up: 12 months

3

200 per 1000

154 per 1000 (96 to 246)

Medium risk population1 400 per 1000 308 per 1000 (192 to 492)

High risk population1 800 per 1000 616 per 1000 (384 to 984) RR 0.63 (0.38 to 1.04) 206 (2 studies) ⊕⊕ low2,4

Compliance: 2b. With Low risk population1 follow-up - received in126 per 1000 tervention but left the 200 per 1000 (76 to 208) study early - long term Follow-up: 12 months Medium risk population1 400 per 1000 252 per 1000 (152 to 416)

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

High risk population1 800 per 1000 504 per 1000 (304 to 832) RR 0.73 (0.62 to 0.85) 146 per 1000 (124 to 170) 790 (6 studies) ⊕⊕ low4,6

Relapse: 1. Relapse for Low risk population5 any reason - long term 200 per 1000 Follow-up: 12 months

Medium risk population5

4

400 per 1000

292 per 1000 (248 to 340)

High risk population5 800 per 1000 584 per 1000 (496 to 680) RR 0.71 (0.56 to 0.89) 142 per 1000 (112 to 178) 206 (2 studies) ⊕⊕ low2,4

Relapse: 2. Relapse with Low risk population7 readmission - long term 200 per 1000 Follow-up: 12 months

Medium risk population7 400 per 1000 284 per 1000 (224 to 356)

High risk population7 800 per 1000 568 per 1000 (448 to 712) RR 0.4 (0.17 to 0.96) 116 (1 study) ⊕⊕ low2,4

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Satisfaction with mental Low risk population1 health services: 3. bi80 per 1000 nary outcome - medium 200 per 1000 (34 to 192) term - unsatisfied Follow-up: 12 months Medium risk population1 400 per 1000 160 per 1000 (68 to 384)

High risk population1

5

800 per 1000

320 per 1000 (136 to 768) RR 1.39 (0.24 to 8.11) ⊕⊕ low2,4 14 per 1000 (2 to 81) 344 (2 studies)

Adverse event: Death - Low risk population8 long term 10 per 1000 Follow-up: 12 months

Medium risk population8 30 per 1000 42 per 1000 (7 to 243)

High risk population8 50 per 1000 69 per 1000 (12 to 405)

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.

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Control risk from studies - about 30% Randomisation poorly described 3 High heterogeneity not explained by study design, population or interventions 4 Small sample size - confidence interval around best estimate of effect include both no effect and appreciable benefit/harm 5 Control risk from studies - about 50% 6 50% of the included studies used scientific randomisation methods and provided description of methods, but the other 50% did not describe randomisation methods 7 Control risk from studies - about 70% 8 Control risk from studies - about 1%

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BACKGROUND

Description of the condition
Schizophrenia is a chronic, severe and disabling illness which affects approximately 1% of the population. It is a worldwide illness that crosses all cultures and socioeconomic groups (Fortinash 2000). The severe and long-lasting symptoms of schizophrenia cause considerable disability.

Description of the intervention
Psychoeducation may be defined as the education of a person with psychiatric disorder in subject areas that serve the goals of treatment and rehabilitation. The terms ’patient education’, ’patient teaching’, and ’patient instruction’ have also been used for this process. All imply that there is a focus on knowledge. The purpose of patient education is to enable the patient to engage in behaviour change. Compliance with treatment for seriously or persistently mentally ill people is of great concern and is often a focus of patient education. Many people with severe mental illness are frequently and repeatedly hospitalised due to poor compliance with treatment. Many patients feel stigmatised by their illness and may deny its existence, which ultimately increases non-compliance. This issue is even more of a problem when people are living in the community, and is often related to adverse effects of medication as well as a lack of adequate knowledge about medication (Antai-Otong 1989). Therefore, the goal of patient education may be to try to prevent hospitalisation or to manage the illness or condition to help the patient attain her/his maximum degree of health. The psychiatric and mental health nursing practice standards include patient teaching and, according to these standards, client adherence to treatment regimens increases when health education is an integral part of the client’s care (ANA 1982).

Relapse is a major challenge in the rehabilitation of people with schizophrenia (Ayuso-Gutierrez 1997), and high relapse rates are often related to non-compliance with treatment (Lacro 2002). Therefore, teaching patients and families with a view to improving treatment compliance is a major goal in psychiatric nursing (Antai-Otong 1989). Illness management programmes such as psychoeducation have traditionally provided information for adhering to treatment and minimizing relapse. Extensive research has been conducted around the effectiveness of such interventions. While many prior studies indicated positive effects of psychoeducation on reducing symptoms and minimising relapse (Klingberg 1999; Dixon 2000), others showed that the intervention increased patients’ knowledge about mental illness but didn’t affect other outcomes or their behaviour (Barrowclough 1987; Tarrier 1988). The previous version of this review was also inconclusive, as most of the included studies produced equivocal effects or skewed data. Many new studies have been conducted since the previous review, and therefore it is important that we re-evaluate the effectiveness of psychoeducation with the presence of new evidence. This review represents an important and considerable update of the previous version of this work.

OBJECTIVES
The primary objective was to assess the efficacy of psychoeducational interventions as means of helping severely mentally ill people when added to ’standard’ care, compared to the efficacy of standard care alone. The secondary objective was to investigate whether there is evidence that a particular kind (individual/ family/group) or duration (brief/other) of psychoeducational intervention is superior to others.

How the intervention might work
Education is a gradual process by which a person gains knowledge and understanding through learning. Learning, however, involves more than knowledge and, according to Rankin 1996, it can involve cognitive, affective and psychomotor processes. Learning implies changes in behaviour, skill or attitude (Falvo 1994). Patient education can take a variety of forms depending upon the abilities and interest of the patient and family. For example, the education may take place in small groups or on a one-to-one basis; it may involve the use of videotapes or pamphlets or a combination of these.

METHODS

Criteria for considering studies for this review
Types of studies All relevant randomised controlled trials (RCTs). We excluded quasi-randomised trials, using, for example, alternation as the method of randomisation. Types of participants People suffering from severe non-affective mental disorders such as schizophrenia and schizophreniform, schizoaffective or schizotypal disorders, and including those with multiple diagnoses.
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Why it is important to do this review

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Types of interventions 1. We included all didactic interventions of psychoeducation or patient teaching involving individuals or groups. We have defined psychoeducational interventions as any group or individual programme involving interaction between information provider and patient. These programmes address the illness from a multidimensional viewpoint, including familial, social, biological and pharmacological perspectives. Patients are provided with support, information and management strategies. We considered programmes of 10 sessions or less as ’brief ’, and of 11 or more as ’standard’ for the purposes of this review. We excluded interventions including elements of behavioural training, such as social skills or life skills training, as well as education performed by patient peers, from this review. We also excluded staff education studies. 2. Standard care was defined as the normal level of psychiatric care provided in the area where the trial was carried out. Types of outcome measures For the first version of the review (Pekkala 2002) we did not prespecify specific time periods into which to cluster outcomes. For this update we asked an editor of the Cochrane Schizophrenia Group, who was not familiar with the data to help us divide the data by time. For this update we grouped outcomes into the short term (up to 12 weeks), medium term (13-52 weeks) and long term (over 52 weeks).
Primary outcomes

1. Compliance 1.1 Compliance with medication 1.2 Compliance with follow-up 2. Relapse
Secondary outcomes

1. Knowledge 1.1 Improvement of understanding of his/her illness and need for treatment - recipient/family member 1.2 Level of knowledge about expected and undesired effects of medication - recipient/family member 2. Behaviour 2.1 Level of psychiatric symptoms 2.2 Symptom control skills 2.3 Problem-solving skills 2.4 Social skills 3. Social functioning* 3.1 No clinically important change in social functioning 3.2 No change in social functioning 3.3 Average endpoint in social functioning 3.4 Average change in social functioning 4. Global functioning* 4.1 No clinically important change in general functioning

4.2 No change in general functioning 4.3 Average endpoint in general functioning 4.4 Average change in general functioning 5. Service utilisation 5.1 Use of outpatient treatment 5.2 Length of hospitalisation 6. Global state* 6.1 No overall improvement 6.2 Use of additional medication 6.3 Average endpoint score 6.4 Average change score 6.5 Average dose of drug 7. Mental state* 7.1 No clinically important change in general mental state 7.2 No change in general mental state 7.3 Average endpoint general mental state score 7.4 Average change in general mental state scores 8. Expressed emotion* 8.1 No clinically important change in expressed emotion 8.2 No change in expressed emotion 8.3 Average endpoint general expressed emotion 8.4 Average change in general expressed emotion 9. Quality of life* 9.1 No clinically important change in quality of life 9.2 Not any change in quality of life 9.3 Average endpoint quality of life score 9.4 Average change in quality of life scores 9.5 No clinically important change in specific aspects of quality of life 9.6 No change in specific aspects of quality of life 9.7 Average endpoint specific aspects of quality of life 9.8 Average change in specific aspects of quality of life 10. Satisfaction with care* 10.1 No clinically important change in satisfaction 10.2 No change in satisfaction 10.3 Average endpoint in satisfaction 10.4 Average change in satisfaction 11. Adverse effects/event* 11.1 Clinically important general adverse effects 11.2 Any general adverse effects 11.3 Any serious, specific adverse effects 11.4 Average endpoint general adverse effect score 11.5 Average change in general adverse effect scores 11.6 No clinically important change in specific adverse effects 11.7 No change in specific adverse effects 11.8 Average endpoint specific adverse effects 11.9 Average change in specific adverse effects 12. Health economic outcomes 12.1 Treatment costs * Additional outcomes added for 2010 update (please see Differences between protocol and review and Appendix 1).

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Search methods for identification of studies
We performed both the electronic search and the handsearch. We inspected the references of all identified studies to identify additional studies. Electronic searches 1. Update 2011 - Cochrane Schizophrenia Group Trials Register (May 2011) We searched the register using the phrase: [*Psychoeducat* in interventions of STUDY] This register is compiled by systematic searches of major databases, handsearches and conference proceedings (see Group Module). 2. Previous searches Please refer to Appendix 2; Appendix 3; Appendix 4 for detail of previous searches. 3. The Trials Search Co-ordinator, Samantha Roberts, searched the Cochrane Schizophrenia Group Trials Register register (November 2012) using the phrase: [*Psychoeducat* in interventions of STUDY or title of REFERENCE] The Cochrane Schizophrenia Group’s Trials Register is compiled by systematic searches of major databases, handsearches of relevant journals and conference proceedings (see Group Module). Incoming trials are assigned to relevant existing or new review titles. Searching other resources 1. Reference searching We inspected reference lists of identified studies for more trials. 2. Personal contact We contacted authors of relevant studies to enquire about other sources of relevant information.

or journal of publication. Where difficulties or disputes arose, we asked author MRB for help and if it was impossible to decide, added these studies to those awaiting assessment and contacted the authors of the papers for clarification. Data extraction and management

1. Extraction

JX extracted data from all included studies. In addition, to ensure reliability, LBM and MRB independently extracted data from a random sample of these studies, comprising 10% of the total. Again, we discussed any disagreement, documented decisions and, if necessary, contacted authors of studies for clarification. With remaining problems, LBM helped clarify issues, and we documented those final decisions. We extracted data presented only in graphs and figures whenever possible, but included these only if two authors independently had the same result. We attempted to contact authors through an open-ended request in order to obtain missing information or for clarification whenever necessary. Where possible, we extracted data relevant to each component centre of multicentre studies separately.
2. Management

2.1 Forms We extracted data onto standard, simple forms. 2.2 Scale-derived data We included continuous data from rating scales only if: a. the psychometric properties of the measuring instrument had been described in a peer-reviewed journal (Marshall 2000); and b. the measuring instrument was not written or modified by one of the trialists for that particular trial; and c. the measuring instrument is either i. a self-report or ii. completed by an independent rater or relative (not the therapist). 2.3 Endpoint versus change data There are advantages of both endpoint and change data. Change data can remove a component of between-person variability from the analysis. On the other hand, calculation of change needs two assessments (baseline and endpoint) which can be difficult in unstable and difficult to measure conditions such as schizophrenia. We decided to primarily use endpoint data and only use change data if the former were not available. We combined endpoint and change data in the analysis as we used mean differences rather than standardised mean differences throughout (Higgins 2008, chapter 9.4.5.2 ).
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Data collection and analysis

Selection of studies Reviewer JX inspected all abstracts of studies identified as above and identified potentially relevant reports. In addition, to ensure reliability, LBM and MRB inspected a random sample of these abstracts, comprising 10% of the total. Where disagreement occurred we resolve this by discussion, or where there was still doubt, acquired the full article for further inspection. We also acquired the full articles of relevant reports for reassessment and carefully inspected for a final decision on inclusion (see Criteria for considering studies for this review). Once we obtained the full articles, JX and LBM in turn inspected all full reports and independently decided whether they met inclusion criteria. JX and LBM were not blinded to the names of the authors, institutions

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2.4 Skewed data Continuous data on clinical and social outcomes are often not normally distributed. To avoid the pitfall of applying parametric tests to non-parametric data, we aim to apply the following standards to all data before inclusion: a) standard deviations and means are reported in the paper or obtainable from the authors; b) when a scale starts from the finite number zero, the standard deviation, when multiplied by two, is less than the mean (as otherwise the mean is unlikely to be an appropriate measure of the centre of the distribution (Altman 1996); c) if a scale started from a positive value (such as PANSS which can have values from 30 to 210) the calculation described above was modified to take the scale starting point into account. In these cases skew is present if 2SD>(S-S min), where S is the mean score and S min is the minimum score. Endpoint scores on scales often have a finite start and end point and these rules can be applied. When continuous data are presented on a scale which includes a possibility of negative values (such as change data), it is difficult to tell whether data are skewed or not. We entered skewed data from studies of fewer than 200 participants in additional tables rather than into an analysis. Skewed data pose less of a problem when looking at means if the sample size is large and were entered into syntheses.

2.8 Summary of findings table We anticipated including the following short- or medium-term outcomes in a summary of findings table. (JX was not biased by being familiar with the data.) 1. Compliance with medication 2. Loss to follow-up 3. Relapse 4. Satisfaction with care 4.1 Not improved to an important extent 5. Adverse effects 5.1 Specific adverse event 6. Quality of life 6.1 Not improved to an important extent 7. Economic data

Assessment of risk of bias in included studies Again JX and LMB worked independently to assess risk of bias by using criteria described in the Cochrane Collaboration Handbook (Higgins 2008) to assess trial quality. This set of criteria is based on evidence of associations between overestimate of effect and high risk of bias of the article such as sequence generation, allocation concealment, blinding, incomplete outcome data and selective reporting. If the raters disagree, the final rating was made by consensus, with the involvement of another member of the review group. Where inadequate details of randomisation and other characteristics of trials were provided, authors of the studies were contacted in order to obtain further information. Non-concurrence in quality assessment was reported, but if disputes arose as to which category a trial was to be allocated, again, resolution were made by discussion. The level of risk of bias will be noted in both the text of the review and in the Summary of findings for the main comparison.

2.5 Common measure To facilitate comparison between trials, we intended to convert variables that can be reported in different metrics, such as days in hospital (mean days per year, per week or per month) to a common metric (e.g. mean days per month).

2.6 Conversion of continuous to binary Where possible, we made efforts to convert outcome measures to dichotomous data. This could be done by identifying cut-off points on rating scales and dividing participants accordingly into ’clinically improved’ or ’not clinically improved’. We generally assumed that if there had been a 50% reduction in a scale-derived score such as the Brief Psychiatric Rating Scale (BPRS, Overall 1962) or the Positive and Negative Syndrome Scale (PANSS, Kay 1986), we could consider this as a clinically significant response (Leucht 2005a; Leucht 2005b). If data based on these thresholds were not available, we used the primary cut-off presented by the original authors.

Measures of treatment effect

1. Binary data

2.7 Direction of graphs Where possible, we entered data in such a way that the area to the left of the line of no effect indicated a favourable outcome for psychoeducation.

For binary outcomes we calculated a standard estimation of the risk ratio (RR) and its 95% confidence interval (CI). It has been shown that RR is more intuitive (Boissel 1999) than odds ratios and that odds ratios tend to be interpreted as RR by clinicians (Deeks 2000). For statistically significant results we had planned to calculate the number needed to treat to provide benefit/to induce harm statistic (NNTB/H), and its 95% confidence interval (CI) using Visual Rx (http://www.nntonline.net/) taking account of the event rate in the control group. This, however, was superseded by Summary of findings for the main comparison and the calculations therein.
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2. Continuous data

For continuous outcomes we estimated mean difference (MD) between groups. We preferred not to calculate effect size measures (standardised mean difference (SMD)). However, had scales of very considerable similarity been used, we would have presumed there was a small difference in measurement, and we would have calculated effect size and transformed the effect back to the units of one or more of the specific instruments. We made a post-hoc decision to pool the GAF scale (APA 1994) and its virtually similar earlier version, the GAS scale (Endicott 1976), using WMD statistics. Unit of analysis issues

not appropriate if the condition of interest is unstable (Elbourne 2002). As both effects are very likely in severe mental illness, we only used data of the first phase of cross-over studies.
3. Studies with multiple treatment groups

Where a study involved more than two treatment arms, if relevant, we presented the additional treatment arms in comparisons. Where the additional treatment arms were not relevant, we did not reproduced these data. Dealing with missing data

1. Overall loss of credibility 1. Cluster trials

Studies increasingly employ ’cluster randomisation’ (such as randomisation by clinician or practice), but analysis and pooling of clustered data poses problems. Firstly, authors often fail to account for intra-class correlation in clustered studies, leading to a ’unit of analysis’ error (Divine 1992) whereby P values are spuriously low, confidence intervals unduly narrow and statistical significance overestimated. This causes type I errors (Bland 1997; Gulliford 1999). Where clustering is not accounted for in primary studies, we presented data in a table, with a (*) symbol to indicate the presence of a probable unit of analysis error. In subsequent versions of this review we will seek to contact first authors of studies to obtain intraclass correlation coefficients for their clustered data and to adjust for this by using accepted methods (Gulliford 1999). Where clustering had been incorporated into the analysis of primary studies, we present these data as if from a non-cluster randomised study, but adjusted for the clustering effect. We have sought statistical advice and have been advised that the binary data as presented in a report should be divided by a ’design effect’. This is calculated using the mean number of participants per cluster (m) and the intra-class correlation coefficient (ICC) (Design effect = 1+(m-1)*ICC) (Donner 2002). If the ICC was not reported we assumed it to be 0.1 (Ukoumunne 1999). If cluster studies had been appropriately analysed taking into account intra-class correlation coefficients and relevant data documented in the report, synthesis with other studies would have been possible using the generic inverse variance technique.
2. Cross-over trials

At some degree of loss of follow-up data must lose credibility (Xia 2009). For any particular outcome should more than 50% of data be unaccounted for, we did not reproduce these data or use them within analyses. If, however, more than 50% of those in one arm of a study were lost, but the total loss was less than 50%, we marked such data with (*) to indicate that such a result may well be prone to bias.
2. Binary

In the case where attrition for a binary outcome is between 0 and 50% and where these data were not clearly described, we presented data on a ’once-randomised-always-analyse’ basis (an intention to treat analysis). We assumed those leaving the study early to have the same rates of negative outcome as those who completed, with the exception of the outcome of death. We undertook a sensitivity analysis testing how prone the primary outcomes were to change when ’completed’ data only were compared to the intention to treat analysis using the above assumption.
3. Continuous

3.1 Attrition In the case where attrition for a continuous outcome is between 0 and 50% and completer-only data were reported, we have reproduced these. 3.2 Standard deviations

A major concern of cross-over trials is the carry-over effect. It occurs if an effect (e.g. pharmacological, physiological or psychological) of the treatment in the first phase is carried over to the second phase. As a consequence, on entry to the second phase the participants can differ systematically from their initial state despite a wash-out phase. For the same reason, cross-over trials are

We have first tried to obtain the missing values from the authors. If not, where there are missing measures of variance for continuous data but an exact standard error and confidence interval are available for group means, either P value or T value are available for differences in mean, we will, for the update of this review, calculate them according to the rules described in the Cochrane Handbook (Higgins 2008) - but for later versions of this review:
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When only the standard error (SE) is reported, standard deviations (SDs) are calculated by the formula SD = SE * square root (n). Chapters 7.7.3 and 16.1.3 of the Cochrane Handbook (Higgins 2008) present detailed formula for estimating SDs from P values, T or F values, confidence intervals, ranges or other statistics. If these formula do not apply, we will calculate the SDs according to a validated imputation method which is based on the SDs of the other included studies (Furukawa 2006) in later versions of this review. Although some of these imputation strategies can introduce error, the alternative would be to exclude a given study’s outcome and thus to lose information. We plan, nevertheless, to examine the validity of the imputations in a sensitivity analysis excluding imputed values.

3.2 Employing the I2 statistic We investigated heterogeneity between studies by considering the I2 method alongside the Chi2 P value. The I2 provides an estimate of the percentage of inconsistency thought to be due to chance (Higgins 2003). The importance of the observed value of I2 depends on i. magnitude and direction of effects and ii. strength of evidence for heterogeneity (e.g. P value from Chi2 test, or a confidence interval for I2 ). We interpreted I2 estimate greater than or equal to 50% accompanied by a statistically significant Chi2 statistic as evidence of substantial levels of heterogeneity (Section 9.5.2 - Higgins 2008). When we found substantial levels of heterogeneity in the primary outcome, we explored reasons for heterogeneity (Subgroup analysis and investigation of heterogeneity). Assessment of reporting biases Reporting biases arise when the dissemination of research findings is influenced by the nature and direction of results (Egger 1997). These are described in Section 10 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2008). We are aware that funnel plots may be useful in investigating reporting biases but are of limited power to detect small-study effects. We did not use funnel plots for outcomes where there were 10 or fewer studies, or where all studies were of similar sizes. In other cases, where funnel plots were possible, we sought statistical advice in their interpretation. Data synthesis

3.3 Last observation carried forward We anticipated that in some studies the method of last observation carried forward (LOCF) would be employed within the study report. As with all methods of imputation to deal with missing data, LOCF introduces uncertainty about the reliability of the results. Therefore, where LOCF data has been used in the trial, if less than 50% of the data had been assumed, we reproduced these data and indicated that they are the product of LOCF assumptions.

Assessment of heterogeneity

1. Clinical heterogeneity

We considered all included studies initially, without seeing comparison data, to judge clinical heterogeneity. We simply inspected all studies for clearly outlying situations or people which we had not predicted would arise. When such situations or participant groups arose, we have fully discussed these.

2. Methodological heterogeneity

We considered all included studies initially, without seeing comparison data, to judge methodological heterogeneity. We simply inspected all studies for clearly outlying methods which we had not predicted would arise. Should such methodological outliers arise we will fully discuss these.

We understand that there is no closed argument for preference for use of fixed-effect or random-effects models. The random-effects method incorporates an assumption that the different studies are estimating different, yet related, intervention effects. This often seems to be true to us and the random-effects model takes into account differences between studies even if there is no statistically significant heterogeneity. There is, however, a disadvantage to the random-effects model. It puts added weight onto small studies which often are the most biased ones. Depending on the direction of effect, these studies can either inflate or deflate the effect size. Therefore, we chose the fixed-effect model for all analyses. The reader is, however, able to choose to inspect the data using the random-effects model. Subgroup analysis and investigation of heterogeneity

3. Statistical heterogeneity

1. Subgroup analyses

3.1 Visual inspection We visually inspected graphs to investigate the possibility of statistical heterogeneity.

We are interested in whether a brief form of psychoeducation may have as many effects as the standard and more protracted form. For the purposes of this review we define ’brief ’ as up to 10 sessions and ’standard’ as 11 sessions or more. In addition, we are interested whether a group approach would have similar effects to individual
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psychoeducation. We proposed to undertake comparisons only for primary outcomes to minimise the risk of multiple comparisons.
2. Investigation of heterogeneity

was a substantial difference, we have reported results and discussed them but continue to employ our assumption.

3. Chinese studies

If inconsistency was high, we have reported this. First we investigated whether data had been entered correctly. Second, if data had been correct, we visually inspected the graph and successively removed studies outside of the company of the rest to see if heterogeneity was restored. Should this occur with no more than 10% of the data being excluded, we have presented data. If not, we have not pooled data and discussed issues. Should unanticipated clinical or methodological heterogeneity be obvious we simply stated hypotheses regarding these for future reviews or versions of this review. We pre-specify no characteristics of studies that may be associated with heterogeneity except quality of trial method. If no clear association could be shown by sorting studies by quality of methods, we have performed a randomeffects meta-analysis. Should another characteristic of the studies be highlighted by the investigation of heterogeneity, perhaps some clinical heterogeneity not hitherto predicted but plausible causes of heterogeneity, we have discussed these post hoc reasons, and analyse and present the data. However, should the heterogeneity be substantially unaffected by use of random-effects meta-analysis and no other reasons for the heterogeneity be clear, we have presented the final data without a meta-analysis. Sensitivity analysis

Concerns were raised about the quality of some of the Chinese trials (Wu 2006; Lancet 2010). For this reason, we performed sensitivity analysis for all primary outcomes where Chinese trials were included.

RESULTS

Description of studies
See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of studies awaiting classification; Characteristics of ongoing studies. For more detailed description of each studies, please refer to the Characteristics of included studies and Characteristics of excluded studies tables.

Results of the search

1. Implication of randomisation

1. 2010 update

We aimed to include trials in a sensitivity analysis if they were described in some way as to imply randomisation. For the primary outcomes we included these studies and if there was no substantive difference when we added the implied randomised studies to those with better description of randomisation, then we employed all data from these studies.
2. Assumptions for lost binary data

For the 2010 update we found 210 citations of which we ordered 99 for close inspection. Of these we have included 23, for a total of 44 studies now included in this review. For results of any previous search, please refer to Appendix 2 and Appendix 3.

Included studies See Characteristics of included studies for descriptions of each study. We have chosen to use a rather unconventional means of tagging studies. This is usually done by using the key author name accompanied by the date of the main publication, for example ’Smith 2005’. For this review we thought that using a different and more informative convention would be valuable. We have decided to include some details of the experiential intervention in the study tag trying to succinctly describe length of intervention where reported and whether the education was given one-to-one or by group, and finally the date of study. We are aware that this lengthens the tags - but we think it makes them informative and clusters them in the graphs for easier understanding.
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Where assumptions had to be made regarding people lost to followup (see Dealing with missing data), we compared the findings of the primary outcomes when we used our assumption compared with completer data only. If there was a substantial difference, we reported results and discuss them but continue to employ our assumption. Where assumptions had to be made regarding missing SDs data (see Dealing with missing data), we compared the findings on primary outcomes when we used our assumption compared with complete data only. We undertook a sensitivity analysis testing how prone results were to change when ’complete’ data only were compared to the imputed data using the above assumption. If there

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1. Methods

All included studies were randomised controlled trials. Only 11 of the included studies described randomisation method. Two studies were randomised by independent institutions (Brief - Group 1995; Brief - Group 1999); five studies used random number table (Brief - Individual 1996; Standard - Group 2006; Standard - Individual 03c; Unclear - Both 2007; 2008); one study drew lots (Standard Individual 03b); one study used tossing a coin to randomise (Brief - Group 2007a); one study used block randomisation (Standard - Unclear 1996) and one study used computer generated cards (Standard - Both 1996) - this is also the only study that described allocation concealment (concealed with sealed envelop). Blinding was generally not described. One study (Standard - Individual 03c) was double blind. Four studies were single (assessor) blind (Standard - Group 2007; Standard - Both 1996; Standard - Group 2006; Standard - Unclear 1996). One trial did not use blinding (Brief - Individual 1996). Four other studies had some of their outcomes assessed single blind, but not for all outcomes (Brief - Group 1995; Brief - Group 1999; Standard - Group 1988; Standard - Individual 93). Blinding method was not stated in the other 35 included studies.
2. Study duration

of the included studies range from 20 (Standard - Individual 93) participants to 286 (Brief - Unclear 2005). The three other studies with over 200 participants are Standard - Group 2004, Standard - Group 2005 and Standard - Unclear 1996.
5. Interventions

Thirteen trials used brief psychoeducation, 22 standard psychoeducation and nine did not state whether brief or standard intervention was used (tagged in this review as ’unclear’). Of the 44 included studies, 17 used group therapy, six individual therapy, 13 employed a mixture of both group and individual therapy and eight other studies did not state the type of therapy used.
6. Outcomes

A variety of scales were used to assess clinical response and adverse events. We were, however, unable to use some of the scale-derived data due to poor reporting. Details of scales that provided usable data are shown below. 6.1 Compliance 6.1.1 Schedule for Assessment of Insight - SAI (David 1990) The SAI rates three dimensions of insight: treatment adherence, recognition of illness and symptom re-labelling. These three subscales provide a summed total of insight score. High score indicates better insight. One study reported data from this scale. 6.2 Knowledge 6.2.1 Insight Treatment Attitude Questionnaire - ITAQ (McEvoy 1989) The ITAQ is a 11-item semi-structured interview that measures awareness of illness and attitude to medication and services, as well as follow-up evaluation. Its scores range from 0 to 22, with high score indicating better insight. Four studies reported data from this scale. 6.2.2 Knowledge About Schizophrenia Questionnaire - KASQ (Ascher-Svanum 1999) This is a 23-item multiple-choice questionnaire, which covers the illness-related topics. The maximum score is 23, indicating a high level of knowledge about the illness. One study reported data from this scale. 6.2.3 Krankheitskonzeptskala - KK (Linden 1988) KK is a self-rating instrument which consists of 29 Likert-scale items. People are asked to express their agreement or disagreement with each item on a five-point scale. The scale describes seven dimensions of illness-related attitudes: confidence in medication, confidence in physician, negative expectations towards medication, attribution of illness to chance, susceptibility to illness and to relapse, attribution of guilt and fear to side effects of medication. The higher the score, the higher the expression of the respective item. One study reported data from this scale.
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Study duration varied from one session (Brief - Group 1995a) to five years (Standard - Unclear 2005a) (but intervention frequency was not stated in this particular study). Standard - Unclear 1988 and Standard - Both 1996 are both of 18 months’ duration but the median study duration of all other studies is around 12 weeks.
3. Settings

Most studies were conducted with inpatients, except four ( Standard - Group 2007; Standard - Unclear 1996; Standard Group 2008; Standard - Unclear 2005a). Most of the included trials were carried out in China, while one trial was conducted in France, three in the USA, one in Canada, two in Germany, three in the UK, one in Demark and one in Malaysia.
4. Participants

A total of 5142 participants are included from 44 trials conducted from 1988 and 2009. Participants are patients with schizophrenia or schizoaffective disorder diagnosed using operationalised criteria (DSM, ICD, CCMD). The majority of the studies included patients between the ages of 18 and 60 years, except four that did not describe the age range (Unclear - Group 1996;Unclear - Both 2008; Brief - Group 2006; Brief - Group 2007b). Four studies included only men (Standard - Unclear 2005; Standard - Unclear 2007; Standard - Both 2008a;Unclear - Both 2007 ) and one study included female participants only (Standard - Both 2006). Four other studies did not describe gender and all other remaining studies involved both male and female participants. Size

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6.2.4 Knowledge Questionnaire - KQ (Pitschel-Walz 1997) The maximum score of this questionnaire is 70. High score indicates better outcome. One study reported data from this scale. 6.2.5 Recovery Attitudes Questionnaire - RAQ (Borkin 2000) This is a seven-item self-report scale that assesses attitudes about recovery. Score ranges from 7 to 35, with lower scores indicating more appropriate attitudes. One study reported data from this scale. 6.2.6 Schizophrenia Knowledge Questionnaire - SKQ (Wallace 1985) High score indicates a better outcome. One study reported data from this scale. 6.2.7 The Scale to Assess Unawareness of Mental Disorder SAUMD (Amador 1994) There is a total of 20 questions in SAUMD. Score range 1 to 5 points, high score prompted a poor understanding and attribution. Two studies reported data from this scale. 6.2.8 Understanding of medication questionnaire - UMQ ( Macpherson 1996) UMQ measures knowledge of antipsychotic treatment. Fourteen stem questions generate eight sub-scale knowledge scores, relating to factual information, treatment practice, treatment rationale, effects of stopping treatment, side effects, precautions, tardive dyskinesia and risk/benefit evaluation.The UMQ is an extended version of scales measuring knowledge of illness and treatment and knowledge of tardive dyskinesia. Total knowledge score is 35. Knowledge scoring 0 = no understanding and 35 = full understanding. One study reported data from this scale.

This scale is self-administered and has 20 questions. Each question is scored on a scale of 1-4. High score indicates poor outcome. Three studies reported data from this scale. 6.4.4 Social Adjustment Scale II - SAS II (Schooler 1979) SAS is an interview-based operationalised instrument with two versions; patient version and family version. SAS has 89 items covering widely social, interpersonal, and household aspects. High score indicates poor outcome. One study reported data from this scale. 6.4.5 Zung Self-Rating Depression Scale - SDS (Gregory 1994) High score indicates poor outcome. Three studies reported data from this scale. 6.4.6 Social Disability Screening Schedule - SDSS (Tu 1997) Hign score indicates poor outcome. Two studies reported data from this scale. 6.4.7 Social functioning schedule - SFS (Remington 1979) Lower scores indicate improved behaviour/function. One study reported data from this scale. 6.4.8 Social Networks Schedule - SNS (Dunn 1990) Social Networks Schedule modified consists of mean number of total social contacts: daily, weekly and monthly, mean number of different type of contacts with relatives, confidants, and friends. Low score indicates better outcome. One study reported data from this scale.

6.5 Global functioning* 6.5.1 Global Assessment of Functioning - GAF (APA 1994) The scale is a 90-point rating scale that assesses psychological, social and occupational functioning. GAF is included in DSMIII- R as axis V, but in spite of this there is little research on the reliability and validity of the instrument. A few reliability and validity assessments have been made, indicating that an acceptable interrater reliability can be attained and that modest validity in relation to a disability measure has been demonstrated. High score indicates better outcome. 6.5.2 Global Assessment Scale - GAS (Endicott 1976) GAS is a 0-100 point rating scale, a global measure of overall functioning and symptomatology. High scores indicate better functioning. 6.5.3 Specific Level of Functioning Scale - SLOF (Schnieder 1983) A Likert-like scale with high score indicating better outcome. One study reported data from this scale.

6.3 Behaviour 6.3.1 Nurse Observation Scale for Inpatient Evaluation-30 NOSIE-30 (Honigfeld 1965) An 80-item scale with items rated on a five-point scale from zero (not present) to four (always present). Ratings are based on behaviour over the previous three days. The seven headings are social competence, social interest, personal neatness, cooperation, irritability, manifest psychosis and psychotic depression. The total score ranges from 0 to 320 with high scores indicating a poor outcome. Three studies reported data from this scale.

6.4 Social functioning* 6.4.1 Inpatient Psychiatric Rehabilitation Outcome Scale - IPROS (Li 1994) High score indicates poor outcome. One study reported data from this scale. 6.4.2 Morningside Rehabilitation Status Scale - MRSS ( McCreadie 1987) High score indicates worse outcome. One study reported data from this scale. 6.4.3 Zung Self-Rating Anxiety Scale - SAS (Ramirez 2008)

6.6 Global state* 6.6.1 Clinical Global Impression - CGI (Guy 1970) The CGI is a three-item scale commonly used in studies on schizophrenia that enables clinicians to quantify severity of illness and overall clinical improvement. It employs a seven-point scoring system is usually used with low scores indicating decreased severity and/or greater recovery. One study reported data from this scale.
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6.7 Mental state* 6.7.1 Brief Psychiatric Rating Scale - BPRS (Overall 1962) The BPRS is an 18-item scale measuring positive symptoms, general psychopathology and affective symptoms. The original scale has 16 items, but a revised 18-item scale is commonly used. Scores can range from 0 to 126. Each item is rated on a seven-point scale varying from ’not present’ to ’extremely severe’, with high scores indicating more severe symptoms. Seventeen studies reported data from this scale. 6.7.2 General Well-being Schedule - GWB (Taylor 2003) This is an 18-item, reliable measurement scale for psychological well-being. High scores indicate better outcome. One study reported data from this scale. 6.7.3 Positive and Negative Syndrome Scale - PANSS (Kay 1986) This is a 30-item scale, each of which can be defined on a sevenpoint scoring system from absent to extreme. It has three sub-scales for measuring the severity of general psychopathology, positive symptoms (PANSS-P), and negative symptoms (PANSS-N). A low score indicates lesser severity. Two studies reported data from this scale. 6.7.4 Rosenberg Self-esteem Scale - SES (Rosenberg 1965) The scale is a 10-item Likert scale with items answered on a fourpoint scale - from strongly agree to strongly disagree. High scores indicate better outcome. One study reported data from this scale.

6.9.4 General Quality of Life Inventory -74 - GQOLI-74 (Wang 1999) A 74-item quality of life assessment scale. It contains four subscales that assess physical functioning, psychological functioning, social functioning, and standard of living. High scores indicate better quality of life. One study reported data from this scale. 6.9.5 Psychological General Well-being Scale - PGWB (Dupuy 1984) High scores indicate better well-being. One study reported data from this scale. 6.10 Satisfaction with care* 6.10.1 Verona Service Satisfaction Scale - VSSS (Ruggeri 1993) The scale consists of 54 items in versions for patients and relatives. It is a questionnaire that covers seven dimensions of satisfaction with service: overall satisfaction, professionals’ skills and behaviour, information, access, efficacy, types of intervention and relatives involvement. (Ruggeri 1996) The VSSS satisfaction ratings are given on a five-point Likert scale. The instrument has been validated in community psychiatric samples (Ruggeri 1994; Ruggeri 1996). One study reported data from this scale. Outcomes with ’*’ are extra outcomes added in this 2010 update review. 6.11 Missing outcomes Most trials reported on primary outcomes that we were interested in, i.e. compliance and relapse. However, there were few data on health economic outcomes; only one study (Standard - Both 1996) reported some skewed data on hospital charges. Excluded studies We excluded 68 studies from the review. Many had to be excluded because they were not randomised controlled trials. We excluded 12 studies because there were no usable data reported, usually due to the lack of mean or standard deviation. Liu 2007 had to be excluded because the outcome data in this study are identical (to the decimal points) to another included trial (Unclear - Both 2005). We suspect these two trials are the same study but are not sure and therefore treated Liu 2007 as separate but we felt we could not prove the veracity of the data.
Studies awaiting assessment

6.8 Expressed emotion* 6.8.1 Family Questionnaire - FQ (Feinstein 1989) The FQ is based on the Camberwell Family Interview and is a 20-item questionnaire developed to enable a less time-consuming evaluation of expressed emotion in relatives. It covers the two dimensions of criticism and emotional over involvement and the items are scored on a four-point scale. The questionnaire is reliability tested and validated in the German language (Feinstein1994 personal communication).

6.9 Quality of life* 6.9.1 Family Assessment Device - FAD (Epstein 1983) High scores indicate unhealthy family functioning. Two studies reported data from this scale. 6.9.2 Family Burden Interview Schedule - FBIS (Pai 1981) High scores indicate worse outcome. Two studies reported data from this scale. 6.9.3 Quality of Life - QOL (Heinrichs 1984) The scale consists of four factors: interpersonal relations and social network, instrumental role functioning, intrapsychic foundations and common objects and activities. The scale consists of 21 items. Each item is rated on a seven-point scale 0-6. Range is 0-126. The scale is rated from a semi-structured interview providing information on symptoms and functioning during the preceding four weeks. High score reflects normal or unimpaired functioning.

Two studies await assessment (Bentall 2001; Day 2000). In both cases we have not been able to locate the full text of the studies and were unable to make a decision regarding inclusion without the full report. From the 2012 update search 27 studies were added to this section and 29 studies are now awaiting assessment.
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Ongoing studies

Kissling 2007 is an ongoing study, which is expected to complete in August 2010.

Risk of bias in included studies
Our overall impression of risk of bias in the included studies is represented in Figure 1. The suggestion is that there is, at the very least, a moderate risk of bias and therefore a risk of overestimating any positive effects of psychoeducation.

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Figure 1. Methodological quality summary: review authors’ judgements about each methodological quality item for each included study.

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Allocation All 44 included studies were stated to be randomised, but only seven provided descriptions of the methods used to generate the sequence (Standard - Both 1996; Standard - Unclear 1996; Standard - Both 2008b; Standard - Group 2006; Standard - Individual 03b; Standard - Individual 03c; Unclear - Both 2007). Only Standard Both 1996 described method of concealment. Most studies, therefore, are classified as of ’unclear’ quality with a moderate risk of selection bias and of overestimate of positive effect.

PANSS and ITAQ scores, but did not report numerical data. Brief - Group 2009 measured SSQ-6 and SES score and, again, did not report. Standard - Unclear 2005a and Unclear - Both 2007 collected data on BRRS, SOSS and MRSS, but failed to report these data in the report. Other potential sources of bias There were no other obvious potential sources of bias. We are aware that research in China has shown that trials many from China may not be of high quality (Wu 2006). This is a significant issue for this review, in which 31 out of 44 trials are certainly from China. It was problematic to illustrate this in Figure 1 but, until quality control improves in Chinese trials, many of the results from these studies have to be treated with caution.

Blinding Seven studies were stated to have used single (assessor) blinding (Brief - Group 1999; Standard - Both 1996; Standard - Group 1988; Standard - Group 2006; Brief - Group 2007; Standard Individual 93; Standard - Unclear 1996). One trial was double blind (Standard - Individual 03c) and one open label (Brief Individual 1996). Of those studies that were blinded in some way, most did not describe the blinding methods used, and none tested the success of blinding for participants or assessors. The remaining studies did not report whether blinding had been used. We therefore had to rate the risk of observer bias as (at best) ’unclear’. This gathers further potential for overestimate of positive effects and underestimate of negative ones.

Effects of interventions
See: Summary of findings for the main comparison ANY FORM OF PSYCHOEDUCATION compared with STANDARD CARE for schizophrenia 1. Comparison 1. Any form of psychoeducation vs standard care

Incomplete outcome data Most studies used Intention-to-treat (ITT) method of analysis, except for eight which did not include any data from those who left early (Unclear - Both 2007; Unclear - Individual 2008; Brief - Unclear 2005; Standard - Both 2004; Standard - Individual 03c; Standard - Both 2008b; Standard - Group 2006; Standard Individual 03b).

1.1 Compliance (primary outcomes)

1.1.1 Compliance: 1a. With medication - non-compliance (Analysis 1.1) We included 10 short-term studies and found incidences of noncompliance were lower in the psychoeducation group (n = 1400, RR 0.52 CI 0.40 to 0.67, NNT 11 CI 9 to 16) compared with standard care. Medium-term (6 RCTs, n = 781, RR 0.36 CI 0.27 to 0.49, NNT 5 CI 5 to 7) and long-term data (3 RCTs, n = 282) also favoured the psychoeducation group, but long-term data were heterogeneous (RR 0.48 CI 0.31 to 0.75, NNT 6 CI 5 to 12, I2 = 78%). Also see Figure 2.

Selective reporting We did not have any protocols for the included studies. Most studies included in this version of the review seemed to report all outcomes measured, except for four. Brief - Group 2007b measured

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Figure 2. Forest plot of comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, outcome: 1.1 Compliance: 1a. With medication - non-compliance.

1.1.2 Compliance: 1b. With medication - partial compliance (Analysis 1.2) Overall, partial compliance data favours the psychoeducation group (n = 590, RR 0.53 CI 0.37 to 0.76, NNT 6 CI 5 to 12). However, medium-term data were not statistically significant (RR 0.57 CI 0.26 to 1.26).

1.1.4 Compliance: 2a. With follow up - loss to follow-up for any reason (Analysis 1.4) We found no significant difference between psychoeducation and standard care groups in terms of loss to follow-up in general. Medium-term (RR 1.0 CI 0.79 to 1.26) and long-term results are equivocal (two years RR 0.83 CI 0.62 to 1.10; five years RR 0.77 CI 0.48 to 1.23).

1.1.3 Compliance: 1c. With medication - continuous outcomes - skewed data (Analysis 1.3) Brief - Individual 1996 did not demonstrate a significant advantage in compliance for the intervention groups with one or three sessions of education, and presented skewed data at one-month on the compliance sub-scale of SAI. 1.1.5 Compliance: 2b. With follow up - received intervention but left the study early (Analysis 1.5) Outcome data show an equivocal effect between two groups. No significant difference was found between group in the short term

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(RR 3.04 CI 0.36 to 25.67), medium term (RR 0.56 CI 0.29 to 1.10) or long term (RR 0.63 CI 0.38 to 1.04).

1.3.2 Knowledge: 1b. Average change (UMQ, high = favourable, data skewed) Brief intervention: in the brief individual intervention group, Macpherson 1996 showed knowledge change at one-month follow-up in favour of the single session intervention as well as the three sessions’ intervention, but data were skewed.

1.1.6 Compliance: 2c. With follow up - allocated but never accepted treatment (Analysis 1.6) Compared with standard care, more people in the psychoeducation group allocated to the treatment but never accepted it (n = 213, RR 12.27 CI 2.58 to 58.33, NNT 9 CI 64 to 2).

1.3.3 Knowledge: 2. Average endpoint scores on various insight scales Neither short-term SAUMD data (WMD -0.63 CI -1.86 to 0.61) nor medium-term RAQ data (WMD 1.80 CI -0.85 to 4.45) showed any significant differences between groups. These outcome data are also highly heterogeneous (I2 = 91% and 86% respectively).

1.2 Relapse (primary outcomes)

1.2.1 Relapse: 1. Relapse for any reason (Analysis 1.7) Medium-term relapse outcome included data from 11 RCTs and results favour the psychoeducation group (n = 1214, RR 0.70 CI 0.61 to 0.81, NNT 9 CI 7 to 14). Long-term data up to five years (RR 0.73 CI 0.62 to 0.85, NNT 8 CI 6 to 14, - exclusive of five years) and at seven years (RR 0.62 CI 0.42 0.92, NNT 3 CI 2 to 15) also favour the psychoeducation group. The five-year followup result appears to favour the psychoeducation group too, but wasn’t statistically significant (RR 0.89 CI 0.73 to 1.08). 1.3.4 Knowledge: 3. Average endpoint score on illnessrelated attitudes - 4 months (KK, high = high expressed) Results favoured the psychoeducation group in terms of ’confidence in physician’ (MD -1.40 CI -2.73 to -0.07). No significant results were found between groups with any other sub-scales.

1.3.5 Knowledge: 4. Level of knowledge did not improve More people in the standard care did not have improved knowledge level compared with psychoeducation group (RR 0.13 CI 0.06 to 0.28, NNT 3 CI 3 to 4).

1.2.2 Relapse: 2. Relapse with readmission (Analysis 1.8) Psychoeducation group had better long-term outcome data on relapse with readmission (n = 206, RR 0.71 CI 0.56 to 0.89, NNT 5 CI 4 to 13). Medium-term data appear to favour the psychoeducation group, but was not statistically significant (n = 206, RR 0.77 CI 0.56 to 1.07).

1.4 Behaviour

1.4.1 Behaviour: Average score (NOSIE-30, endpoint, high = poor)
1.3 Knowledge

Results were from three RCTs, all favoured standard care group (short-term MD 16.85 CI 11.90 to 21.80; medium-term MD 14.00 CI 3.03 to 24.97; long-term MD 41.33 CI 31.02 to 51.64).

1.3.1 Knowledge: 1a. Average endpoint scale scores on various knowledge scales KQ data favour standard care group in both the short (WMD -12.00 CI -17.67 to -6.33) and long term (WMD -8.00 CI 14.64 to -1.36). Both short-term (WMD 0.20 CI -2.12 to 2.52) and medium-term (WMD 1.60 CI -0.84 to 4.04) KASQ scores showed an equivocal effect between two groups. ITAQ scores favour the psychoeducation group in both the short (WMD 5.53 CI 4.56 to 6.49) and medium term (WMD 4.83 CI 1.51 to 8.15). Short-term SKQ score favours standard care group (WMD -16.26 CI -22.72 to -9.80).
1.5 Social functioning

1.5.1 Social functioning: 1a. Average change scores on various scales - medium term (high = poor) Medium term MRSS (MD 13.68 CI 12.51 to 14.85) and SDSS (MD 1.96 CI 1.83 to 2.09) data from one small study (Brief Both 2004) both favour standard care group.
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1.5.2 Social functioning: 1b. Average endpoint scores on various scales (high = poor) Short term IPROS score from one small study (Standard Individual 03a, n = 116, MD -6.64 CI -11.02 to -2.26), SAS score (n = 378, MD -8.53 CI -10.50 to -6.55), SDS score (n = 378, MD -5.60 CI -7.55 to -3.65) and medium-term SDSS score (n = 85, MD -3.74 CI -6.05 to -1.43) all favoured the psychoeducation group, although SAS outcome data are heterogeneous (I2 = 99%).

1.7.2 Service utilisation: Days in hospital using ’acute services’ - during 18 months (data skewed) These particular outcome data were from one small study ( Standard - Both 1996) and were markedly skewed. It did not appear to favour any one particular group.

1.8 Global state

1.5.3 Social functioning: 1c. Average SAS, SFS, SNS scale scores - skewed data (low = favourable) There did not appear to be any significant differences between groups.

1.8.1 Global state: 1. Medium term average endpoint score (CGI, high = poor) Medium term CGI severity score favours standard care group (n = 61, MD 0.50 CI 0.08 to 0.92). But medium-term CGI change score favours psychoeducation group (n = 61, MD -0.80 CI -1.45 to -0.15).

1.6 Global functioning

1.6.1 Global functioning: 1. No clinically significant improvement Medium-term outcome included two RCTs and result favours psychoeducation group (n = 178, RR 0.59 CI 0.43 to 0.82, NNT 4 CI 3 to 10), but the data were heterogenous (I2 = 69%). Shortterm (n = 208, RR 0.61 CI 0.32 to 1.13) and long-term (n = 132, RR 0.70 CI 0.48 to 1.04) outcomes also appear to favour the psychoeducation group, but results are not statistically significant.

1.8.2 Global state: 2. Increased medication dose by 25% More people in the standard care group required increased medication dose (n = 20, RR 0.43 CI 0.15 to 1.20) compared with the psychoeducation group, but this result was not statistically significant.

1.8.3 Global state: 3. Disability 1.6.2 Global functioning: 2. Average endpoint scale score Medium term GAF/GAS data included four RCTs and results favoured standard care group (n = 321, MD -5.44 CI -8.51 to 2.38), as does the long term GAS outcome at two years’ follow-up (MD -6.70 CI -13.38 to -0.02). Short-term outcome data of the same scales were from one small trial (Brief - Group 1999) and were not significant (MD -2.64 CI -12.74 to 7.46). SLOF data came from one small trial (Standard - Group 2007), and both short-term (MD 23.60 CI 11.88 to 35.32) and medium-term (MD 46.40 CI 34.45 to 58.35) outcomes favour the psychoeducation group. Long-term disability data from one small trial (Standard - Both 2004) clearly favoured the psychoeducation group (RR 0.29 CI 0.13 to 0.64, NNT 3 CI 3 to 6).

1.9 Mental state

1.9.1 Menal state: 1a. Global - continuous - average total endpoint scale score (high = poor) BPRS scores generally favoured the psychoeducation group in the short term (10 RCTs, n = 1107, MD -1.00 CI -1.38 to -0.63), medium term (seven RCTs, n = 760, MD -4.73 CI -5.55 to 3.91) and long term up to two years (n = 370, MD -6.89 CI 8.55 to -5.23). However, short-term and medium-term data are heterogeneous (I2 = 88% and 79% respectively). Longer term BPRS follow-up data (from one small trial up to seven years) did not show any difference between groups (n = 48, MD -0.20 CI -6.55 to 6.15). Medium PANSS outcome also favoured the psychoeducation group (n = 163, MD -2.52 CI -5.01 to -0.04).
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1.7 Service utilisation

1.7.1 Service utilisation: days in hospital Outcome data were from two small trials (Standard - Group 2007; Standard - Unclear 2006) and results favoured the psychoeducation group in both the short (MD -3.23 CI -5.44 to -1.01) and medium term (MD -8.40 CI -10.44 to -6.36).

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1.9.2 Mental state: 1b. Global - continuous - average change scale scores - medium term (high = good) Data were from one small RCT (Brief - Both 2004). Compared with the standard care group, psychoeducation achieved better outcome with both GWB (n = 118, MD 10.89 CI 9.82 to 11.96) and SES assessments (n = 118, MD 8.00 CI 7.77 to 8.23). 1.9.3 Mental state: 1c. Global - continuous - average total endpoint scale scores - (BPRS, high = poor, data skewed) The skewed data did not show any significant difference between groups in either the short or long term. 1.9.4 Mental state: 2a. Specific - binary - specific symptoms short term Data from a small RCT (Brief - Both 2004a) showed that in the short term, the standard care group had worse outcomes with both anxiety (n = 146, RR 0.49 CI 0.25 to 0.93, NNT 7 CI 5 to 47) and depression (n = 146, RR 0.47 CI 0.25 to 0.88, NNT 5 CI 4 to 20) compared with psychoeducation. 1.9.5 Mental state: 2b. Specific - continuous - average endpoint PANSS scores (high = poor) Only one small RCT (Standard - Group 2006) reported specific PANSS scores and data did not show any significant differences between groups, except for medium term negative symptoms (n = 61, WMD 3.10 CI 0.16 to 6.04), which favoured the standard care group.

One small trial reported PGWB data (Standard - Group 2006), which did not show any significant differences between groups. QOL data from a small trial (Unclear - Group 1996) favoured standard care group (n = 108, MD -9.70 CI -17.22 to -2.18).

1.11.2 Quality of life: Average endpoint scores FBIS (high = poor) Psychoeducation group had better outcome on the FBIS scale compared with standard care group in both the short (n = 84, MD -4.70 CI -7.19 to -2.21) and medium term (n = 84, MD -6.24 CI -7.80 to -4.68).

1.12 Satisfaction

1.12.1 Satisfaction with mental health services: 1. Short term - average change score (VSS, high = good) No significant differences were found between groups either in term of patients’ satisfaction (n = 32, MD -2.15 CI -13.96 to 9.66), or relatives’ satisfaction (n = 17, MD -8.31 CI -29.72 to13.10).

1.12.2 Satisfaction with mental health services: 2. Average change - at 1 year (VSS scale, high = poor) Standard care group had better patient satisfaction with relatives’ involvement compared with the psychoeducation group (n = 30, MD -4.35 CI -7.09 to -1.61). No other significant differences were found between groups.

1.10 Expressed emotions

1.12.3 Satisfaction with mental health services: 3. Binary outcome 1.10.1 Expressed emotions: Participants with high EE relatives (FQ) Short-term outcome favoured the psychoeducation group (n = 282, RR 0.84 CI 0.76 to 0.94, NNT 8 CI 5 to 20), whereas outcome at nine to twelve months was not significant (RR 1.07 CI 0.64 to 1.78). More people in standard care group were unsatisfied with mental health services compared with the psycheducation group (n = 236, RR 0.24 CI 0.12 to 0.50, NNT 5 CI 5 to 8).

1.13 Adverse event: Death

1.11 Quality of life

No significant differences were found between groups in terms of death.

1.11.1 Quality of life: Average endpoint scores on various scales Medium term FAD score favoured the psychoeducation group (n = 146, MD -6.79 CI -11.67 to -1.91), although short-term data were equivocal. Short-term GQOLI-74 score was not significant (n = 62, MD 0.63 CI -0.79 to 2.05), but medium-term data favoured the psychoeducation group (n = 62, MD 2.13 CI 1.03 to 3.23).

1.14 Economic outcome

1.14.1 Economic outcomes: Costs (US$ per person, data skewed) Economic data were skewed and did not show any significant differences between groups.
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2. Subgroup analyses 1. Brief psychoeducation/standard psychoeducation versus standard care

Short-term non-compliance data favoured group psychoeducation (n = 412, RR 0.26 CI 0.13 to 0.52), while short-term partial compliance data favoured individual psychoeducation (n = 136, RR 0.61 CI 0.41 to 0.92).

2.1 Compliance (primary outcomes)

2.1.1 Compliance: 1a. With medication - binary outcomes (Analysis 2.1) Short-term non-compliance data showed an equivocal effect between brief psychoeducation group (n = 448, RR 0.63 CI 0.41 to 0.96) and standard psychoeducation group (n = 286, RR 0.41 CI 0.25 to 0.67). Equivocal effect was also found for medium-term outcome. 2.1.2 Compliance: 2 With follow up - loss to follow up for any reason (Analysis 2.2) While medium-term data favoured brief psychoeducation group (n = 170, RR 0.59 CI 0.37 to 0.94), long-term data showed an equivocal effect between the two types of interventions. 2.1.3 Compliance: 2a With follow up - received intervention but left the study early (Analysis 2.3) No significant differences were found between groups.

3.1.2 Compliance: 2. With follow up - leaving the study early/loss to follow-up (Analysis 3.2) Equivocal effect was found between group (n = 213, RR 0.52 CI 0.25 to 1.0) and individual psychoeducation (n = 20, RR 3.00 CI 0.14 to 65.90) in terms of receiving intervention but left the study early. No significant differences was found between groups with medium-term loss to follow-up for any reason data. There was a trend that individual psychoeducation group had a better outcome (n = 124, RR 0.70 CI 0.43 to 1.15), but it was not statistically significant. Again, no significant difference was found between groups for long-term loss to follow-up for any reason data.

3.1.3 Relapse: relapse for any reason (primary outcomes, Analysis 3.3) Compared with the individual psychoeducation group, mediumterm relapse for any reason data slightly favoured group psychoeducation (n = 410, RR 0.74 CI 0.57 to 0.96). But the long-term data were equivocal.

4. Sensitivity analysis 2.1.4 Relapse: Relapse for any reason (primary outcomes, Analysis 2.4) Medium-term relapse data were equivocal between brief psychoeducation group (n = 292, RR 0.61 CI 0.43 to 0.89) and standard psychoeducation group (n = 438, RR 0.87 CI 0.77 to 0.99), but standard group’s data were heterogeneous (I2 = 63%). Long-term relapse data favoured standard psychoeducation group (n = 666, RR 0.70 CI 0.59 to 0.84). Medium-term relapse with readmission data were equivocal, but the long-term data favoured standard psychoeducation group (n = 82, RR 0.53 CI 0.35 to 0.82). 3. Subgroup analyses 2. Group psychoeducation/individual psychoeducation versus standard care
4.1 Chinese studies versus non-Chinese studies

3.1 Compliance (primary outcomes)

3.1.1 Compliance: 1a. With medication - binary outcomes (Analysis 3.1)

In the 2010 update we included 31 trials that were conducted in China. We performed sensitivity analyses for all primary outcomes and results demonstrated that the outcomes of Chinese trials followed the same general affect as trials conducted in western countries. For instance, the medium-term relapse rate in nonChinese studies were (n = 514, RR 0.85 CI 0.73 to 0.99). Whilst, in medium-term Chinese studies were (n = 700, RR 0.48 CI 0.35 to 0.66). Similarly, the risk ratio for lost to follow-up in medium term non-Chinese studies were (n = 603, RR 1.04 CI 0.8 to 1.34) compared with three medium-term Chinese studies (n = 346, RR 0.85 CI 0.48 to 1.51). The only exception was the long-term non-compliance outcome, where the result of two Chinese studies (n = 200, RR 0.35 CI 0.22 TO 0.58) showed significant difference from the only non-Chinese study (Standard - Both 1996) (n = 81, RR 3.5 CI 0.77 to 15.85). However, the difference is unlikely to be due to the settings of the studies, as the compliance outcome of this particular non-Chinese study was significantly different from all other studies under the same outcome, including both Chinese and non-Chinese studies.
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4.2 Chinese studies versus full analysis

1.2 Relapse Psychoeducation group had less relapse in the medium term and long term, compared with standard care group (short term data are heterogeneous, I2 = 59%). Overall these data are taken from quite a few trials with large total numbers of participants. Again, biases may have inflated the estimate of effect, but there is more than a suggestion that a psychoeducation approach may have beneficial effects in the short, medium and even long term. Of course, this may be mediated by compliance with medication but may also have other positive effects. In terms of relapse with readmission, psychoeducation also had a better outcome than standard care group although readmission data were only from two small trials (n = 206).

We also compared primary outcomes of Chinese studies with primary outcomes of the full analysis (full analysis = Chinese studies + non-Chinese studies) and found no clear differences. For example, non-compliance rate of Chinese studies was 0.85 CI 0.48 to 1.51 (n = 346) and that of all studies 1.00 CI 0.79 to 1.26 (n = 949). The same applies to the outcome of relapse (Chinese studies n = 700, RR 0.48 CI 0.35 to 0.66; all studies n = 1214 RR 0.7 CI 0.61 to 0.81). Please see Table 1 for details.

4.3 English studies versus full analysis

We performed similar sensitivity analysis for non-Chinese trials(i.e. trials of any other language) and found no significant difference. Please refer to Table 2 for details.

1.3 Knowledge - KQ, KASQ, ITAQ, SKQ and SAUMD data KQ data found standard care group to have had more improvement on the knowledge of the illness compared with psychoeducation group. Short term SKQ data also favoured the standard care group. KASQ and SAUMD scores showed an equivocal effect between two groups but ITAQ score and the binary outcome on ‘level of knowledge’ both favoured the psychoeducation group. Standard - Unclear 1996 reported how psychoeducation group promotes confidence in physician, compared with standard group. As can be seen, conflicting conclusions were offered by different measures. Most data are from 1-3 small RCTs. Without better data it is difficult to make any conclusions as to whether psychoeducation improves knowledge of schizophrenia any more than a good standard approach to care.

DISCUSSION Summary of main results

Comparison 1. Any form of psychoeducation versus standard care

(Summary of findings for the main comparison)

1.1 Compliance This was a primary outcome of this review. Overall, psychoeducation promoted considerably better compliance with medication compared with standard care. This was recorded over different time periods and by different means, but the finding seems to be a consistently favouring the psychoeducation group. Even with the risk of overestimation of effect (Juni 2001) there may be some residual evidence that a psychoeducation approach does help people towards taking medication on a more regular basis. Numbers needed to treat are relatively small, and, although they may inflate in everyday care, where the skill of the psychoeducation therapist may not be as great as was seen in these trials, the effort expended to gain increased medication compliance may be seen as acceptable. Where it comes to loss to follow-up or leaving the study early, there is no evidence that either treatment is less acceptable than the other. About 25% of people left early in both groups. For the outcome of ‘allocated but never accepted treatment’ (Analysis 1.6) more people in the psychoeducation group were not compliant (2 RCTs, n = 213, RR 12.27 CI 2.58 to 58.33, NNT 9 CI 64 to 2) but we are unsure if this outcome was available to the standard care group. 1.4 Behaviour All results from three trials using the NOSIE-30 favoured standard care. We are not clear on the clinical meaning of differences of 1440 points but feel it likely that these may be of clinical importance. It is hard to see how the improvements reported overall for the psychoeducation group fit with a deterioration in behaviour.

1.5 Social functioning It is also difficult to be clear about the various measures of social functioning. Change scores seem to favour the standard care, whereas psychoeducation promotes better social functioning compared with standard care group according to endpoint scores (although some of these data are unacceptably heterogeneous). It may well have been better to record binary, clinically relevant, outcomes consistently across all studies (eg ‘considerably less socially isolated’).

1.6 Global functioning
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For the gross outcome overall ‘no clinically significant improvement’, in the medium term, treating four people with psychoeducation instead of standard care resulted in one additional person showing improvement. Short-term and long-term data also favoured the psychoeducation group, but they were not statistically significant. Data from various scales, again, were confusing and conflicting. A consistent approach to recording data would greatly help understand findings. Overall there is a suggestion that global functioning is helped by the psychoeducation approach. 1.7 Service utilisation On average people treated with psychoeducation had fewer number of days in hospital. These data were from very small studies (total n = 200), and findings could be even more prone to bias than larger trials. If, however, psychoeducation reduces inpatient care by about three days over only 12 weeks, or by eight days across a full year, as these data suggest, this is a finding of considerable clinical and economic importance. 1.8 Global state Only one small trial (n = 61) reported conflicting data on CGI scale over short and medium terms. More people in the standard care group needed increased medication and longer term disability seemed also to favour the psychoeducation group. All these findings are based on too few numbers and are prone to bias. Nevertheless, psychoeducation does seem to positively affect several important and clinically meaningful outcomes. 1.9 Mental state We found studies indicated a greater improvement for participants in the psychoeducation group compared with those allocated to standard care, but the data were heterogeneous, the differences in overall reduction were small, and the clinical significance of a difference of this magnitude may be questioned. PANSS scores based on two small trials (n = 163) were also found to favour the psychoeducation group. Also data from one small RCT (Brief - Both 2004, total n = 118) indicated that participants in the psychoeducation group achieved better self-esteem and general well-being compared with standard care. Only one study reported outcome on specific mental state symptoms. Results suggested that less participants in the psychoeducation group suffered from anxiety or depression. As with all findings from few small studies, these findings should be replicated before being considered reliable and conclusive. 1.10 Expressed emotions Short-term outcome based on two trials (n = 282) demonstrated statistically significant reduction on expressed emotion status of relatives in the psychoeducation group as compared to control

group. This improvement was not sustained in the medium term. Without more data, it is difficult to conclude if psychoeducation is indeed better than standard care on reducing expressed emotion in relatives, but these and other findings are consistent with the picture of psychoeducation helping the person as well as the family dealing with the illness.

1.11 Quality of life Again the various measures serve to confuse rather than clarify. Data tended to be equivocal or favour the psychoeducation group. Consistency of measure as well as more data are needed before anyone can be confident of the effects of psychoeducation on quality of life.

1.12 Satisfaction Only Brief - Group 1999 reported on patients and relatives’ satisfaction using the VSS scale. Most data indicated an equivocal effect between groups. This is an important outcome. It is to the credit of those designing Brief - Group 1999 that they have considered the satisfaction of patients and relatives - but much more data are needed to understand how psychoeducation really effects this outcome.

1.13 Adverse event: Death Across the time periods of the few studies that reported on this outcome (about two years) about 1% of people died. There was no suggestion that psychoeducation had any effect on this outcome.

1.14 Economic outcome As is frequent, economic data were few and skewed. It would seem likely that, if psychoeducation does really have an effect on relapse and service use that, if recorded properly and reported clearly, there should be an economic effect to find.

2. Subgroup analyses 1. Brief psychoeducation/standard psychoeducation versus standard care

For subgroup analyses we found no direct comparisons. We therefore compared each approach (brief/standard and group/individual) with the standard (non-psychoeducational) care. We are aware that techniques are available to undertake indirect comparisons of interventions (section 16.6.2 of Cochrane Handbook, Higgins 2008) but have not employed these at this juncture on such weak data.
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Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

2.1 Compliance For the various measures of compliance we found no clear difference in measures of effect size between brief versus standard care and standard duration psychoeducation versus standard care. This could be a function of power but there are several hundred participants per sub-group. 2.2 Relapse: Relapse for any reason The same applies to the outcome of relapse and, certainly, this generates the hypothesis that a brief form of psychoeducation may be cost efficient and effective. Direct comparisons are justified.

3. Subgroup analyses 2. Group psychoeducation/individual psychoeducation versus standard care

comes to scale-derived continuous measures. It is possible to add data from different but similar scales and perform meta-analysis, but we feel that this gives spurious authority to weak data. There are too many assumptions. Scale-derived data are proxy measures, often not truly continuous and are frequently incomplete. Then to calculate an effect size estimate and then estimate how that would relate to one favoured scale is, we suggest, more of an academic contrivance than of direct clinical value. Outcomes were mainly physician-oriented. Participant-oriented outcomes, such as quality of life, satisfaction or days out of hospital were seldom reported. Participant satisfaction was only reported in three studies and no studies reported family burden. We would suggest that future research should focus more on participantoriented aspects, such as general and social functioning, family burden and participants acceptability. Policymakers will certainly want more and better reported economic data.

There were fewer numbers in each of these subgroup analyses compared with the findings reported in the brief/standard duration set of calculations. 3.1 Compliance We found no convincing evidence that those given psychoeducation in a group differed in terms of compliance with those where the intervention was delivered individually.

2. Applicability Most trials were undertaken in hospital, whereas the majority of people with schizophrenia are treated in the community. We are unsure that, in the context of well-functioning community services, psychoeducation, as a separate package, has a place. This is the sort of information that would not be difficult to generate. As many of the included trials are conducted in China, the findings of this review are applicable to the Chinese population. Nevertheless, most of the included Chinese trials are also conducted in hospitals, thus raising the same concern that it may be inappropriate to apply the results to community based patients.

3.1.3 Relapse: Relapse for any reason There was no suggestion that relapse rates really did differ between those who had the intervention delivered by group compared with people given individual psychoeducation. These findings were, however, not direct comparisons, were not well powered and serve only to generate theories for future studies.

Quality of the evidence
Overall, the quality of reporting was poor. Most included studies did not describe how the randomisation was conducted. Blinding was only used in eight studies and blinding concealment was not tested. Therefore, there is a moderate risk of overestimating the estimate of effect. Please refer to Figure 1 for a graphic representation of the methodological quality of included studies.

Overall completeness and applicability of evidence

1. Completeness We were pleased that most included studies did report the outcomes of compliance and relapse - the outcomes we had chosen as being of primary interest. A general problem in assessing the efficacy of psychoeducational interventions for people with schizophrenia is, however, the scarcity of data. Poor reporting of data compounds the problem. We excluded 11 studies primarily due to lack of extractable data. This is potentially a truly valuable intervention and policymakers are still left having to make sweeping decisions for services based on outcomes with only a few hundred participants involved in less than ideal studies. This point is especially obvious where it

Potential biases in the review process
The process of searching for studies was thorough. We strictly followed the review protocol in the process of study selection, data extraction and analysis. However, we only worked with published reports in this review and may be perpetuating a publishing bias. Many trials included in this update version were from the People’s republic of China. The quality of some of the Chinese trials has been called into question (Wu 2006), as many that are stated to be randomised are not. In this update version, we found two Chinese trials (Liu 2007; Unclear - Both 2005) conducted at different places and time periods to have reported exactly the same
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Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

numerical outcomes. We excluded the one found at a later date (Liu 2007). However, we did not find any other overt bias in the results and therefore, have left these Chinese trials in.

1. General We had to exclude 11 trials (please refer to Characteristics of excluded studies for detail), due to the poor quality of data reporting, diminishing the already limited evidence-base. Following CONSORT for good reporting of clinical trials more closely would have helped to considerably increase the amount of data available in this review.

Agreements and disagreements with other studies or reviews
This review substantially updates and improves past work (Pekkala 2002). It largely concurs with findings from the previous version but puts less emphasis on the positive findings, perhaps because of the new Risk of Bias table function of this version of RevMan.

2. Specific More well-designed, conducted and reported randomised studies investigating the efficacy of psychoeducation are needed. This is an intervention that looks as if it works in terms of compliance and relapse, but we still know relatively little about many important effects. Certainly, any future trials should employ well standardised psychoeducational programmes with clear definitions of the content of interventions to help professionals planning evidencebased psychoeducational interventions, people with schizophrenia and family members participating in psychoeducation programmes. Not only should compliance, relapse and readmission be recorded as outcomes, but also psychosocial function, quality of life and insight. Health economic outcomes should also be measured, as the efficiency of psychoeducation is crucial in making it an attractive option for managers and policy makers. Continuous data should be reported with mean, standard deviations and number of participants. Endpoint scores should always be used when reporting data derived from scales. We have not the experience nor have we invested the effort of thought or commitment of those who have undertaken trials in this difficult area. There are, however, some gains from producing an overview in this way and we suggest an outline design for future trials (Table 3). Further research is also needed for assessment of the efficacy of different formats of psychoeducational interventions as brief or group approaches may well be cost efficient.

AUTHORS’ CONCLUSIONS Implications for practice

1. For people with schizophrenia Psychoeducational interventions may initially seem ’off putting’ for the person with schizophrenia, but it can reduce the relapse, readmission and encourage medication compliance, as well as reduce the length of hospital stay. It may well have other outcomes that are, at this point, under-researched.

2. For clinicians The reduction in relapse and length of hospital stay with psychoeducational interventions and the increase of medication compliance rate should make it useful for clinicians as a part of their treatment programme. More should be known on other important outcomes and efficient ways of implementation.

3. For managers and policy makers Not much data exist concerning the economic consequences of implementing psychoeducation as a routine service. A single study indicates that the combined costs for hospital and ambulatory services are comparable for the intervention group and standard treatment group. Much better work should be undertaken in this area to explore the true costs of the intervention and variations of approach, such as use of a brief form of psychoeducation or group delivery rather than individual to individual. 4. Note: the new 27 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.

ACKNOWLEDGEMENTS
For the original version of this review, comments on all aspects of the review by Kristian Wahlbeck have been greatly appreciated. The authors wish to thank Eila Sailas for her help in the selection of trials and in double-checking data extraction. Thanks go to Anne Vainikka, Kristiina Holmberg and Asko J Huotarinen at the Central Library of Health Sciences Terkko, Helsinki, Finland, who uncomplainingly dealt with our requests for articles. Thanks to Stina Blomberg and Siv Laxén, who have been helpful in translating articles in Spanish and Ulla Wang in translating a Chinese study. The review authors sent several letters to authors of studies, asking for extra information about their trials. Dr Atkinson, Dr Herz, Dr Hornung, Dr Lesage, Dr Macpherson, Dr Pitschel-Walz,
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Implications for research

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Professor Tarrier and Dr Youssef were kind enough to respond, for which we are very grateful. For the 2010 update, the authors would like to thank Samantha Roberts for running the trial search, Clive Adams for editorial input and John Rathbone for practical guidance during the stage of writing up. The Methods section of this review uses text from the Cochrane Schizophrenia Group’s generic text for methods sections. This has been written over a period of years to ensure consistency and clarity. We fully acknowledge use of this text which we have adapted for relevance to this particular review.

REFERENCES

References to studies included in this review
Brief - Both 2004 {published data only} Liu L, Gao CF, Yue SY, Zhan LY, Liu WG. Effect of family intervention on rehabilitation of schizophrenic patients in community. Journal of Nursing Science 2004;3(19):3–6. Brief - Both 2004a {published data only} Zhang L, Ren QL, Li CP, Yao N, Han FZ. Improvement of anxiety and depression in patients with schizophrenia at recovery stage via education of health conviction mode. Journal of Nursing Science 2004;19(15):51–3. Brief - Group 1995 {published data only} Buchkremer G, Klingberg S, Holle R, Schulze Monking H, Hornung WP. Psychoeducational psychotherapy for schizophrenic patients and their key relatives or caregivers: results of a two-year follow-up. Acta Psychiatrica Scandinavica 1997;96(6):483–91. Feldmann R, Buchkremer G, Hornung WP. Cognitive deficits of schizophrenic patients as predictors of the course of illness after psychoeducational psychotherapeutic interventions [Prognostische und therapeutische relevanz kognitiver ressourcen für den langenzeitverlauf schizophrener erkrankung nach psychoedukativ– psychoterapeutischer behandlung]. Fortschritte der Neurologie Psychiatrie 2000;68(2):54–60. Hornung WP, Buchkremer G, Redbrake M, Klingberg S. Patient modified treatment. What are the effects of neuroleptic drugs on people with schizophrenia? [Patientmodifizierte medikation: Wie gehen schizophrene patienten mit ihren neuroleptika um?]. Nervenarzt 1993; 64:434–9. Hornung WP, Feldman R, Klingberg S, Buchkremer G, Reker T. Long-term effects of a psychoeducational psychotherapeutic intervention for schizophrenic outpatients and their key-persons - results of a five-year follow-up. European Archives of Psychiatry and Clinical Neuroscience 1999;249:162–7. Hornung WP, Feldman R, Schonauer K, Schäfer A, Schulze Mönking H, Klingberg S, Buchkremer G. Psychoeducational-psychotherapeutic treatment

of schizophrenic patients and their caregivers. II. Supplementary findings at a 2-year follow-up [Psychoedukativ–psychotherapeutische behandlung von schizophrenen patienten und ihren bezugspersonen. II. Erganzende befunde der 2–jahres– katamnese]. Nervenarzt 1999;70(5):444–9. ∗ Hornung WP, Holle R, Schulze Monking H, Klingberg S, Buchkremer G. Psychoeducational-psychotherapeutic treatment of schizophrenic patients and their caregivers. Results of a one-year catamnestic study [Psychoedukativ– psychotherapeutische behandlung von schizophrenen patienten und ihren bezugspersonen. Ergebnisse einer 1–jahres–katamnese]. Nervenarzt 1995;66:828–34. Hornung WP, Kieserg A, Feldman R, Buchkremer G. Psychoeducational training for schizophrenic patients: background, procedure and empirical findings. Patient Education and Counseling 1996;29:257–68. Hornung WP, Klingberg S, Feldmann R, Schonauer K, Schulze Monking H. Collaboration with drug treatment by schizophrenic patients with and without psychoeducational training: results of a one-year follow-up. Acta Psychiatrica Scandinavica 1998;97(3):213–9. Hornung WP, Schonauer K, Feldmann R, Schulze Mönking H. Medication-related attitudes of chronic schizophrenic patients. A follow-up study after psycho-educational intervention [Medikationsbezogene einstellungen chronisch schizophrener patienten. Eine follow–up untersuchung 24 monate nach psychoedukativer Intervention]. Psychiatrische Praxis 1998;25(1):25–8. Klingberg S, Buchkremer G, Holle R, Schulze Mönking H, Hornung WP. Differential therapy effects of psychoeducational psychotherapy for schizophrenic patients - results of a 2-year follow-up. European Archives of Psychiatry and Clinical Neuroscience 1999;249(2):66–72. Brief - Group 1995a {published data only} ∗ Razali MS, Yahua H. Compliance with treatment in schizophrenia: a drug intervention program in a developing country. Acta Psychiatrica Scandinavica 1995;91:331–5. Razali SM, Yahua H. Health education and drug counseling
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for schizophrenia. International Medical Journal 1997;4(3): 187–9. Brief - Group 1999 {published data only} ∗ Merinder LB. Impact of Patient and Relative Education on Knowledge, Satisfaction With Services and Clinical Outcome in Schizophrenia. Faculty of Health Sciences, University of Aarhus, Department of Psychiatric Demography, Institute for Basic Psychiatric Research. Psychiatric Hospital in Aarhus, 2000. Merinder LB, Viuff AG, Laugesen H, Clemmensen K, Misfelt S, Espensen B. Patient and relative education in community psychiatry: a randomised controlled trial regarding its effectiveness. Social Psychiatry and Psychiatric Epidemiology 1999;34(6):287–94. Merinder LB, Viuff AG, Laugesen HD, Clemmensen K, Misfelt S, Espensen B. Patient and relative education in community psychiatry; a randomised trial regarding its usefulness. Proceedings of the 9th Congress of the Association of European Psychiatrists; 1998 Sep 20-24; Copenhagen, Denmark. 1998. Merinder LB, Viufff AG, Laugesen H, Clemendsen K, Misfelt S, Espensen B. Effects of psychoeducative methods; a randomized controlled study. Nordic Journal of Psychiatry Supplement 1998;41:144. Brief - Group 2003 {published data only} Li FM, Xu JH. Comparative study on the effect of family intervention on schizophrenia patients in convalescence and their family members. Health Psychology Journal 2003;11 (2):129–30. Brief - Group 2006 {published data only} Zhang H, Wang P, Wu Z. Influence of health education on compliance of orally taking medicines in schizophrenia patients of the first episode seeing doctor in out-patient clinic. Chinese Nursing Research 2006;20(5):1246–7. Brief - Group 2007 {published data only} Chan SH-W, Lee SW-K, Chan IW-M. TRIP: a psychoeducational programme in Hong Kong for people with schizophrenia. Occupational Therapy International 2007;14 (2):86–98. Brief - Group 2007a {published data only} Lv C-M, Lu D-C, Lv W-Q, Jin L-Z, Zheng Q-L. Effects of follow- up on family function of schizophrenia patients’ families and their quality of life. Nanfang Journal of Nursing 2007;14(9):7–9. Brief - Group 2007b {published data only} Dai JQ. Health education on compliance of schizophrenic patients. Medical Journal of Chinese People’s Health 2007; Vol. 19, issue 12:1089–90. Brief - Group 2009 {published data only} Chan SW, Yip B, Tso S, Cheng B-S, Tam W. Evaluation of a psychoeducation program for Chinese clients with schizophrenia and their family caregivers. Patient Education and Counseling 2009;75(1):67–76.

Brief - Individual 1996 {published data only} ∗ Macpherson R, Jerrom B, Hughes A. A controlled study of education about drug treatment in schizophrenia. British Journal of Psychiatry 1996;168:709–17. Brief - Unclear 2005 {published data only} Li H. Systematic psychoeducation for medication compliance in patients with schizophrenia. Journal of Qilu Nursing 2005;11(7B):897–8. Standard - Both 1996 {published data only} Herz MI. Psychosocial treatment. Psychiatric Annals 1996; 26:531–5. ∗ Herz MI, Lamberti JS, Minz J, Scott R, O’Dell SP, McCartan L, Nix G. A program for relapse prevention in schizophrenia: a controlled study. Archives of General Psychiatry 2000;57(3):277–83. Standard - Both 2004 {published data only} Li Y, Jia JD, Zhang MS. Influence of family mental intervention on social function, family environment and relapse rate in first-episode schizophrenics. Chinese Journal of Clinical Rehabilitation 2004;8(21):4184–5. Standard - Both 2006 {published data only} Dong J. Psychoeducation for medication compliance in patients with schizophrenia. Journal of the Shanxi Medical College for Continuing Education 2006; Vol. 16, issue 1: 57–8. Standard - Both 2008 {published data only} Zhang Z, Chen Q. Effect of pschoeducation on rehabilitation of schizophrenia. Guide to Chinese Medicine 2007;5(9):1–3. Zhang Z-C, Chen Q-N. Effect of family health education on the family burden with schizophrenia. Contemporary Nursing 2008;5:1–2. Standard - Both 2008a {published data only} Zhu Y-R. Effect of health education on rehabilitation of first episode schizophrenia during the recovery period. Chinese Journal of Modern Nursing 2008;14(10):1156–8. Standard - Both 2008b {published data only} Li JH. Psychoeducation for the post-intervention recovery of first episode schizophrenia. Journal of Qiqihar Medical College 2008; Vol. 29, issue 11:1404–6. Standard - Group 1988 {published data only} Barrowclough C, Tarrier N. Social functioning in schizophrenic patients. Social Psychiatry and Psychiatric Epidemiology 1990;25:125–9. Tarrier N, Barrowclough C. Social functioning in schizophrenia. Social Psychiatry and Psychiatric Epidemiology 1990;25:130–1. ∗ Tarrier N, Barrowclough C, Vaughn C, Bamrah JS, Porceddu, Watts S, Freeman H. The community management of schizophrenia. A controlled trial of a behavioural intervention with families to reduce relapse. British Journal of Psychiatry 1988;153:532–42. Tarrier N, Barrowclough C, Vaughn C, Bamrah JS, Porceddu K, Watts S, Freeman H. Community management of schizophrenia. A two-year follow-up of a behavioural
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intervention with families. British Journal of Psychiatry 1989;154:625–8. Standard - Group 2004 {published data only} Jiang LP, Zhang YM, Wang XR. Effects of health education on the rehabilitation of inpatients with schizophrenia in convalescence. Chinese Journal of Clinical Rehabilitation 2004;8(27):5748–9. Standard - Group 2005 {published data only} ∗ Chabannes J, Bazin N, Leguay D, Nuss P, Perreti C, Tatu P, Khalfi F, Hameg A, Ferreri M. Could a psychoeducational programme reduce relapse in schizophrenic patients?. European Neuropsychopharmacology 2005;15(Suppl 3):499. Chabannes J-P, Bazin N, Leguay D, Nuss P, Peretti C-S, Tatu P, Hameg A, Garay RP, Ferreri M. Two-year study of relapse prevention by a new education program in schizophrenic patients treated with the same antipsychotic drug. European Psychiatry 2008;23(1):8–13. Standard - Group 2006 {published data only} Vreeland B, Miinsky S, Yanos PT. Efficacy of the team solutions programme for educating patients about illness management and treatment. Psychiatric Services 2006;57 (6):822–8. Standard - Group 2007 {published data only} Chien WT, Wong K-F. A family psychoeducation group program for Chinese people with schizophrenia in Hong Kong. Psychiatric Services 2007;58(7):1003–6. Standard - Group 2008 {published data only} Wang C, Li Y. Effect of community health education process applied to convalescent schizophrenic patients. Journal of Nursing Science 2008;23(15):66, 76. Standard - Individual 03a {published data only} Fu FZ, Liu L, Guo J, Ma ZF, Zhan LY. The rehabilitation effect of health education on schizophrenia patients in remission. Journal of Nursing Science 2003;18(5):385–6. Standard - Individual 03b {published data only} Zeng ZX. An extended two-year follow-up of psychological education on insight recovery and drug therapy compliance and recurrence in schizophrenic patients. Chinese Journal of Clinical Rehabilitation 2003;7(12):1774–5. Standard - Individual 03c {published data only} Zhang YJ, Zhao FY, Zhou CM, Wang BL. A comparative study of psychological education of stress to schizophrenia patients’ effect during recovery period. Medical Journal of Chinese People’s Health 2003;15(10):633–5. Standard - Individual 93 {published data only} ∗ Goulet J, Lalonde P, Lavoie G, Jodoin F. Effects of neuroleptic treatment education in young psychotics [Effets d’une éducation au traitement neuroleptique chez de jeunes psychotiques]. Revue Canadienne de Psychiatrie 1993;38(8): 571–3. Standard - Unclear 1988 {published data only} Clarkin JF, Glick ID, Haas G, Spencer JH. The effects of inpatient family intervention on treatment outcome. In: Mirin SM, Gossett JT, Grob MC editor(s). Psychiatric

Treatment: Advances in Outcome Research. American Psychiatric Press, Inc, 1991:47–59. ∗ Glick ID, Clarkin JF, Haas GL, Spencer JH. Clinical significance of inpatient family intervention: conclusions from a clinical trial. Hospital and Community Psychiatry 1993;44(9):869–73. Glick ID, Clarkin JF, Haas GL, Spencer JH, Chen CL. A randomized clinical trial of inpatient family intervention: VI. Mediating variables and outcome. Family Process 1991; 30:85–99. Glick ID, Clarkin JF, Spencer JH Jr, Haas GL, Lewis AB, Peyser J, DeMane N, Good Ellis M, Harris E, Lestelle V. A controlled evaluation of inpatient family intervention. Preliminary results of the six-month follow-up. Archives of General Psychiatry 1985;42(9):882–6. Glick ID, Spencer JH, Clarkin JF, Haas GL, Lewis AB, Peyser J, DeMane N, Good-Ellis M, Harris E, Lestelle V. A randomized clinical trial of inpatient family intervention: IV. Followup results for subjects with schizophrenia. Schizophrenia Research 1990;3(3):187–200. Haas GL, Glick ID, Clarkin JF, Spencer JH, Lewis AB. Gender and schizophrenia outcome: a clinical trial of an inpatient family intervention. Schizophrenia Bulletin 1990; 16(2):277–92. Haas GL, Glick ID, Clarkin JF, Spencer JH, Lewis AB, Peyser J, DeMane N, GooD Ellis M, Harris E, Lestelle V. Inpatient family intervention: a randomized clinical trial: II. Results at hospital discharge. Archives of General Psychiatry 1988;45(3):217–24. Spencer JH, Glick ID, Haas GL, Clarkin JF, Lewis AB, Peyser J, DeMane N, Good Ellis M, Harris E, Lestelle V. A randomized clinical trial of inpatient family intervention: III. Effects at 6-month and 18-month follow-ups. American Journal of Psychiatry 1988;145(9):1115–21. Standard - Unclear 1996 {published data only} ∗ Bäuml J, Kissling W, Pitschel-Walz G. Psychoeducational groups for schizophrenic patients: impact on knowledge and compliance [Psychoedukative gruppen für schizophrene patienten: Einfluss auf wissensstand und compliance]. Nervenheilkunde 1996;15:145–50. Bauml J, Pitschel-Walz G, Volz A, Engel RR, Kessling W. Psychoeducation in schizophrenia: 7-year follow-up concerning rehospitalization and days in hospital in the Munich psychosis information project study. Journal of Clinical Psychiatry 2007;68(6):854–61. Kissling W, Bäuml J, Pitschel-Walz G, Buttner P, Boerner R, Engel R, et al.Psychoeducation and compliance in the treatment of schizophrenia: results of the Munich PIPstudy. In preparation 1999. Pitschel-Walz G, Bauml J, Bender W, Engel RR, Wagner M, Kissling W. Psychoeducation and compliance in the treatment of schizophrenia: results of the Munich psychosis information project study. Journal of Clinical Psychiatry 2006;67(3):443–52. Pitschel-Walz G, Boerner R, Mayer C, Engell R, Peuker I, Welschehold M, Bauml J, Buttner P, Kissling W. Psychoeducational groups for schizophrenic patients and
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their relatives: influence on knowledge, attitudes and familial expressed emotions. Pharmacopsychiatry. 1993; Vol. 26:186. Pitschel-Walz G, Boerner R, Mayer C, Wagner M, Engell RR, Peuker I, Welschehold M, Bender W, Bauml J, Buttner P, Kissling W. Effects of psychoeducational groups for schizophrenic patients and their relatives on knowledge, compliance and relapse. Pharmacopsychiatry 1995;28:204. Pitschel-Walz G, Engel RR. Psychoeducation in the treatment of schizophrenia [Psychoedukation in der Schizophreniebehandlung]. Psycho 1997;23(1):22–36. Standard - Unclear 2005 {published data only} Zhou ZY. Psychoeducation as a post-discharge intervention for people with schizophrenia. Journal of Medical Forum 2005; Vol. 26, issue 20:91. Standard - Unclear 2005a {published data only} Chen HH, Wang FH, Zhang DM, Zhang HY, Li LF . Psychological intervention for the rehabilitation of people with schizophrenia. Journal of Qilu Nursing 2005; Vol. 11, issue 12A:1820. Standard - Unclear 2006 {published data only} Xie Y. Effects of mental health education on the accompanying dependants of hospitalized schizophrenics. Journal of Clinical Psychosomatic Diseases 2006;12(4):297–8. Standard - Unclear 2007 {published data only} Zhang Z. Analysis of medication compliance of schizophrenia patients. Journal of Clinical Medicine 2007;9: 61–2. Unclear - Both 2001 {published data only} Gao XC, Wu CJ, Kong Y, Han FZ, Cui AH, Tian B, Zhang YL. An investigation about the rehabilitation of schizophrenics insight by health education. Journal of Qilu nursing 2001;7(9):641–3. Unclear - Both 2005 {published data only} Sun SZ, Zhang YJ, Liu MX, Xing SY, Zhao L. Effects of health education on recovery of insight and treatment compliance in schizophrenics. Journal of Clinical Psychosomatic Disease 2005;11(1):37–47. Unclear - Both 2007 {published data only} Zhao Z, Fan M-L, Liu K-H. Effect of health education on schizophrenia relapse interference. Occupation and Health 2007;23(9):684–6. Unclear - Both 2007a {published data only} Zeng GE. Psychoeducation for medication compliance of hospitalised schizophrenia. China Foreign Medical Treatment 2007, issue 20:41. Unclear - Both 2008 {published data only} He RF. Effect of psychoeducation for family members of people with schizophrenia. World Health Digest [Journal of New Medicine] 2008; Vol. 5, issue 7:1249. Unclear - Group 1996 {published data only} ∗ Atkinson JM, Coia DA, Gilmour WH, Harper JP. The impact of education groups for people with schizophrenia on social functioning and quality of life. British Journal of Psychiatry 1996;168:199–204.

Unclear - Group 2008 {published data only} Huang Y, Xiong Y. Researches of health education methods in schizophrenics. Journal of Clinical Psychosomatic Diseases 2008;14(4):356–7. Unclear - Individual 2008 {published data only} Wang J, Long J, Gao J. The effect of health education on the treatment of schizophrenia patient. Chinese Journal of Health Psychology 2008;16(10):1163–5. Unclear - Unclear 2008 {published data only} Hu JR. Application of health pathway therapy to people with schizophrenia. Attend to Practice and Research 2008; Vol. 5, issue 4:86–7.

References to studies excluded from this review
Agara 2007 {published data only} Agara AJ, Onibi OE. Effects of group psychoeducation (GPE) on compliance with scheduled clinic appointments in a neuro-psychiatric hospital in Southwest Nigeria: a randomised control trial (RCT). Annals of the Academy of Medicine Singapore 2007;36(4):272–6. Aguglia 2007 {published data only} Aguglia E, Pascolo-Fabrici E, Bertossi F, Bassi M. Psychoeducational intervention and prevention of relapse among schizophrenic disorders in the Italian community psychiatric network. Clinical Practice and Epidemiology in Mental Health 2007;3(7):1745–79. An 2005 {published data only} An XF, Niu CX. Psychoeducation for medication compliance and relapse prevention of people with schizophrenia. Journal of Hebei Medical College for Continuing Education 2005; Vol. 22, issue 4:65–6. Angunawela 1998 {published data only} ∗ Angunawela II, Mullee MA. Drug information for the mentally ill: a randomised controlled trial. International Journal of Psychiatry in Clinical Practice 1998;2:121–7. Azrin 1998 {published data only} ∗ Azrin NH, Teichner G. Evaluation of an instructional program for improving medication compliance for chronically mentally ill outpatients. Behaviour Research & Therapy 1998;36(9):849–61. Barnes 2001 {unpublished data only} Barnes TRE. A controlled study of cognitive versus psychoeducational intervention in compliance with a depot neuroleptic regime among patients with schizophrenia. Current Controlled Trials (http://www.controlledtrials.com/) 2001. BaumI 2006 {published data only} BaumI J, Frobose T, Kraemer S, Rentrop M, PitschelWalz G. Psychoeducation: a basic psychotherapeutic intervention for patients with schizophrenia and their families. Schizophrenia Bulletin 2006;32(Suppl 1):S1–9. Bechdolf 2005a {published data only} Bechdolf A, Kohn D, Knost B, Pukrop R, Klosterkotter J. A randomized comparison of group cognitive-behavioural therapy and group psychoeducation in acute patients with
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schizophrenia: outcome at 24 months. Acta Psychiatrica Scandinavica 2005;112(3):173–9. Bechdolf 2007 {published data only} Bechdolf A. Development and pilot evaluation of modified cognitive behavioural therapy for adolescents with early onset psychosis. http://www.clinicaltrials.gov 2007. Bi 2000 {published data only} Bi YH. Psychoeducation for people with schizophrenia. Today Nurse 2000;2:13–4. Boczkowski 1985 {published data only} ∗ Boczkowski JA, Zeichner A, DeSanto N. Neuroleptic compliance among chronic schizophrenic outpatients: an intervention outcome report. Journal of Consulting and Clinical Psychology 1985;53:666–71. Borell 1995 {published data only} ∗ Borell P, Orhagen T, D’Elia G. Feasibility and effects of a patient information program in schizophrenia [Sjukdomsrelaterad information vid schizofreni: klinisk tillämpning och effekter]. Scandinavian Journal of Behaviour Therapy 1995;24(3-4):75–86. Cao 2002 {published data only} Cao XM, Zhang SL, Li H, Yue P, Lu P, Xu DJ. Psychoeducation for patients with schizophrenia and their family members. Chinese Journal of Nursing 2002; Vol. 37, issue 4:266–8. Castrogiovanni 2006 {published data only} Castrogiovanni S, Simoncini M, Iovieno N, Cecconi D, Dell’Agnello G, Donda P, Quadrigli M, Rossi A, Mauri M. Efficacy of a psychoeducational program for weight loss in patients who have experienced weight gain during treatment with olanzapine. European Neuropsychopharmacology 2006; 16(Suppl 4):S441. Chaplin 1998 {published data only} ∗ Chaplin R, Kent A. Informing patients about tardive dyskinesia. British Journal of Psychiatry 1998;172:78–81. Chen 2005 {published data only} Chen R, Chen XZ, Zhang QY. Effect of psychoeducation for chronic schizophrenia with diabetes. Sichuan Mental Health 2005; Vol. 18, issue 4:245–6. Cormier 1995 {published data only} Cormier H, Leblanc G, Picher F, Lachance L. A FrenchCanadian trial of the symptom and medication modules. Proceedings of the 150th Annual Meeting of the American Psychiatric Association; 1997 May 17-22; San Diego, California, USA. 1997. ∗ Cormier H, Leblanc G, Picher F, Lachance L. Results of a clinical trial of the symptom and medication modules in schizophrenia. Schizophrenia Research. 1995; Vol. 1, 2: 146. Dang 2007 {published data only} Dang W, Zhang H, Ren Y. Influence of mental health education on quality of life of female patients with chronic schizophrenia. Chinese Nursing Research 2007;21(2A): 340–1.

Degmecic 2007 {published data only} ∗ Degmecic D, Pozgain I, Filakovic P. Psychoeducation and compliance in the treatment of patients with schizophrenia. Collegium Antropologicum 2007;31(4):1111–5. Eckman 1992 {published data only} ∗ Eckman TA, Wirshing WC, Marder SR, Liberman RP, Johnston-Cronk K, Zimmermann K, Mintz J. Technique for training schizophrenic patients in illness self-management: a controlled trial. American Journal of Psychiatry 1992;149 (11):1549–55. Goldman 1988 {published data only} ∗ Goldman CR, Quinn FL. Effects of a patient education program in the treatment of schizophrenia. Hospital and Community Psychiatry 1988;39(3):282–6. Gumley 2003 {published data only} Gumley A, O’Grady M, McNay L, Reilly J, Power K, Norrie J. Early intervention for relapse in schizophrenia: results of a 12-month randomized controlled trial of cognitive behavioural therapy. Psychological Medicine 2003;33(3): 419–31. He 2008 {published data only} He SF, Huang QC, Yin JX. Application of goal attainment theory in the psychoeducation of people with schizophrenia. Journal of Clinical Psychosomatic Diseases 2008; Vol. 14, issue 5:404–6. Hogarty 1986 {published data only} Hogarthy GE, Anderson CM. Medication, family psychoeducation and social skills training: first year relapse results of a controlled study. Psychopharmacology Bulletin 1986;22:860–2. ∗ Hogarty GE, Anderson CM, Reiss DJ, Kornblith SJ, Greenwald DP, Javna CD, Madonia MJ, Environmentalpersonal indicators in the course of Schizophrenia Research Group. Family psychoeducation, social skills training and maintenance chemotherapy in the aftercare treatment of schizophrenia. I. One-year effects of a controlled study on relapse and expressed emotion. Archives of General Psychiatry 1986;43(7):633–42. Hogarty GE, Anderson CM, Reiss DJ, Kornblith SJ, Greenwald DP, Ulrich RF, Carter M, Environmentalpersonal indicators in the course of Schizophrenia (EPICS) Research Group. Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenia. II. Two-year effects of a controlled study on relapse and adjustment. Archives of General Psychiatry 1991;48(4):340–7. Hu 1998 {published data only} Hu RW, Li H, Zhu XG. The effect of insight education on insight recovering and drug therapy compliance in schizophrenia patients. Chinese Journal of Psychiatry 1998; 31(3):145–7. Hua 2008 {published data only} Hua T. Effects of psychoeducation for the rehabilitation of people with schizophrenia. Inner Mongolia Journal of Traditional Chinese Medicine 2008, issue 12:68–9.
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Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Huang 2007 {published data only} Huang JR, Guo JM, Li SF, Cui HH, Kang SL, Lv SM, Xiao YC. Effect of psychoeducation for the medication compliance and relapse prevention of people with chronic schizophrenia. Medical Journal of Chinese People’s Health 2007; Vol. 19, issue 12:1091, 1093. Kelly 1990 {published data only} ∗ Kelly GR, Scott JE. Medication compliance and health education among outpatients with chronic mental disorders. Medical Care 1990;28(12):1181–97. Kleinman 1993 {published data only} ∗ Kleinman I, Schachter D, Jeffries J, Goldhamer P. Effectiveness of two methods for informing schizophrenic patients about neuroleptic medication. Hospital and Community Psychiatry 1993;44:1189–91. Kleinman I, Schachter D, Jeffries J, Goldhamer P. Informed consent and tardive dyskinesia. Journal of Nervous and Mental Disease 1996;184(9):517–22. Klingberg 2009 {published data only} Klingberg S, Buchkremer G. Evidence-based psychotherapy for schizophrenia. World Psychiatry 2009;8(Suppl 1):SS30. Kopelowicz 1998 {published data only} Kopelowicz A. Integrating psychotherapy and pharmacotherapy for schizophrenia. In Session: Psychotherapy in Practice 1997;3(2):79–98. ∗ Kopelowicz A, Wallace CJ, Zarate R. Teaching psychiatric inpatients to re-enter the community: a brief method of improving the continuity of care. Psychiatric Services 1998; 49(10):1313–6. Kopelowicz A, Zarate R, Wallace CJ. Successful transition from the hospital to the community. Schizophrenia Research. 1997; Vol. 24:224. Mackain SJ, Smith TE, Wallace CW, Kopelowicz A. Evaluation of a community re-entry program. International Review of Psychiatry 1998;10(1):76–83. Kuipers 1994 {published data only} ∗ Kuipers J, Bell C, Davidhizar R, Cosgray R, Fawley R. Knowledge and attitudes of chronic mentally ill patients. Journal of Advanced Nursing 1994;20(3):450–6. Lester 2004a {published data only} Lester H, Birchwood M, Tait L, Shanks A. Evaluating the effectiveness of an educational intervention on first episode psychosis in primary care. Schizophrenia Research 2004;70 (1):39. Li 2002 {published data only} Li L. Psychoeducation for first-admission inpatient schizophrenia. Chinese Nursing Management Conference 2002;0:169–70. Li 2004 {published data only} Li P. Effect of systematic psychoeducation for people with schizophrenia. Chinese Journal of Clinical Medicine Research 2004;112:11740–1. Liu 2007 {published data only} Liu Q-L. Effect of health-education on compliance of schizophrenic patients for taking medicine. Chinese Journal of Rehabilitation Theory and Practice 2007;13(10):987–8.

Liu 2008 {published data only} Liu X, Sun W. Discussion of hospitalization in patients with schizophrenia health education. Medical Journal of Chinese People’s Health 2008;20(23):2816–8. Liu 2008a {published data only} Liu Y, Sun Q, Wang H. Effect of mental health in the treatment of schizophrenia on cognition function. Chinese Journal of Health Psychology 2008;16(12):1380–2. Liu 2008b {published data only} Liu Y-H, Huo X-P, Su H-M, Wang C-M, Li Q-X. Clinical control study on the effect of health education in improving the social function of schizophrenia patients. Journal of Chinese Modern Nursing 2008;14(12):1347–50. Li Zheng 2004 {published data only} ∗ Li Z, David A, Wang Z. The effect of nurse initiated patient/family education strategy on people with schizophrenia in Beijing. Chinese Journal of Nursing 2004; 39(7):481–85. Lv 2005 {published data only} Lv JZ. Psychological intervention for schizophrenia patients in remission. Medical Journal of Chinese People’s Health 2005; Vol. 17, issue 6:334–5. Ma 1998 {published data only} ∗ Ma A, Wang X, Sun Z, Sun T. influence of family intervention on self-knowledge competence of inpatients with initial onset of schizophrenia. Acta Medicinae Sinica 1998;11(4):393–4. Magliano 2006 {published data only} Magliano L, Fiorillo A, Malangone C, De Rosa C, Maj M. Patient functioning and family burden in a controlled, realworld trial of family psychoeducation for schizophrenia. Psychiatric Services 2006;57(12):1784–91. Mak 1997 {published data only} ∗ Mak KY, Wong MC, Ma LK, Fung SC. A costeffectiveness study of a community-based family management rehabilitation programme for schizophrenic outpatients in Hong Kong: a six-month report. Hong Kong Journal of Psychiatry 1997;7(2):26–35. McGill 1983 {published data only} ∗ McGill CW, Falloon IR, Boyd JL, Wood-Siverio C. Family educational intervention in the treatment of schizophrenia. Hospital and Community Psychiatry 1983;34(10):934–8. Mo 2007 {published data only} Mo WJ, Zhu YX, Xu DM, Zhang N, Zhou XK. Effect of psychoeducation on 40 inpatients with schizophrenia. Medical Journal of Chinese People’s Health 2007; Vol. 19, issue 12:1092–3. Motlova 2003 {published data only} ∗ Motlova L, Dragomirecka E, Spaniel F, Goppoldova E, Zalesky R, Selepova P. Schizophrenia and quality of life: patient reported outcomes on group family psychoeducation. Proceedings of the 156th Annual Meeting of the American Psychiatric Association; 2003 May 17-22; San Francisco, California, USA. 2003.
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Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Pei 2008 {published data only} Pei JY, Liu YP, Chen HB. Effects of psychoeducation for remission stage schizophrenia patients. Medical Journal of Chinese People’s Health 2008; Vol. 20, issue 14:1661, 1668, 1681. Poplawska 2004 {published data only} Poplawska R, Czernikiewicz A, Szulc A, Galinska B, Konarzewska B, Rudnik-Szalaj I. The effectiveness of psychoeducation in schizophrenic and depressive patients preliminary report. Psychiatria Polska 2004;38(3):433–42. Rotondi 2005 {published data only} Rotondi AJ, Haas GL, Anderson CM, Newhill CE, Spring MB, Ganguli R, Gardner WB, Rosenstock JB. A clinical trial to test the feasibility of a telehealth psychoeducational intervention for persons with schizophrenia and their families: intervention and 3-month findings. Rehabilitation Psychology 2005;50(4):325–36. Scocco 2006 {published data only} Scocco P, Longo R, Caon F. Weight change in treatment with olanzapine and a psychoeducational approach. Eating Behaviors 2006;7(2):115–24. Shin 2002 {published data only} ∗ Shin S-K, Lukens EP. Effects of psychoeducation for Korean Americans with chronic mental illness. Psychiatric Services 2002;53(9):1125–31. Song 2008 {published data only} Song W-Y, Yi X, Liu Y. Effects of mental healthy guidance to the recovery of schizophrenic inpatients. Laboratory Medicine and Clinic 2008;5(14):851-2, 854. Su 2007 {published data only} Su KY. Psychoeducation for the rehabilitation of people with schizophrenia. Clinical Nursing 2007; Vol. 13, issue 22:103–5. Sun 2005 {published data only} Sun H, Zhou LF, Sun SX, Yang ZH, Han Y. An investigation into the model of psychoeducation for people with schizophrenia. Journal of Community Medicine 2005; Vol. 3, issue 9:22–4. Wang 2004 {published data only} ∗ Wang G, Wang Y, Wen X, Hu Q, Sun C, Lu M, Tang G. The effect of cognition insight therapy and family intervention on the compliance of schizophrenia patients during therapy. Chinese Journal of Nervous and Mental Diseases 2004;30(3):208–10. Wang 2007 {published data only} Wang Y, Diao Y, Sun M. Effects of different health education mode on the rehabilitation of patients with schizophrenia. Chinese Journal of Health Psychology 2007;15(8):674–5. Wang 2008 {published data only} Wang J, Niu XM. Psychoeducation for hospitalised patients with schizophrenia. Chinese Journal of Misdiagnostics 2008; Vol. 18, issue 2:452–3. Wei 2005 {published data only} Wei Q, Huang GG, Liu SF. Effect of psychological intervention for the psychological health of remission stage

schizophrenia. Chinese Journal of Behavioral Medical Science 2005; Vol. 14, issue 10:926. Xiang 2007 {published data only} Xiang Y-T, Weng Y-Z, Li W-Y, Gao L, Chen G-L, Xie L, Chang Y-L, Tang W-K, Ungvari GS. Efficacy of the community re-entry module for patients with schizophrenia in Beijing, China: outcome at 2-year follow-up. British Journal of Psychiatry 2007;190(1):49–56. Xiong 1994 {published data only} ∗ Xiong W, Phillips MR, Hu X, Wang R, Dai Q, Kleinman J, Kleinman A. Family-based intervention for schizophrenic patients in China. A randomised controlled trial. British Journal of Psychiatry 1994;165(2):239–47. Xiong 2007 {published data only} Xiong Y, Xiong Q, Shang L, Yang C. Influence of health education to schizophrenia recovery. Journal of Nursing Science 2007; Vol. 22, issue 21:65–6. Youssef 1987 {published data only} ∗ Youssef FA. Discharge planning for psychiatric patients: the effects of a family-patient teaching programme. Journal of Advanced Nursing 1987;12(5):611–6. Zhang 1994 {published data only} ∗ Zhang M, Wang M, Li J, Phillips MR. Randomisedcontrol trial of family intervention for 78 first episode male schizophrenic patients. An 18-month study in Suzhou, Jiangsu. British Journal of Psychiatry 1994;165(Suppl 24): 96–102. Zhang 2005 {published data only} Zhang HM, Li RD. Psychoeducation for the social functioning of people with schizophrenia. Zhejiang Clinical Medical Journal 2005; Vol. 7, issue 8:852–3. Zhang 2006 {published data only} Zhang H. Effect of psychological intervention for the quality of life of male patients with schizophrenia. Chinese Journal of Practical Nursing 2006;22(11):43–4. Zheng 2008 {published data only} Zheng W LMLT. A study on family health education of schizophrenia patients. Chinese Nursing Research 2008; Vol. 22, issue 6B:1536–7. Zhu 2002 {published data only} Zhu YL, Zhu Q, Sun XZ, Qin W, Wang F. A controlled study of the effects of family education on patients with schizophrenia in rehabilitation. Health Psychology Journal 2002;10(3):169–71.

References to studies awaiting assessment
Aho-Mustonen 2011 {published data only} Aho-Mustonen K, Tiihonen J, Repo-Tiihonen E, Ryynanen OP, Miettinen R, Raty H. Group psychoeducation for longterm offender patients with schizophrenia: An exploratory randomised controlled trial. Criminal Behaviour & Mental Health 2011;21(3):163–76. [MEDLINE: 20859932] Bentall 2001 {unpublished data only} Bentall R. A multidisciplinary study of the management of neuroleptic medication in schizophrenia: educational and
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Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

collaborative approaches. Current Controlled Trials (http:// www.controlled-trials.com/) 2001. Day 2000 {unpublished data only} Day J. A multi centre study of the management of neuroleptic medication in schizophrenia. National Research Register 2000. Fiorillo 2011 {published data only} Fiorillo A, Bassi M, De Girolamo G, Catapano F, Romeo F. The impact of a psychoeducational intervention on family members’ views about schizophrenia: Results from the oasis italian multi-centre study. International Journal of Social Psychiatry 2011;57(6):596–603. Gassmann 2011 {published data only} Gassmann W, Christ O, Berger H. The influence of psychoeducative family intervention in schizophrenic patients on perceived quality of life. European Archives of Psychiatry and Clinical Neuroscience 2011;261:S100. Hegde 2012 {published data only} Hegde S, Rao SL, Raguram A, Gangadhar BN. Addition of home-based cognitive retraining to treatment as usual in first episode schizophrenia patients: A randomized controlled study. Indian Journal of Psychiatry 2012;54(1):15–22.

Navidian 2010 {published data only} Navidian A, Pahlavanzadeh S, Yazdani M. The effectiveness of family training on family caregivers of inpatients with mental disorders. Iranian Journal of Psychiatry and Clinical Psychology 2010;16(2):99–106. NCT01547026 {published data only} NCT01547026. Self-regulation strategies to improve exercise behavior among schizophrenic patients. http:// ClinicalTrials.gov/show/NCT01547026 2012. NCT01601587 {published data only} NCT01601587. Introduction seminar about patient participation and treatment options decisional preferences. http://ClinicalTrials.gov/show/NCT01601587 2012. Nischk 2011 {published data only} Nischk D, Gasser M, Polaine K, Rusch J, Schonauer K, Rockstroh B. Effects of a brief psychoeducative intervention for acute psychotic patients. Zeitschrift fur Klinische Psychologie und Psychotherapie 2011;40(3):1616–3443.

Nordentoft 1999 b {published data only} Nordentoft M, Secher G, Bertelsen M, Thorup A, Austin S, Albert N, et al.Opus: Concept and recent findings. ISRCTN32545295 {published data only} European Archives of Psychiatry and Clinical Neuroscience ISRCTN32545295. Efficacy of a psychoeducative 2011;261:S37–S8. intervention program to prevent or reduce the burden Secher RG, Austin SF, Ole Mors NP, Nordentoft M. The associated with caring for a patient with schizophrenia opus-trial: Intensive, early, psycho-social intervention or schizoaffective disorder: A two arm, evaluator versus treatment as usual for first-episode psychosis patients. blind, multicentre, randomized controlled trial. http: Results from the 10-year follow-up. European Archives of //www.controlled-trials.com/ISRCTN32545295/ Psychiatry and Clinical Neuroscience 2011;261:S59. schizo%25+psychosis+psychoses+psychotic+tardive+dyskinesia+akathisia Thorup A. Gender differences in first-episode psychosis 2012. at five-year followup - results from the danish opus study gender differences have been found. Early Intervention in ISRCTN33576045 {published data only} Psychiatry 2010;4(Suppl 1):53. ISRCTN33576045. Contingency intervention for reduction of cannabis in early psychosis -circle. http:// Rabovsky 2012 {published data only} www.controlled-trials.com 2011. Rabovsky K, Trombini M, Allemann D, Stoppe G. Efficacy ISRCTN33576045. Randomised controlled trial of the of bifocal diagnosis-independent group psychoeducation in clinical and cost-effectiveness of a contingency management severe psychiatric disorders: Results from a randomized intervention for reduction of cannabis use and of relapse in controlled trial. European Archives of Psychiatry and early psychosis. Circle. http://public.ukcrn.org.uk/ 2012. Clinical Neuroscience 2012;262(5):431–40. [MEDLINE: Jahn 2011 {published data only} 22290638] Jahn T, Pitschel-Walz G, Gsottschneider A, Frobose T, Ran 2002 {published data only} Kraemer S, Bauml J. Neurocognitive prediction of illness Ran M. Community mental health in China : a randomized knowledge after psychoeducation in schizophrenia: Results controlled trial of psychoeducational family intervention from the munich cogpip study. Psychological Medicine 2011; for carers of persons with schizophrenia in a rural area 41(3):533–44. in Chengdu. Community mental health in China : a Medalia 2012 {published data only} randomized controlled trial of psychoeducational family Medalia A, Saperstein A, Choi K, Choi J. The efficacy of a intervention for carers of persons with schizophrenia in a brief psycho-educational intervention to improve awareness rural area in Chengdu [thesis]. Hong Kong: Univ. of Hong of cognitive dysfunction in schizophrenia. Psychiatry Kong, 2002. Research 2012;199(3):164–8. Mueser 2012 {published data only} Mueser KT, Glynn SM, Cather C, Xie H, Zarate R, Smith LF, et al.A randomized controlled trial of family intervention for co-occurring substance use and severe psychiatric disorders. Schizophrenia Bulletin 2012 Jan 26. [Epub ahead of print]. [MEDLINE: 22282453] Rotondi 2011 {published data only} Rotondi A. One year outcomes from webbased multifamily psychoeducational therapy designed for those with severe mental illness. Proceedings of the 164th annual general meeting of the American Psychiatric Association; 2011 May 14-18; Honolulu, Hawaii. 2011.
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Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Schlosser 2011 {published data only} Schlosser DA, Miklowitz DJ, O’Brien MP, De Silva SD, Zinberg JL, Cannon TD. A randomized trial of family focused treatment for adolescents and young adults at risk for psychosis: Study rationale, design and methods. Early Intervention in Psychiatry 2011;6(3):283–91. [MEDLINE: 22182667] Schlosser 2012 {published data only} Schlosser DA, Miklowitz DJ, O’Brien MP, De Silva SD, Zinberg JL, Cannon TD. A randomized trial of family focused treatment for adolescents and young adults at risk for psychosis: Study rationale, design and methods. Early Intervention in Psychiatry 2012;6(3):283–91. Schulze 2011 {published data only} Schulze B, Schomerus G. Stigma in context: Predictors, help-seeking and anti-stigma-interventions (recent advances in european stigma research ii). Psychiatrische Praxis 2011; 38:S12. Sharif 2012 {published data only} Sharif F, Shaygan M, Mani A. Effect of a psycho-educational intervention for family members on caregiver burdens and psychiatric symptoms in patients with schizophrenia in shiraz-iran. BMC Psychiatry 2012;12(48):1–9. Shaygan 2011 {published data only} Shaygan M, Sharif F. The effect of family psychoeducational intervention on family burden and patients’ quality of life in iranian outpatients with schizophrenia. European Archives of Psychiatry and Clinical Neuroscience 2011;261:S100. Silverman 2011 {published data only} Silverman MJ. Effects of music therapy on psychiatric patients’ proactive coping skills: Two pilot studies. Arts in Psychotherapy 2011;38(2):125–9. Silverman 2011a {published data only} Silverman MJ. The effect of songwriting on knowledge of coping skills and working alliance in psychiatric patients: A randomized clinical effectiveness study. Journal of Music Therapy 2011;48(1):103–22. Smeerdijk 2010 {published data only} Smeerdijk M, Keet R, Dekker N, Van Raaij B, Krikke M, Koeter M, et al.Motivational interviewing and interaction skills training for parents to change cannabis use in young adults with recentonset schizophrenia. Early Intervention in Psychiatry 2010;4(Suppl 1):6. Valencia 2012 {published data only} Valencia M, Juarez F, Ortega H. Integrated treatment to achieve functional recovery for first-episode psychosis. Schizophrenia Research and Treatment 2012. Zarafonitis 2012 {published data only} Zarafonitis S, Wagner M, Putzfeld V, Berning J, Janssen B, Decker P, et al.Psychoeducation for persons at risk of psychosis. Psychotherapeut 2012;57(4):326–34.

Kissling 2007 {published data only} Kissling W. How can rehospitalisations of patients with schizophrenia be avoided? A comparison between different compliance programs. http://www.controlled-trials.com 2007. Germany. Kissling W, Christine R-K. How can rehospitalisations of patients with schizophrenia be avoided? A comparison between different compliance programs. http:// www.clinicaltrials.gov 2007.

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Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Kay 1986 Kay SR, Opler LA, Fiszbein A. Positive and negative syndrome scale (PANSS) manual. North Tonawanda (NY): MultiHealth Systems, 1986. Klingberg 1999 Klingberg S, Buchkremer G, Holle R, Schulze Monking H, Hornung WP. Differential therapy effects of psychoeducational psychotherapy for schizophrenic patients--results of a 2-year follow-up. European Archives of Psychiatry and Clinical Neuroscience 1999;249(2):66–72. [PUBMED: 10369152] Lacro 2002 Lacro JP, Dunn LB, Dolder CR, Leckband SG, Jeste DV. Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature. Journal of Clinical Psychiatry 2002;63(10): 892–909. [PUBMED: 12416599] Lancet 2010 Anon. Scientific fraud: action needed in China. Lancet 2010;375(9709):94. [PUBMED: 20109871] Leucht 2005a Leucht S, Kane JM, Kissling W, Hamann J, Etschel E, Engel R. Clinical implications of brief psychiatric rating scale scores. British Journal of Psychiatry 2005;187:366–71. [PUBMED: 16199797] Leucht 2005b Leucht S, Kane JM, Kissling W, Hamann J, Etschel E, Engel RR. What does the PANSS mean?. Schizophrenia Research 2005;79(2-3):231–8. [PUBMED: 15982856] Li 1994 Li G, Hu X, Jin D, Tian W, Phillips MR. A rating instrument for the evaluation of in-patient rehabilitation programmes in China. Results of reliability and validity testing. British Journal of Psychiatry Supplement 1994;24: 58–65. [PUBMED: 7946233] Linden 1988 Linden M, Nather J, Wilms HU. For definition, meaning and measurement of the concepts of patient ill health. The ill health concept scale (KK-scale) for schizophrenic patients [Zur definition, bedeutung und messung der krankenheitskonzepte von patienten. Die krankenheitskonzeptskala (KK–skala) für schizophrene patienten]. Fortschritte Neurologische Psychiatrie 1988;56: 35–43. Macpherson 1996 Macpherson R, Jerrom B, Hughes A. A controlled study of education about drug treatment in schizophrenia. British Journal of Psychiatry 1996;168:709–17. Marshall 2000 Marshall M, Lockwood A, Bradley C, Adams C, Joy C, Fenton M. Unpublished rating scales: a major source of bias in randomised controlled trials of treatments for schizophrenia. British Journal of Psychiatry 2000;176: 249–52.

McCreadie 1987 McCreadie RG, Affleck JW, McKenzie Y, Robinson AD. A comparison of scales for assessing rehabilitation patients. British Journal of Psychiatry 1987;151:520–2. [PUBMED: 3447668] McEvoy 1989 McEvoy JP, Apperson LJ, Appelbaum PS, Ortlip P, Brecosky J, Hammill K, Geller JL, Roth L. Insight in schizophrenia. Its relationship to acute psychopathology. Journal of Nervous and Mental Disease 1989;177(1):43–7. [PUBMED: 2562850] Overall 1962 Overall JE, Gorham DR. The brief psychiatric rating scale. Psychological Reports 1962;10:799–812. Pai 1981 Pai S, Kapur RL. The burden on the family of a psychiatric patient: development of an interview schedule. British Journal of Psychiatry 1981;138:332–5. [PUBMED: 7272637] Pitschel-Walz 1997 Pitschel-Walz G. Die Einbeziehung der Angehörigen in Die Behandlung Schizophrener Patienten und ihr Einfluss auf den Krankheitsverlauf. Dissertation, Europäische Hochschulschriften Reihe VI; Psychologie. Vol. 581, Frankfurt am Main: Verlag Peter Lang, 1997. Ramirez 2008 Ramirez SZ, Lukenbill J. Psychometric properties of the zung self-rating anxiety scale for adults with intellectual disabilities (SAS-ID). Journal of Developmental and Physical Disabilities 2008;20(6):573–80. Rankin 1996 Rankin SH, Stallings KD. Patient education: issues, principles, practices. Philadelphia: Lippincott-Raven, 1996. Remington 1979 Remington M, Tyrer P. The social functioning schedule - a brief semi-structured interview. Social Psychiatry 1979;14: 151–7. Rosenberg 1965 Rosenberg M. Society and the adolescent self-image. Princeton, NJ: Princeton University Press, 1965. Ruggeri 1993 Ruggeri M, Dall’Agnola R. The development and use of the Verona expectations for care scale (VECS) and the Verona service satisfaction scale (VSSS) for measuring expectations and satisfaction with community-based psychiatric services in patients, relatives and professionals. Psychological Medicine 1993;23(2):511–23. Ruggeri 1994 Ruggeri M, Dall’Agnola R, Agostini C, Bisoffi G. Acceptability, sensitivity and content validity of VECS and VSSS in measuring expectations and satisfaction in psychiatric patients and their relatives. Social Psychiatry and Psychiatric Epidemiology 1994;29:265–76.
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Ruggeri 1996 Ruggeri M. Verona Service Satisfaction Scale (VSSS-54) Manual. Verona: WHO Collaborating Centre, 1996. Schnieder 1983 Schnieder LC, Struening EI. SLOF: A behavioral rating scale for assessing the mentally ill. Social Work Research and Abstracts 1983;41:9–21. Schooler 1979 Schooler C, Hogarthy G, Weissman MM. Social adjustment scale II (SAS-II). In: Hargreaves WA, Attkisson CC, Sorensen JE editor(s). Resource Materials for Community Mental Health Program Evaluations. Second Edition. Washington, DC: US Department of Health, Education and Welfare, 1979:290–330. Tarrier 1988 Tarrier N, Barrowclough C, Vaughn C, Bamrah JS, Porceddu K, Watts S, Freeman H. The community management of schizophrenia. A controlled trial of a behavioural intervention with families to reduce relapse. British Journal of Psychiatry 1988;153:532–42. [PUBMED: 3074860] Taylor 2003 Taylor JE, Poston WS 2nd, Haddock CK, Blackburn GL, Heber D, Heymsfield SB, Foreyt JP. Psychometric characteristics of the general well-being schedule (GWB) with African-American women. Quality of Life Research 2003;12(1):31–9. [PUBMED: 12625516] Tu 1997 Tu LJ, Zhu L, Xu GB. Nursing study of social disability in schizophrenics. Chinese Journal of Nursing 1997;32(8): 440–2. [PUBMED: 9495959]

Ukoumunne 1999 Ukoumunne OC, Gulliford MC, Chinn S, Sterne JAC, Burney PGJ. Methods for evaluating area-wide and organisation-based intervention in health and health care: a systematic review. Health Technology Assessment 1999;3(5): 1–75. Wallace 1985 Wallace CJ, Liberman RP. Social skills training for patients with schizophrenia. Psychiatric Research 1985;15:239–47. Wang 1999 Wang XD. The Handbook of Assessment of Mental Health. Changsha: Chinese Journal of Mental Health, 1999. Wu 2006 Wu T, Li Y, Liu G, Bian Z, Li J, Zhang J, et al.Investigation of authenticity of ’claimed’ randomized controlled trials (RCTs) and quality assessment of RCT reports published in China. Proceedings of the 14th Cochrane Colloquium; 2006 October 23-26; Dublin. 2006. Xia 2009 Xia J, Adams C, Bhagat N, Bhagat V, Bhoopathi P, El-Sayeh H, Pinfold V, Takriti Y. Losing participants before trial ends erodes credibility of finding. Psychiatric Bulletin 2009;33 (7):254–57.

References to other published versions of this review
Pekkala 2002 Pekkala ET, Merinder LB. Psychoeducation for schizophrenia. Cochrane Database of Systematic Reviews 2002, Issue 2. [DOI: 10.1002/14651858.CD002831] ∗ Indicates the major publication for the study

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CHARACTERISTICS OF STUDIES

Characteristics of included studies [ordered by study ID]
Brief - Both 2004 Methods Allocation: randomised - no further description. Blindness: not stated. Duration: 6 months. Setting: JiNing Psychiatric Prevention Hospital, China. Diagnosis: schizophrenia (CCMD-3). N = 118. Age: average age ~ 41years (SD ~ 9). Sex: male and female. History: average length of illness ~ 14.5 years (SD ~ 9). Inclusion: living in JiNing city district with relative; stabilised condition, BPRS score < 30. Exclusion: patients with heart, liver, renal impairment, drug or alcohol dependency 1. Family intervention + routine rehabilitation therapy: 60-90 minutes/month, for 6 months in the form of outpatient home visit: familiarise patients with basic knowledge of schizophrenia; provide patients with individualised guidance on communication skills, common drug adverse events and coping strategies, as well as how to recognise early warning signs of relapse; answer family members’ enquiries regarding patients behaviour and social functioning; organise seminars for patients and family to exchange experience (two seminars in total run at 2-3 hours each). N = 59 2. Routine rehabilitation therapy. N = 59. Social functioning: MRSS, SDSS. Mental state: GWB, SES. Unable to use Knowledge: increase (unpublished scale). Compliance: (unpublished scale).

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomised, but no detail described.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not described. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes

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Brief - Both 2004

(Continued)

Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Brief - Both 2004a Methods

Low risk

No incomplete outcome data.

Low risk Unclear risk

All measured outcomes were reported. None obvious.

Allocation: randomised - no further description. Blindness: not stated. Duration: 4 weeks. Setting: JiNing Psychiatric Prevention Hospital, ShangDong, China Diagnosis: schizophrenia (CCMD-3). N = 146. Age: average age ~ 37 years (SD ~ 11). Sex: male and female. History: length of illness 3 months - 10 years. Inclusion: patients with stabilised psychotic symptoms after systematic anti-psychotic medication, and most cognitive functioning have recovered; without medication side effects; 4) can independently complete questionnaire. Exclusion: patients with either self- or drug-induced depression or anxiety 1. Health belief model: this is delivered in the form of both group and individual therapy - i. analyse cause & nature of illness with patients; ii. guide patients to associate recovery with health education; encourage patients to participate in sports, entertainment activities and travel; help patients to develop hobbies; communicate their feelings with nurses or family, friends; 30 minutes/time, 2 times/week for 4 weeks. N = 74 2. Routine health education. N = 72. Social functioning: SAS. Mental state: SDS, anxiety and depression incidence rate*. *SAS score>51 is considered as having anxiety; SDS score > 51 is considered as having depression

Participants

Interventions

Outcomes

Notes

Risk of bias Bias Authors’ judgement Support for judgement Randomised, no further description.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not described.

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Brief - Both 2004a

(Continued)

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Brief - Group 1995 Methods Low risk

Not stated.

No incomplete outcome data.

Low risk Low risk

All measured outcomes were reported. None obvious.

Allocation: randomisation in which age, sex, prognosis and medication compliance were balanced by preliminary matching. Randomisation by an independent institution, ZMBT. Blinding: raters were not blind to the treatment conditions except compliance rated by independent raters at 1 year. Duration: 15 weeks and follow-up 5 years. Analysis of drop-outs: withdrawals partially described, modified ITT mentioned (data unclear) Diagnosis: schizophrenia (DSM-III-R) with the exception of schizoaffective disorder. N = 191. Age: mean 31.9 years, SD ~ 7.8 years. Sex: male and female. History: ’chronic’, outpatients, > 2 acute episodes in last 5 years, illness duration mean 8.3 years (SD 5.7), onset of illness mean ~ 24 years, mean ~ 4 (SD 3.1) hospitalisations, BPRS mean ~ 27 (SD 6.4), GAS mean 55 (SD 10.4), daily neuroleptic dose mean ~ 470 mg CPZ (SD 680) 1. Psychoeducational medication training (PT) + leisure time group (LTG) at 7 study centres: 10 sessions in groups of 4-6 patients with one or two psychotherapists during 15 weeks. First 5 sessions once a week, next five twice a fortnight. N = 32. 2. PT + key person counselling 10 sessions (KC) + LTG. N = 35. 3. PT + cognitive psychotherapy (CP). N = 34. 4. PT + KC + CP. N = 33. 5. Control group patients attended a structured but unspecific leisure-time group of same length. N = 57 Relapse. Global functioning: GAS. Unable to use Medication compliance (no usable data). Mental state: BPRS (no usable data). Qualification for medication self-management (no usable data). Illness-related attitudes: KK-Skala (no usable data). Satisfaction with knowledge (no usable data).
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Participants

Interventions

Outcomes

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Brief - Group 1995

(Continued)

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomised by independent third party.

Random sequence generation (selection Low risk bias) Allocation concealment (selection bias) Unclear risk

Unclear. Blind rating for readmission (independent criterion as researchers had no influence on this). Relapse data, compliance data and other outcomes where not blindly rated 44 patients dropped out before start of intervention and were not included in analysis but compared on socio-demographic and other characteristics to trial group All measured outcomes reported. None obvious.

Blinding (performance bias and detection High risk bias) All outcomes

Incomplete outcome data (attrition bias) All outcomes

High risk

Selective reporting (reporting bias) Other bias Brief - Group 1995a Methods

Low risk Low risk

Allocation: random. Blinding: not reported. Duration: one session and follow-up 1 year. Analysis of drop-outs: withdrawals not described. Diagnosis: schizophrenic disorder (DSM-III-R). N = 165. Age: < 15 years 6 patients and > 60 years 2 patients, most between 20-30. Sex: male 69, female 96. History: all poor compliance, 46 patients had depot injection, 30% treated with chlorpromazine, haloperidol or trifluoperazine, 30% chronic 1. Counseling session: by trained hospital pharmacist at discharge in presence of key relative; frequency of drug dosage was reduced to twice a day. N = 85 2. No counselling: also received routine prescription of medication. N = 80 Relapse.

Participants

Interventions

Outcomes Notes

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Brief - Group 1995a

(Continued)

Risk of bias Bias Authors’ judgement Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection High risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Unclear risk

Not stated concerning total dropout and ITT (intention to treat criteria fulfilled) Only compliance and readmission measured and reported. Control patients were not given as much therapist time.

Low risk

Other bias

High risk

Brief - Group 1999 Methods Allocation: stratified for gender and for illness duration, randomisation carried out by an independent institution. Blinding: relapse and compliance assessed blindly. Duration: 8 weeks, 1 year follow-up. Analysis of drop-outs: follow-up of withdrawals reported. Diagnosis: schizophrenia (F20.2-F20.9) ICD Danish version, OPCRIT. N = 46. Age: median 35.9 years, interquartile range 30.3-39.6 years. Sex: male and female. History: illness duration median 8.2 years, earlier admissions median 5. In treatment at 2 community psychiatric centres 1. Psychoeducational sessions: 8 sessions, using didactic, interactive method standardised with manual for group leaders and booklet for participants; weekly group of 5-8 participants conducted separately for patients and relatives. N = 24 2. Standard care: psychopharmacological treatment, psychosocial rehabilitation efforts and some supportive psychotherapy. N = 22 Compliance: non-compliance episodes of 14 days. Relapse. Global functioning: GAF. Mental state: BPRS.
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Participants

Interventions

Outcomes

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Brief - Group 1999

(Continued)

Satisfaction: VSSS. Expressed emotion: FQ. Unable to use Knowledge: (instrument non-validated). Insight: IS (instrument non-validated). Notes Risk of bias Bias Authors’ judgement Support for judgement Randomisation carried out by an independent institution. Patients included before randomisation, given participant numbers, separated from patient identification data. Allocation of patent-numbers to intervention/control done subsequently. Single blind (assessor blind).

Random sequence generation (selection Low risk bias) Allocation concealment (selection bias) Low risk

Blinding (performance bias and detection Low risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Brief - Group 2003 Methods Low risk

ITT(Intention treat principle) used.

Low risk Low risk

ITT(Intention treat principle) used. None obvious.

Allocation: randomised - no further description. Blindness: not stated. Duration: 6 months. Setting: ChuXiongZhou Psychiatric Hospital, YunNan Province, China Diagnosis: schizophrenia (CCMD-2-R). N = 120. Age: average age ~ 37 (SD ~ 10). Sex: male and female. History: average length of illness ~ 13 years (SD ~ 9). Inclusion: not stated. 1. Family intervention (psychoeducation): introduce to patients and family basic information about schizophrenia, its treatment and rehabilitation, adverse effects of medication & importance of continuous treatment; guidance on communication & social
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Participants

Interventions

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Brief - Group 2003

(Continued)

skills; 1/month for 6 months. N = 68 2. Routine care. N = 52. Outcomes Mental state: BPRS. Unable to use -: Mental state: BPRS sub-scale scores. Behavioural outcome - level of symptoms: SCL-90 sub-scale scores

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomised, but no randomisation detail described. Not described. Not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Brief - Group 2006 Methods Low risk

No incomplete outcome data.

Low risk Low risk

All measured outcomes were reported. None obvious.

Allocation: randomised - no further description. Blinding: not stated. Duration: 8 weeks. Setting: Mental Health Centre of Shantou University, Guangdong, China Diagnosis: schizophrenia (CCMD-3). N = 60. Age: not stated. Sex: not stated. History: not stated. Exclusion: severe physical or other mental illness, drug/alcohol dependent 1. Psychoeducation + standard drug therapy: provide patients with information on cause, development & symptoms of illness, crisis strategy, communication with family member, maintain medication; 30 minutes/session, 1 session/week. N = 30 2. Standard drug therapy. N = 30.
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Participants

Interventions

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Brief - Group 2006

(Continued)

Outcomes

Compliance with medication. Mental state: BPRS score.

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Brief - Group 2007 Methods Low risk

No incomplete outcome data.

Low risk Low risk

All measured outcomes reported. None obvious.

Allocation: randomised - no further description. Blinding: not stated. Duration: 2 weeks + 12 months follow-up. Setting: Pamela Youde Nethersole Eastern Hospital, Hongkong, China Diagnosis: schizophrenia (DSM-IV). N = 81. Age: 18-65 years. Sex: male and female. History: not stated. Exclusion: not stated. 1. Psychoeducation: didactic presentation on mental health, schizophrenia, rehabilitation resources, medication management & compliance, relapse prevention & stress management; 50 minutes/session, 10 sessions. N = 44 2. Routine care. N = 37. Relapse. Insignt: SAUMD scores. Unable to use Quality of life: SF-36 (sub-scores only).
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Participants

Interventions

Outcomes

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Brief - Group 2007

(Continued)

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Brief - Group 2007a Methods Low risk

No incomplete data.

Low risk Low risk

All measured outcomes reported. None obvious.

Allocation: randomised - by tossing a coin. Blinding: not stated. Duration: 8 weeks + 9 months. Setting: Jinhua Number 2 Hospital, Zhejiang, China. Diagnosis: schizophrenia (inpatients). N = 62. Age: mean ~ 35 years, SD ~ 6 years. Sex: male and female. History: not stated. Exclusion: severe physical illness. 1. Psychoeducation: background knowledge on schizophrenia; importance of family environment; role of family members; group therapy, one session/week. N = 30 2. Routine care. N = 30. Quality of life: FAD, GQOLI-74.

Participants

Interventions

Outcomes Notes Risk of bias Bias

Authors’ judgement

Support for judgement

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Brief - Group 2007a

(Continued)

Random sequence generation (selection Low risk bias) Allocation concealment (selection bias) Unclear risk

Randomised by tossing a coin.

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Brief - Group 2007b Methods Low risk

No incomplete data.

Low risk Low risk

All measured outcomes reported. None obvious.

Allocation: randomised. Blinding: not stated. Duration: 8 weeks. Setting: Yangzhou Wutaishan Hospital, Jiangsu Province, China Diagnosis: schizophrenia (CCMD-3). N = 102. Age: not stated. Sex: not stated. History: not stated. Exclusion: severe physical or other mental illness. 1. Psychoeducation + routine drug therapy: provide patients with information on cause, development & symptoms of illness, crisis strategy, communication with family member, maintain medication; 30-60 minutes/week. N = 51 2. Routine drug therapy. N = 51. Compliance: with medication. Behaviour: NOSIE score.

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated.
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Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Brief - Group 2007b

(Continued)

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Low risk

Not stated.

No incomplete outcome data.

High risk

PANSS, ITAQ scores measured, but not reported. None obvious.

Other bias Brief - Group 2009 Methods

Low risk

Allocation: randomised. Blinding: not stated. Duration: 3 months treatment + 12 months follow-up. Setting: Hong Kong, China. Diagnosis: schizophrenia (DSM -4). N = 73. Age: 18-65 years. Sex: male and female. History: not stated. Exclusion: clients with secondary diagnosis of a mental or physical disorder 1. Psychoeducation + routine care: providing information on cause, development & treatment of schizophrenia, its recovery, relapse & early warning signs; 10 sessions over 3 months. N = 36 2. Routine care. N = 37. Knowledge: ITAQ endpoint scale score. Mental state: BPRS endpoint scale score (data skewed). Unable to use Satisfaction: continuous satisfaction data - unclear from which scale they are derived from. Quality of life: FBIS endpoint scale score, no n number reported, data are skewed

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated.
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Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Brief - Group 2009

(Continued)

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Low risk

Not stated.

No incomplete data.

High risk

Some scale data (SSQ-6, SES) were not reported. None obvious.

Other bias Brief - Individual 1996 Methods

Low risk

Allocation: random - a random numbers table. Blinding: all ratings were carried out by the author, without blinding procedures. Duration: 7 weeks. Analysis of drop outs: withdrawals described. Diagnosis: schizophrenia (DSM-III-R). N = 67. Age: mean 45.2 years, SD ~ 13 years. Sex: male 48, female 16. History: largely (54/64) community based, chronic, institutionalised population, at least 6 months cumulative antipsychotic drug exposure and clinical stability. Years in institution mean 12.8 (SD 11.8). Education mean 11 y (SD 1.9). 1. Single individualised educational session: followed manual guidelines based on psychoeducation literature & principles of general health education. N = 24 2. Individualised teaching: in 3 education sessions 25-35 minutes/session at weekly interval. N = 23 3. No education. N = 20. Compliance: SAI - compliance sub-scale. Knowledge change: UMQ. Insight: SAI. Unable to use Mental state (no usable data). All education was performed by the author RM.

Participants

Interventions

Outcomes

Notes Risk of bias Bias

Authors’ judgement

Support for judgement Using a random numbers table

Random sequence generation (selection Low risk bias)
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Brief - Individual 1996

(Continued)

Allocation concealment (selection bias)

Unclear risk

Not stated. Open label.

Blinding (performance bias and detection High risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Brief - Unclear 2005 Methods Low risk

No incomplete data.

Low risk Low risk

All measured outcomes reported. None obvious.

Allocation: randomised. Blinding: not stated. Duration: 8 weeks intervention + 3 months follow-up. Setting: Kangning Hospital, Shenzhen City, China. Diagnosis: schizophrenia (CCMD-3-R). N = 286. Age: mean ~ 32.5 years, SD ~ 17.2 years. Sex: male and female. History: < 10 years. Exclusion: with combined other mental health problem, or if their conditions are obviously deteriorating 1. Psychoeducation: introduce patients to i. background of prescribed medication; ii. importance of taking medication; iii. review on benefit of medication; iv. discussion on schizophrenia as an illness; v. medication management after discharge; frequency 1/week. N = 143 2. Routine health education:provided as a part of standard care. N = 143 Compliance: with medication and follow up (leaving the study early) Unable to use Compliance: with medication continuous data - derived from unpublished scale

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated.
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Brief - Unclear 2005

(Continued)

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Standard - Both 1996 Methods High risk

Not stated.

Drop out was excluded in the analysis.

Low risk Low risk

All measured outcomes reported. None obvious.

Allocation: randomly assigned - computer generated cards stored in sealed envelopes. Blinding: assessments done by research interviewers blinded to patient’s group assignment, not associated with clinical care & instructed not to inquire about patient’s treatment. Duration: 18 months. Analysis of drop-outs: withdrawals reported. Diagnosis: schizophrenia or schizoaffective disorder (DSM-III-R). N = 82. Age: study group mean 33.3 years (SD 8.8), control mean 26 years (SD 9.3). Sex: male 53, female 29. History: outpatients at high risk for relapse, maintained on standard doses of antipsychotic medication, previous hospitalisations study group 2.27(SD 1.29), control 2.64(SD 1.28), participants were included in the study even if they did not comply with the medication 1. Program for relapse prevention: education for patients & family members about process of relapse in schizophrenia & how to recognise prodromal symptoms & behaviours, active monitoring for prodromal symptoms, clinical intervention within 24-48 hours, when prodromal episodes detected, one-hour weekly supportive group or individual therapy emphasising improving coping skills; 90 minute multifamily psychoeducation groups biweekly for six months and monthly thereafter. N = 41 2. Treatment as usual: individual 15’-30’ biweekly sessions of medication management, symptom monitoring & individual supportive therapy. N = 41 Compliance. Relapse. Service utilisation: length of hospital stay. Health economic outcomes: costs.

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement
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Standard - Both 1996

(Continued)

Random sequence generation (selection Low risk bias) Allocation concealment (selection bias) Low risk

Using computer generated random number card. Sealed envelopes. Single blind.

Blinding (performance bias and detection Low risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Standard - Both 2004 Methods Low risk

No incomplete outcome data.

Low risk Low risk

All measured outcomes reported. None obvious.

Allocation: randomised - no further description. Blindness: not stated. Duration: 9 months treatment, 1 year follow-up. Setting: ZhuMaDian City Psychiatric Hospital, HeNan Province, China Diagnosis: first episode schizophrenia (CCMD-2-R). N = 86. Age: average age ~ 23 (SD ~ 6). Sex: male and female. History: average length of illness ~ 6.5 months (SD ~ 5.5). Inclusion: without learning disability or severe physical impairment, educated to middle school level minimum; there is at least one carer/relative living with the patient after discharge 1. Family psychological intervention + routine drug therapy: 3 stages, i. familiarise patients & family with knowledge of schizophrenia, information on medication & coping with side effects; 30 minutes/2weeks; ii. crisis intervention & communication skills was demonstrated to patients & family, patient’s harmful behaviours corrected; 60 minutes/ month; iii. organise seminars for patients & family member to exchange experience; 120 minutes/2 months. N = 43 2. Routine drug therapy. N = 42. Compliance: leaving the study early Relapse*. Global state: no clinical improvement**. Mental state: BPRS endpoint score. Unable to use Satisfaction: FES-CV sub-scale scores.

Participants

Interventions

Outcomes

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Standard - Both 2004

(Continued)

Notes

* Any one of the following items, 10, 11, 12, 15, 17, in BPRS scored > 3 (inclusive of 3), or BPRS total score > 36 (inclusive of 36) is considered as relapse. ** BPRS total score < 25 (inclusive of 25) is considered as full recovery

Risk of bias Bias Authors’ judgement Support for judgement Randomised, but further detail provided on randomisation. Not described. Not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Standard - Both 2006 Methods High risk

Drop-out was excluded from final analysis.

Low risk Low risk

All measured outcomes were reported. None obvious.

Allocation: randomised. Blinding: not stated. Duration: 3 months. Setting: Taiyuan mental health hospital, Shanxi province, China Diagnosis: schizophrenia (CCMD-2-R). N = 100. Age: mean ~ 48.63 years, SD ~ 1.33 years. Sex: female. History: mean ~ 25.34 years, SD ~ 1.33 years. Exclusion: not stated. 1. Psychoeducatin + routine drug therapy: introduce to patients and their family basic information about schizophrenia, treatment & rehabilitation, adverse effects of medication & importance of continuous treatment, group therapy; 30 minutes/session, 2 session/week; individual therapy; 15-20 minutes/session, 3 sessions/week. N = 50 2. Routine drug therapy: N = 50. Compliance with medication.

Participants

Interventions

Outcomes Notes

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Risk of bias Bias Authors’ judgement Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Standard - Both 2008 Methods Low risk

No incomplete outcome data.

Low risk Low risk

All measured outcomes reported. None obvious.

Allocation: randomised. Blinding: not stated. Duration: 6 months. Setting: Xiangya Mental Health Centre, Changsha City, China. Diagnosis: schizophrenia (CCMD-3). N = 156. Age: 18-60 years. Sex: male and female. History: mean ~ 4.2 years, SD ~ 1.6 years, Exclusion: severe physical or other mental illnesses. 1. Psychoeducation + standard drug therapy: provide patients with information on illness, crisis strategy, communication with family member, maintain medication; 60 minutes/ session, 2 sessions/month. N = 79 2. Standard drug therapy. N = 78. Compliance: with follow up, with treatment. Mental state: BPRS. Quality of life: FBIS.

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement
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Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Randomisation method not stated.

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Standard - Both 2008a Methods Low risk

ITT was used.

Low risk Low risk

All measured outcomes reported. None obvious.

Allocation: randomised. Blinding: not stated. Duration: 12 weeks. Setting: Wuxi Mental Health Centre, China. Diagnosis: schizophrenia (CCMD-3). N = 60. Age: mean ~ 31.2 years, SD ~ 10.4 years. Sex: male only. History: mean ~ 10.2 months, SD ~ 8.5 months. Exclusion: severe physical illness, history of medication allergy 1. Psychoeducation + standard care: provide patients with information on illness, crisis strategy, communication with family member, maintain medication, small group sessions; 2 session/week, 30-60 minutes/session; also big group sessions; 1 session/fortnight, 60-120 minutes/session. N = 30 2. Standard care. N = 30. Mental state: BPRS. Unable to use Behaviour: NOSIE sub-scale score (sub-scale not validated).

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias)
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Allocation concealment (selection bias)

Unclear risk

Not stated. Not described.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Standard - Both 2008b Methods Low risk

No incomplete outcome data.

Low risk Low risk

All measured outcomes reported. None obvious.

Allocation: randomised using random number table. Blinding: not stated. Duration: 8 weeks treatment + 12 months follow-up. Setting: Rongjun Hospital, Jiangxi Province, China. Diagnosis: schizophrenia (CCMD-3). N = 90. Age: 18-60 years. Sex: not stated. History: < 1 year. Exclusion: severe physical or other mental illness. 1. Psychoeducation + standard drug therapy: provide patients with information on causes, development symptoms of illness, crisis strategy, communication with family member, maintain medication; 30 minutes/session, 2 sessions/week. N = 45 2. Standard drug therapy. N = 60. Compliance with medication. Relapse. Social functioning: SDSS. Mental state: BPRS

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomised with random number table.

Random sequence generation (selection Low risk bias) Allocation concealment (selection bias) Unclear risk

Not stated.

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Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Standard - Group 1988 Methods High risk

Not stated.

ITT was not used, drop-outs were excluded from analysis. All measured outcomes reported. None obvious.

Low risk Low risk

Allocation: random. High and low EE groups were randomised separately, stratified for multiple episodes and presence/absence of residual symptoms. Blinding: at follow-up EE, PSE ratings and assessment of relapse blindly. Duration: 9 months. Analysis of drop-outs:non-participators and withdrawals described Diagnosis: schizophrenia (PSE). N = 83. Age: mean 35.3 years, SD ~ 12.8 years. Sex: male 29, female 54. History: acute case ward patients, first episode 25 patients, mean number of admissions 2.8 (SD 3,6), mean duration ill 6.3 years (SD 7.4), mean time since last admission 1. 6 years (SD 3.1), mean days in hospital prior to index admission 91 (SD 149), mean days in hospital (index admission) 35.5 (SD 25); neuroleptic medication - 10 discharged with oral medication only, of 63 on depot injection 24 also received oral neuroleptics 1. Education: 2 sessions high EE-group N = 16, low EE-group. N = 9 2. Behavioral intervention: symbolic 13 sessions high EE-group. N = 16 3. Routine treatment: high EE-group N = 16, low EE group N = 10 4. Behavioral intervention: inactive. N = 16. Relapse. Expressed emotion: CFI. Unable to use Compliance: with medication (no usable data). Contact with psychiatric services (no usable data). Social functioning: SAS (no usable data). Interventions 1-3 are taken into account. Only high EE group was randomised to intervention 2, therefore have all outcomes of intervention group 2 been compared only to high EE group of control intervention 3

Participants

Interventions

Outcomes

Notes

Risk of bias

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Bias

Authors’ judgement

Support for judgement Randomization stated as stratified but no further information concerning method Not stated. Some outcomes (relapse, EE, PSE ratings) are assessed single blind

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Blinding (performance bias and detection Low risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Standard - Group 2004 Methods Low risk

All treatment or assessment dropouts were included in analyses None obvious. None obvious.

Low risk Low risk

Allocation: randomised - no further description. Blindness: not stated. Duration: 3 months. Setting: JiNing Medical College Hospital, JiNing City, China Diagnosis: schizophrenia (CCMD-3). N = 250. Age: average age ~ 30 (SD ~ 9). Sex: male and female. Inclusion: stabilized condition, BPRS rating < 30, not suffer from drug side effect and educated to primary school 11 or above. Exclusion: patients with severe physical illnesses; patients with drug and alcohol dependency 1.Psychoeducation + routine care: information given on i. cause and clinical symptoms; ii. medication management and compliance; iii. side effects & coping strategies; iv. prevention of relapse & recognition of early warning sign; v. control temper & release anger; vi. marriage & having family; viii. recovery; frequency 20-40 minutes each time, 4 times per week for 3 months. N = 125 2. Routine care only: 3 months. N = 125. Compliance: with medication*. Mental state: BRPS. Unable to use Curative effect: did not clarify how categorised result. Behaviour: improvement in hostile behaviour (scales used not stated)

Participants

Interventions

Outcomes

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Notes

*conclusion derived from self-designed questionnaire; divided into compliance, partial compliance and non-compliance

Risk of bias Bias Authors’ judgement Support for judgement Patients were randomly divided into two groups, no further detail on randomisation method Not described. Not stated.

Random sequence generation (selection Unclear risk bias)

Allocation concealment (selection bias)

Unclear risk

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Standard - Group 2005 Methods Low risk

No incomplete outcome data.

Low risk Low risk

All measured outcomes reported. None obvious.

Allocation: randomised - no further description. Blinding: not stated. Duration:21 sessions + 2 years follow-up. Setting: multi-centred, France. Diagnosis: schizophrenia (diagnostic standard not stated). N = 220 Sex: not stated. Age: ~ 33 years old. History: not stated. Exclusion criteria: not stated. 1. Psychoeducational Soleduc programme + amisulpride: including eight modules concerning disease, assumption of responsibility, neuroleptic treatments, course, methods of care & specialised follow-up, reintegration & psychosocial rehabilitation. N = 111 2. Control group: usual information + amisulpride. N = 109. Relapse: defined as “a schizophrenia episode leading to hospitalisation whatever its duration”

Participants

Interventions

Outcomes

Notes

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Risk of bias Bias Authors’ judgement Support for judgement Randomised - each participating Centre received a list with randomisation order (from a central study site) Not stated. Not stated.

Random sequence generation (selection Low risk bias)

Allocation concealment (selection bias)

Unclear risk

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Unclear risk

No incomplete outcome.

Low risk Unclear risk

None obvious. Control group contained many protocol deviating patients.

Standard - Group 2006 Methods Allocation: randomised - using random number table. Blinding: single blind (assessor blind). Duration: 24 weeks. Setting: University of Medicine and Dentistry of New Jersey, USA Diagnosis:schizophrenia or schizoaffective disorder (DSM-IV). N = 71 (+3 dropped out). Age: ~ 22-65 years old. Sex: male and female. History: not stated. Exclusion criteria: patients with comorbid diagnosis of demential or mental retardation, severely impaired intellectual functioning, or unable/willing to give informed consent, had been exposed to more than oneTeam Solutions workbook, at risk of suicide are excluded from the study 1. Team solutions + routine care: first 8 week sessions covered understanding illness & recovering from schizophrenia; second 8 week sessions covered understanding treatment & getting best results from medication; third 8 week sessions covered helping prevent relapse & avoiding crisis situations; frequency met twice per day, 2 days per week for 24 weeks. N = 38 2. Treatment as usual: all aspects of day treatment programmes. N = 33

Participants

Interventions

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Outcomes

Knowledge/attitude: KASQ, RAQ, ROMI. Mental state: PANSS Quality of life/Well being: GAF-DIS, PGWB. Unable to use General functioning: GAF - only sub-scale scores reported (sub-scores not validated). Global state: CGI - only sub-scale scores reported (sub-scores not validated). Insight: SUMD (only non-validated sub-scale scores). Knowledge: IAPSRS, TSCKAS (Team Solutions comprehensive knowledge assessment scale) (not clearly validated scale). Complance: TCI (Treatment Compliance Interview) (not clearly validated scale)

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomised with random number table.

Random sequence generation (selection Low risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Single blind - assessor blind.

Blinding (performance bias and detection Low risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Standard - Group 2007 Methods High risk

Drop-outs were excluded from final analysis. All measured outcomes were reported. None obvious.

Low risk Low risk

Allocation: randomised. Blinding: single blind (assessor blind). Duration: approximately 36 weeks of intervention + 12 months follow-up. Setting: community, Hong Kong, China. Diagnosis: Schizophrenia (diagnostic standard not stated). N = 84 families. Age: 22-60 years. Sex: male and female. History: unclear. Exclusion: if family member care for more than one relative with a chronic mental or physical illness

Participants

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Interventions

1. Psychoeducation + routine care: 4 stage intervention including - orientation and engagement, educational workshop, therapeutic family role & strength rebuilding; 2 hours/session, 1 session every 2 weeks, 18 sessions. N = 42 2. Routine care. N = 42. Relapse/re-admission. Global functioning: SLOF. Mental state: BPRS. Quality of life: FBIS. Service utilisation: length of hospital stay. Unable to use Family functioning: FAD (usually high score indicate unhealthy family functioning, but author of paper reported high score as indication of better family functioning. When data incorporated (high score = favourable), these caused heterogeneity. We, therefore, think there was some mistake in reporting of these data)

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Single blind.

Blinding (performance bias and detection Low risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Standard - Group 2008 Methods Allocation: randomised. Blinding: not stated. Duration: 6 months. Setting: community, Wuhan city, China. Diagnosis: schizophrenia (CCMD-3). N = 198. Age: 18-60 years. Low risk

No incomplete data.

Low risk Low risk

All outcome reported. None obvious.

Participants

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Sex: male and female. History: not stated. Exclusion: severe physical illness. Interventions 1. Psychoeducation: background knowledge of schizophrenia, importance of medication compliance, medication side effects, ways of expressing feelings & emotion, guidance on family life; frequency 2 per week, group therapy. N = 99 2. Routine care. N = 99. Complance: with medication.

Outcomes Notes Risk of bias Bias

Authors’ judgement

Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Standard - Individual 03a Methods Low risk

No incomplete outcome data.

Low risk Low risk

All measured outcomes reported. None obvious.

Allocation: randomised - no further description. Blindness: not stated. Duration: 8 weeks. Setting: Psychiatric prevention hospital, JiNing City, China Diagnosis: schizophrenia (CCMD-2-R). N = 116. Age: average age ~ 32 years (SD ~ 10). Sex: male and female. History: average history ~ 5.5 years (SD ~ 3.19). Inclusion: stabilised with BPRS < 30, no drug side effects, education > 5 years (inclusive of 5), without heart, liver or renal illnesses or history of drug/alcohol dependency

Participants

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Interventions

1. Psychoeducation + routine drug therapy: individualised guidance about onset, nature and symptoms, guided to differentiate before & after treatment, to associate improvement with good medication compliance, counselling when necessary, asked to write reflective diary; 45-60 minutes/session, 2/week. N = 58 2. Routine drug therapy. N = 58. Social functioning: SAS. Global state: IPROS. Mental state: BPRS, SDS. Unable to use Global state: IPROS factor scores (non-validated sub-scale scores)

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Patients randomly divided into two group, no further detail on randomisation Not described. Blinding is not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Standard - Individual 03b Methods Low risk

No incomplete outcome data

Low risk Low risk

No selective reporting. None obvious.

Allocation: random (draw lots). Blindness: not stated. Duration: 8 weeks treatment, 2 years follow-up. Setting: JiNing Psychiatric Prevention Hospital, JiNing City, China Diagnosis: first onset schizophrenia (CCMD-2-R). N = 136. Age: < 50 years (inclusive of 50). Sex: male and female. History: average length of illness ~ 1.4 years (SD ~ 0.8). Inclusion: first onset; never received systematic anti-psychotic treatment before hospitalisation; family members agree the patient to receive at least 8 weeks treatment in hos67

Participants

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(Continued)

pital. Exclusion: severe physical impairment; drug allergy, or alcohol dependency Interventions 1. Routine drug therapy (Clozapine < 300mg/d) + psychoeducation: i. therapist explained symptoms to patients & enlighten them on the difference between now (ill) and before (well), to increase ability to recognise psychotic symptoms; ii. guide patients to associate improvement with good medication compliance & to realize benefit of anti-psychotics; iii. encourage patients to write reflective diary; 30-40 minutes/time, 2-3 times/week for 8 weeks. N = 68 2. Routine drug therapy (Clozapine < 300mg/d). N = 68. Compliance: leaving the study early*. Relapse* Knowledge: ITAQ. Mental state: BPRS. * Data entered with intention-to-treat method.

Outcomes

Notes Risk of bias Bias

Authors’ judgement

Support for judgement Randomised by draw lots.

Random sequence generation (selection Low risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Standard - Individual 03c Methods High risk

Incomplete outcome data at follow-up was excluded from analysis All measured outcomes were reported. None obvious.

Low risk Low risk

Allocation: randomised with random number table. Blindness: double blind. Duration: 12 weeks treatment + 1 year follow-up. Setting: JiNing Veterans’ Hospital, ShanDong, China. Diagnosis: schizophrenia (CCMD-2-R). N = 110. Age: average age ~ 36.5 years(SD ~ 11).
68

Participants

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Sex: male and female. History: average length of illness ~ 13.5 years (SD ~ 10.5). Inclusion: living with at least one member of the family after discharge. Exclusion: patients with severe physical impairment or mental retardation Interventions 1. Conventional psychoeducation + psychological stress education + routine drug therapy: 1.5 hours/week for 12 weeks. N = 37* 2. Conventional psychoeducation + routine drug therapy: delivered in form of individual therapy, included basic knowledge about schizophrenia, symptoms & causes, encourage patients to write reflective diary; 1 hour/week for 12 weeks. N = 37 3. Routine drug therapy. 12 weeks. N = 36. Relapse.** Global state: NOSIE-30. Mental state: BPRS. Unable to use Behaviour: NOSIE-30 (non-validated sub-scale scores only). Cognitive function: Simplified Coping Style Questionnaire (not clearly validated) *Results of this group is not included in analysis. ** Any of the following items in BRPS, 4, 7, 11, 12, 15, scored > 5, or any combined two items scored > 4 is considered as relapsed

Outcomes

Notes

Risk of bias Bias Authors’ judgement Support for judgement Randomised with random number table.

Random sequence generation (selection Low risk bias) Allocation concealment (selection bias) Unclear risk

Not described. Double blind.

Blinding (performance bias and detection Low risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias High risk

Addressed in some outcomes, but not others. All measured outcomes were reported. None obvious.

Low risk Low risk

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Standard - Individual 93 Methods Allocation: random, from a list of 30 patients attending a specialised clinic for young adults, the research team identified with the clinicians those with stable enough clinical state, considered able to attend group therapy. Blinding: knowledge, social functions and symptomatology assessed blindly. Duration: 2-3 months. Analysis of drop-outs: withdrawal reported. Diagnosis: schizophrenia or schizophreniform or schizoaffective disorder (DSM-III). N = 20. Age: mean ~ 23 years (SD 3.4), range 18-30 years. Sex: male 15, female 5. History: outpatients. 1. Medication management group: 3 times per week for 2-3 months. N = 10 2. Control group. N = 10. Knowledge: SKQ. Social functions: SAS II. Mental state: BPRS. Increased medication.

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomisation method used: dice.

Random sequence generation (selection Low risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Some outcomes are assessed single blind.

Blinding (performance bias and detection Low risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Unclear risk

Not stated, but only one subject retired from the study. None obvious. None obvious.

Low risk Low risk

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Standard - Unclear 1988 Methods Allocation: stratification patients with schizophrenia/schizophreniform disorder and schizoaffective disorders, respectively, was based on the average level of pre-hospital functioning rated by RPTS using a cutting score of 3.5 (the median on this scale). Within each of these four groups randomly - no further description Blinding: not reported. Duration: 18 months. Analysis of drop-outs: inadequate description. Diagnosis: schizophrenia DSM-III, schizoaffective or schizophreniform disorder. N = 92. Age: mean ~ 27(SD 8.2), range 15-58 years. Sex: male 49, female 43. History: recent admission to the unit, prior episodes 2.1 (SD 2.2), previous admissions 2.0 (SD 2.7), GAS score mean 25.0 (SD 6.2), PRF mean 4 (SD 1.2) 1. Inpatient family intervention (IFI): brief family treatment with emphasis on psychoeducation; average number of sessions 8.6, mode 6, 1 or 2 per week during hospitalisation. N = 37 2. Standard hospital treatment: included medication, individual supportive psychotherapy, occupational therapy & other activities common to hospital treatment. N = 55 Global functioning: GAS. Unable to use General symptoms: PEF (no usable data). Family attitudes and behaviour: FAI (no usable data). Rehospitalisation: (no usable data). Complance: with treatment and medication - TMCDS (no usable data). Role functioning: RAPS (no usable data). Negative outcomes (no usable data).

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Method not described.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Low risk

No incomplete outcome data.

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Selective reporting (reporting bias)

High risk

Some scale scores were measured, but no mean or SD reported. None obvious.

Other bias Standard - Unclear 1996 Methods

Low risk

Allocation: randomised (block randomisation using computer) Blinding: single blind. Duration: 4-5 months and 1 year follow-up. Analysis of drop-outs: withdrawals described and analysed. Diagnosis: schizophrenia, schizophreniform disorder, schizoaffective disease (ICD9, DSM-III-R). N = 236. Age: mean 33 years. Sex: male 109, female 127. History: outpatients, GAS mean 49, BPRS mean 42, illness duration mean 7 years, hospitalisations mean 4, first episode 24% of patients 1. Information group: 8 sessions using information booklet. 4 sessions weekly, followed by 4 further sessions at monthly interval. N = 125 2. Control group. N = 111. Readmission. Knowledge: KQ. Insight: KK-skala. Expressed emotion: FQ. Negative outcomes. Unable to use Complance: with medication (no usable data, continuous data derived from unpublished scale). Mental state: BPRS (no usable data). Social functioning: GAS (no usable data).

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Block randomisation using computer.

Random sequence generation (selection Low risk bias) Allocation concealment (selection bias) Unclear risk

Not stated.

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Blinding (performance bias and detection Low risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Standard - Unclear 2005 Methods Low risk

Single blind.

ITT-analysis and completer analysis performed and drop-out reported None obvious. None obvious.

Low risk Low risk

Allocation: randomised. Blinding: not stated. Duration: 2 weeks intervention + 2 years follow-up. Setting: Shangqiu number 2 hospital, Henan province, China. Diagnosis: schizophrenia (CCMD-2-R). N = 142. Age: 18-55 years. Sex: male only. History: mean ~ 10.2 months, SD ~ 6.5 months. Exclusion: severe physical illness, history of medication allergy 1. Psychoeducation + standard care: provide patients with information on illness, crisis strategy, communication with family member, maintain medication; 12 session provided within 2 weeks prior to discharge, 1 hour/session. N = 69 2. Standard care. N = 73. Relapse. Unable to use Mental state: N-BPRS (not published scale).

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomisaiton method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes
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(Continued)

Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Standard - Unclear 2005a Methods

Unclear risk

No incomplete data.

Unclear risk Unclear risk

All measured outcomes reported. None obvious.

Allocation: randomised. Blinding: not stated. Duration: 5 years. Setting: community, Binzhou, Shandong province, China. Diagnosis: schizophrenia (CCMD-3). N = 40. Age: 16-60 years. Sex: male and female. History: 6-20 months. Exclusion: other illnesses. 1. Psychoeducation: provide patients with information on causes, development symptoms of illness, crisis strategy, communication with family member, maintain medication; frequency not clear. N = 20 2. Routine care. N = 20. Compliance: with medication. Global state: no clinical improvement.

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomisation method not described.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Low risk

No incomplete outcome data.

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Selective reporting (reporting bias)

High risk

BPRS and SOSS score measured but not reported. None obvious.

Other bias Standard - Unclear 2006 Methods

Low risk

Allocation: randomised - no further description. Blinding: not stated. Duration: 1 month intervention + 1 year follow-up. Setting: Tianshui mental health hospital, Gansu province, China Diagnosis: schizophrenia (CCMD-3). N = 116. Age: 21-58 years. Sex: male and female. History: not stated. Exclusion: severe physical or other mental illness. 1. Psychoeducation + routine care: patients & family members given booklets to read on cause, development & treatment of schizophrenia, relapse & relapse prevention; frequency > 2 times each week for 4 weeks. N = 58 2. Routine care. N = 58. Compliance: with follow-up. Relapse. Global state: no clinical improvement. Mental state: SDS, SAS. Satisfaction with care.

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Low risk

No incomplete data.

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(Continued)

Selective reporting (reporting bias) Other bias Standard - Unclear 2007 Methods

Low risk Low risk

All measured outcomes reported. None obvious.

Allocation: randomised. Blinding: not stated. Duration: 8 weeks. Setting: Shizhu number 2 hospital, Chongqing city, China. Diagnosis: schizophrenia (CCMD-3). N = 100. Age: 17-68 years. Sex: male. History: 4 months to 28 years. Exclusion: severe physical illness. 1. Psychoeducation + standard care: provide patients with information on cause, development & symptoms of illness, crisis strategy, communication with family member, maintain medication; 2 sessions/week for 8 weeks. N = 50 2. Standard care. N = 50. Compliance: with medication.

Participants

Interventions

Outcomes Notes Risk of bias Bias

Authors’ judgement

Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Low risk

No incomplete outcome data.

Low risk Low risk

All measured outcomes reported. None obvious.

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Unclear - Both 2001 Methods Allocation: randomised - no further description. Blindness: not stated. Duration: 12 weeks. Setting: Psychiatric prevention hospital, JiNing City, China Diagnosis: schizophrenia (CCMD-2-R). N = 80. Age: 18-60 years old. Sex: male and female. History/inclusion: duration ill 3 months-10 years, BRPS >/= 36, no severe physical illness, drug/alcohol dependency, heart, liver, renal functioning test normal 1. Psychoeducation + routine drug therapy: intervention given both individually & in groups; individual psychoeducation emphasise on reminding patients to take medication & to receive routine care; group psychoeducation focused on cause of illness & benefit of good medication compliance, prior to discharge focus of intervention on relapse prevention, self-monitoring & returning to family/society; frequency not stated. N = 40 2. Routine drug therapy only. N = 40. Knowledge: SAUMD. Unable to use Knowlege: SAUMD total and factor scores (two groups’ data combined and cannot be separated). Mental state: BPRS total and factor scores (two groups’ data combined and cannot be separated)

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Patients randomly divided into two groups, no further detail on randomisation Not described. Not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Low risk

No incomplete outcome data.

Low risk Low risk

All measured outcomes reported. None obvious.

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Unclear - Both 2005 Methods Allocation: randomised - no further description. Blindness: not stated. Duration: > 8 weeks (no further detail). Setting: HeNan Psychiatric Hospital, HeNan Province, China. Diagnosis: schizophrenia (CCMD-3). N = 86. Age: 16-62 years old. Sex: male and female. History: not stated. Exclusion: patients with organic mental health problem, or severe physical impairment 1. Psychoeducation + routine drug therapy: promote treatment compliance, independent living, recognition of psychotic symptoms, analyse causes of illness & effect of medication with patients, associate improvement with good medication compliance; 8 weeks, frequency not stated. N = 43 2. Routine drug therapy. N = 43 Compliance: with medication.* Knowledge: ITAQ. Mental state: BPRS. *assessment based on nurse observation; divided into compliance, partial compliance and non-compliance

Participants

Interventions

Outcomes

Notes

Risk of bias Bias Authors’ judgement Support for judgement Randomised, without further description.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not described. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Low risk

No incomplete outcome data.

Low risk Low risk

All measured outcomes were reported. None obvious.

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Unclear - Both 2007 Methods Allocation: randomised with random number table. Blinding: not stated. Duration: 1 year. Setting: Xinxiang Mental Health Hospital, Henan Province, China Diagnosis: schizophrenia (CCMD-3). N = 129 (but only 102 completed study). Age: mean ~ 20.4 years, SD ~ 6 years. Sex: male and female. History: mean ~ 6.5 years, SD ~ 3.2 years. Exclusion: not stated. 1. Psychoeducation + standard care: provide patients with information on illness, crisis strategy, communication with family member, maintain medication; sessions held once every 1-2months for 1 year. N = 52 2. Standard care. N = 50. Compliance: with medication. Relapse. Mental state: PANSS.

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomised with random number table.

Random sequence generation (selection Low risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias High risk

Drop-outs were excluded from analysis.

High risk Low risk

MRSS was measured but not reported. None obvious.

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Unclear - Both 2007a Methods Allocation: randomised. Blinding: not stated. Duration: unclear. Setting: Rongjun Hospital, Jiangxi Province, China. Diagnosis: schizophrenia (CCMD-3). N = 120. Age: 18-36 years. Sex: male. History: > 2 years. Exclusion: not stated. 1. Psychoeducation + standard drug therapy: provide patients with information on causes, development symptoms of illness, crisis strategy, communication with family member, maintain medication; frequency not stated. N = 60 2. Standard drug therapy. N = 60. Compliance: with medication. Outcome is analysed as short term.

Participants

Interventions

Outcomes Notes Risk of bias Bias

Authors’ judgement

Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Low risk

No incomplete data.

Low risk Low risk

All measured outcomes reported. None obvious.

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Unclear - Both 2008 Methods Allocation: randomised. Blinding: not stated. Duration: intervention period unclear + 6 months follow-up. Setting: inpatients, China. Diagnosis: schizophrenia (CCMD-3). N = 96. Age: unclear. Sex: male and female. History: unclear. Exclusion: not stated. 1. Psychoeducation: provide patients with information on causes, development symptoms of the illness, crisis strategy, communication with family member, maintain medication. 40 minutes/session, 1 session/week. N = 48 2. Routine care. N = 48. Relapse. Knowledge.

Participants

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Low risk

No incomplete outcome data.

Low risk Low risk

All measured outcomes reported. None obvious.

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Unclear - Group 1996 Methods Allocation: random - no further description. Blinding: not described. Duration: 20 weeks, follow-up 3 months. Analysis of drop-outs: the data is presented for study group attenders, rather than those allocated to groups Diagnosis: schizophrenia (SADS and DSM-III-R). N = 146. Age: not reported Sex: male 92, female 54. History: community based outpatients good depot clinic attenders, illness length 9-14 years 1. Education groups: on 8 geographical areas, each session 90’ including break; sessions alternated between information & problem solving; manual outlining the content was given. N = 73 2. Waiting list. N = 73. Social functioning: SFS, modified SNS. Quality of life: Heinrichs’ scale. Unable to use Compliance with medication (no usable data). Mental state: BPRS (no data). Knowledge + self-esteem assessed but reported elsewhere.

Participants

Interventions

Outcomes

Notes Risk of bias Bias

Authors’ judgement

Support for judgement No description.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Low risk

No incomplete outcome.

Low risk Low risk

Everything measured are reported. None obvious.

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Unclear - Group 2008 Methods Allocation: randomised. Blinding: not stated. Duration: 4 weeks. Setting: Zigong Mental Health Centre, Sichuan City, China. Diagnosis: schizophrenia (CCMD-3). N = 100. Age: 15-60 years. Sex: male and female. History: not stated. Exclusion: not stated. 1. Psychoeducation + routine care: education on causes, development & treatment of schizophrenia, group therapy; frequency not stated. N = 50 2. Routine care. N = 50 Behaviour: NOSIE.

Participants

Interventions

Outcomes Notes Risk of bias Bias

Authors’ judgement

Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Unclear - Individual 2008 Methods Low risk

No incomplete data.

Low risk Low risk

All measured outcomes reported. None obvious.

Allocation: randomised. Blinding: not stated. Duration: length of treatment period unclear + 2 years follow-up. Setting: Henan Zhumadian Mental Health Hospital, China.

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Unclear - Individual 2008

(Continued)

Participants

Diagnosis: schizophrenia (CCMD-3). N = 160. Age: 15-55 years. Sex: male and female. History: 3 months to 6 years. Exclusion: severe physical illness. 1. Psychoeducaiton + routine care: provide patients with information on the illness, crisis strategy, communication with family member, maintain medication. 30 ~ 50 minutes/ session, 3 sessions/week. N = 80 2. Routine care. N = 80. Compliance: with medication, and follow-up. Mental state: BPRS.

Interventions

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Unclear - Unclear 2008 Methods High risk

Drop outs were excluded from analysis.

Low risk Low risk

All measured outcomes reported. None obvious.

Allocation: randomised. Blinding: not stated. Duration: 4 weeks. Setting: Number 6 Renmin Hospital, Hebei Province, China. Diagnosis: schizophrenia (CCMD-3). N = 120. Age: mean ~ 20.5 years, SD ~ 7.2 years.. Sex: male and female.
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Participants

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Unclear - Unclear 2008

(Continued)

History: mean ~ 4.6 years, SD ~ 5.6 years.. Exclusion: not stated. Interventions 1. Psychoeducation: provide patients with information on the causes, development symptoms of the illness, crisis strategy, communication with family member, maintain medication. Intervention frequency unclear. N = 60 2. Routine care. N = 60. Knowledge. Satisfaction.

Outcomes

Notes Risk of bias Bias Authors’ judgement Support for judgement Randomisation method not stated.

Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Unclear risk

Not stated. Not stated.

Blinding (performance bias and detection Unclear risk bias) All outcomes Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Low risk

No incomplete data.

Low risk Low risk

All measured outcomes reported. None obvious.

Rating scale abbreviations BPRS - Brief Psychiatric Rating Scale CGI - Clinical Global Impression FAD - Family Assessment Device FBIS - Family Burden Interview Schedule GAS - Global Assessment Scale GAF - Global Assessment of Functioning GQOLI-74 - General Quality of Life Inventory -74 GWB - General Well-being Schedule IPROS - Inpatient Psychiatric Rehabilitation Outcome Scale ITAQ - Insight Treatment Attitude Questionnaire KASQ - Knowledge About Schizophrenia Questionnaire KK-skala - Krankenheitskonzept Skala KQ - Knowledge Questionnaire MRSS - Morningside Rehabilitation Status Scale NOSIE-30 - Nurse Observation Scale for Inpatient Evaluation-30
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PANSS - Positive and Negative Syndrome Scale PGWB - psychological general well being scale QOL - Quality of Life RAQ - Recovery Attitudes Questionnaire SAI - Schedule for Assessment of Insight SAS - Zung Self-Rating Anxiety Scale SAS II - Social Adjustment Scale II SAUMD - The Scale to Assess Unawareness of Mental Disorder SDS - Zung Self-Rating Depression Scale SDSS - Social Disability Screening Schedule SES - Rosenberg Self-esteem Scale SFS - Social functioning schedule SKQ - Schizophrenia Knowledge Questionnaire SLOF - Specific Level of Functioning Scale SNS - Social Networks Schedule TCI - Treatment Compliance Interview TSCKAS - Team Solutions comprehensive knowledge assessment scale UMQ - Understanding of medication questionnaire VSSS - Verona Service Satisfaction Scale General abbreviations DSM - Diagnostic and Statistical Manual of Mental Disorders EE - expressed emotion ICD - International Classification of Diseases ITT - intention to treat SD - standard deviation ZMBT - Statistics and Data Center for Clinical Trials at the Institute of Medical Biometry and Informatics CP CPZ FAI FBIS FQ IAPSRS IS KC OPCRIT PEF PT RAPS ROMI RPTS SSQ SUMD TMCDS

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Characteristics of excluded studies [ordered by study ID]

Study Agara 2007

Reason for exclusion Allocation: randomised. Participants: schizophrenia and depressive disorders. Intervention: psychoeducation vs standard care. Outcomes: no usable data - no mean or SD reported, only P values Allocation: random. Participants: schizophrenia. Intervention: Psychoeducation vs standard care. Outcome: no usable data - no mean or SD reported, only P values reported Allocation: randomised. Participants: schizophrenia. Intervention: psychoeducation with elements of skill training and token economy vs standard care Allocation: random. Participants: adult general psychiatry patients with schizophrenia 21%, affective disorder 57%, neurotic, personality, other non-psychotic disorder 14% and others 8%. No analyses on diagnostic subgroups. Intervention: patient information leaflet vs usual information Allocation: patients matched and randomly assigned. Participants: chronically mentally ill patients: schizophrenia, bipolar and major depressive disorder. No analyses on diagnostic subgroups Allocation: planned to be randomised - trial was not conducted in the end Allocation: not randomised. Allocation: randomised. Participants: schizophrenia. Intervention: CBT vs psychoeducation. Allocation: randomised. Participants: schizophrenia. Interventon: CBT vs routine care. Allocation: randomised. Participants: schizophrenia. Intervention: health education with elements of training and token economy vs routine care Allocation: random. Participants: schizophrenia patients. Interventions: psychoeducation vs control group. Outcomes: no usable data.

Aguglia 2007

An 2005

Angunawela 1998

Azrin 1998

Barnes 2001 BaumI 2006 Bechdolf 2005a

Bechdolf 2007

Bi 2000

Boczkowski 1985

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(Continued)

Borell 1995

Allocation: random. Participants: schizophrenia DSM-III. Interventions: information program versus control waiting list group. Outcomes: no usable data. Allocation: randomised. Participants: schizophrenia. Intervention: psychoeducation vs standard care. Outcome: no usable data - only sub-scale scores were reported Allocation: randomised. Participants: not schizophrenia patients. Allocation: random. Participants: diagnosis functional psychosis, not limited to patients with schizophrenia. No analyses on diagnostic subgroups Allocation: randomised. Participants: schizophrenia. Intervention: health education with elements of training vs standard care Allocation: random. Participants: schizophrenia patients. Intervention: psychoeducation (French version of the Medication and Symptom Management Modules) group, two control groups 1) with leisure activities and 2) usual follow-up activities (support therapy with their treating psychiatrist and neuroleptic medication). Outcomes: no usable data. Allocation: randomised. Participants: chronic schizophrenia. Intervention: psychological intervention with elements of independent living skills training Allocation: not stated. Participants: schizophrenia ICD-10. Intervention: psychoeducation versus control group. Allocation: random. Participants: schizophrenia. Intervention: skills training versus supportive group psychotherapy, not psychoeducation Allocation: random. Participants: schizophrenia. Interventions: didactic program versus standard ward activities Outcomes: no usable data (means, no standard deviations), number of drop-outs unclear Allocation: randomised. Participants: schizophrenia. Intervention: CBT vs treatment as usual.
88

Cao 2002

Castrogiovanni 2006

Chaplin 1998

Chen 2005

Cormier 1995

Dang 2007

Degmecic 2007

Eckman 1992

Goldman 1988

Gumley 2003

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(Continued)

He 2008

Allocation: randomised. Participants: schizophrenia. Intervention: CBT vs standard care. Allocation: random. Participants: schizophrenia or schizoaffective disorder. Intervention: family intervention with minimal psychoeducation versus social skills training versus combination of family intervention and social skills training versus drug treatment Allocation: random. Participants: schizophrenia Intervention: insight education + routine drug therapy versus routine drug therapy alone Allocation: randomised. Participants: schizophrenia. Intervention: psychoeducation with elements of skills training and token economy vs standard care Allocation:randomised. Participants: schizophrenia. Intervention: health education with elements of CBT and token economy vs standard care Allocation: random. Participants: non-psychoses 7-11%, schizophrenia 59-71%, no analyses of diagnostic subgroups Allocation: block randomisation after stratifying for hospital affiliation. Participants: schizophrenia. Intervention: educational process group versus single educational session. No standard care group Allocation: randomised. Participants: schizophrenia. Intervention: CBT vs psychoeducation. Outcome: no numerical data reported. No n numbers for groups Allocation: random. Participants: schizophrenia or schizoaffective disorder. Intervention: community re-entry program, not psychoeducation Allocation: random. Participants: schizophrenia and affective disorder. Interventions: structured medication education versus unstructured teaching. No standard care group Allocation: random. Participants: general practitioners, not people with schizophrenia Allocation: randomised. Participants: schizophrenia. Intervention: psychoeducation vs routine care. Outcome: no usable data - no numerical data reported.
89

Hogarty 1986

Hu 1998

Hua 2008

Huang 2007

Kelly 1990

Kleinman 1993

Klingberg 2009

Kopelowicz 1998

Kuipers 1994

Lester 2004a

Li 2002

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(Continued)

Li 2004 Li Zheng 2004

Allocation: not randomised, case control study. Allocation: random. Participants: schizophrenia. Interventions: problem solving and skills training. Allocation: randomised. Participants: schizophrenia. Intervention: psychoeducation + standard drug therapy vs standard drug therapy. Outcome: ITAQ and BPRS scale scores. Authors agreed to exclude this study found in 2010 update search, as all of the continuous scale scores are exactly the same (down to the decimal points) as study ’Unclear - both 2005’. Review authors felt this unlikely to be true Allocation: not randomised, quasi randomisation. Allocation: not randomised, quasi randomisation. Allocation: randomised. Participants: schizophrenia. Intervention: health education with elements of skill training vs routine care Allocation: randomised. Participants: schizophrenia. Intervention: psychoeducation with elements of CBT vs standard care Allocation: randomisation not mentioned and received open management. Participants: schizophrenia, initial onset. Interventions: family intervention versus traditional treatment, not psychoeducation Allocation: random. Participants: schizophrenia. Intervention: family psychoeducation with elements of skills training Allocation: random. Participants: schizophrenia DSM-III outpatients. Intervention: group and individual behavioral family management with psychoeducation provided through printed information versus conventional care. (Psychoeducation component did not involve interaction between information provider and recipients and was thus excluded from the review.) Allocation: random. Participants: PSE schizophrenia. Intervention: complex family therapy intervention versus individual supportive psychotherapy Allocation: randomised. Participants: schizophrenia. Intervention: psychoeducation with elements of skill training vs standard care

Liu 2007

Liu 2008 Liu 2008a Liu 2008b

Lv 2005

Ma 1998

Magliano 2006

Mak 1997

McGill 1983

Mo 2007

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(Continued)

Motlova 2003

Allocation: Case Control design. Participants: ICD-10: schizophrenia, schizoaffective disorder and acute psychotic episode with psychotic symptoms. Intervention: the program provided a combination of education about mental illness, family support, crisis intervention, communication and problem-solving skills training Allocation: randomised. Participants: schizophrenia. Intervention: psychoeducation vs standard care. Outcome: no usable data - data are from sub-scale of NOSIE and another unvalidated scale Allocation: randomised. Participants: schizophrenia. Intervention: psychoeducation vs standard care. Outcome: no usable data (IMHC scale score reported, but the scale is unvalidated) Allocation: randomised. Participants: schizophrenia. Intervention: telehealth psychoeducation - a package of care including elements of problem-solving training Allocation: randomised. Participants: schizophrenia. Intervention: a depot olanzapine trial where one group of patients were told that the drug might cause weight gain - not a psychoeducation programme Allocation: random. Participants: DSM-IV: schizophrenia, schizoaffective or schizophreniform disorder. Intervention: complex intervention including communication and stress management skills, self-help and community resources Allocation: quasi randomisation. Allocation: randomised. Participants: schizophrenia. Intervention: psychoeducation with elements of skill training vs standard care Allocation: randomised. Participants: schizophrenia. Intervention: CBT vs standard care. Allocation: random. Participants: schizophrenia. Intervention: complex family cognition insight therapy and family intervention and the control group treated with common psychotherapy Allocaiton: randomised. Participants: schizophrenia. Intervention: health education with elements of skills training vs standard care
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Pei 2008

Poplawska 2004

Rotondi 2005

Scocco 2006

Shin 2002

Song 2008 Su 2007

Sun 2005

Wang 2004

Wang 2007

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(Continued)

Wang 2008

Allocation: randomised. Participants: schizophrenia. Intervention: psychoeducation with elements of music and exercise therapy vs standard care Allocation: randomised. Participants: schizophrenia. Intervention: CBT vs standard care. Allocation: randomised. Participants: schizophrenia. Intervention: community re-entry module (a module of a structured social skills training programme) vs psychoeducation Allocation: random. Participants: DSM-III-R schizophrenia. Intervention: family intervention with minimal psychoeducation vs standard care Allocation: randomised. Participants: schizophrenia. Intervention: health education with elements of social and independent living skills training vs standard care Allocation: random. Participants: diagnosis unclear: schizo-affective or affective disorder, data not available for a non-affective subgroup. Intervention: education sessions vs standard care. Allocation: random. Participants: schizophrenia. Intervention: family intervention with minimal psychoeducation vs standard care Allocation: randomised. Participants: schizophrenia. Intervention: psychoeducation with elements of social skill training vs standard care Allocaiton: randomised. Participants: schizophrenia. Intervention: health education with social and independent living skills training vs standard care Allocation: randomised. Participants: schizophrenia. Intervention: health education with practical help on social activities and independent living vs standard care Allocation: quasi randomisation.

Wei 2005

Xiang 2007

Xiong 1994

Xiong 2007

Youssef 1987

Zhang 1994

Zhang 2005

Zhang 2006

Zheng 2008

Zhu 2002

BPRS = CBT = cognitive behaviour therapy DSM-III = Diagnostic and Statistical Manual of Mental Disorders, third edition
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DSM-III-R = Diagnostic and Statistical Manual of Mental Disorders, third edition, revised DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, fourth edition ICD-10 = International classification of diseases, tenth revision IMHC = ITAQ = KD-10 = NOSIE = PSE = Present State Examination

Characteristics of studies awaiting assessment [ordered by study ID]
Aho-Mustonen 2011 Methods Participants Interventions Outcomes Notes Bentall 2001 Methods Participants Allocation: unclear. Diagnosis: schizophrenia DSM-IV or schizoaffective disorder. N = 228. History: admitted to acute psychiatric wards. 1. Compliance intervention (patients educated about benefits of neuroleptic medication). 2. Alliance intervention (structured intervention in which patients are encouraged to rationally appraise the costs and benefits of their neuroleptic medication). 3. Treatment as usual. 1. Attitudes towards neuroleptic as measured by the Drug Attitudes Inventory. 2. Psychotic symptoms as measured by the Positive and Negative Syndromes Scale Further information needed on ’Methods’. Publication being sought To be assessed.

Interventions

Outcomes

Notes

Day 2000 Methods Participants Allocation: unclear. Diagnosis: schizophrenia. N = 180-225. History: inpatients on acute psychiatric admission wards presenting with psychotic symptoms, who have been prescribed neuroleptic medication
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Day 2000

(Continued)

Interventions

1. An educational intervention. 2. A collaborative intervention. 3. A control condition. Compliance with prescribed neuroleptic medication regimens. Further information needed on ’methods’, publication being sought

Outcomes Notes

Fiorillo 2011 Methods Participants Interventions Outcomes Notes Gassmann 2011 Methods Participants Interventions Outcomes Notes Hegde 2012 Methods Participants Interventions Outcomes Notes To be assessed. To be assessed. To be assessed.

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ISRCTN32545295 Methods Participants Interventions Outcomes Notes To be assessed.

ISRCTN33576045 Methods Participants Interventions Outcomes Notes Jahn 2011 Methods Participants Interventions Outcomes Notes Medalia 2012 Methods Participants Interventions Outcomes Notes To be assessed. To be assessed. To be assessed.

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Mueser 2012 Methods Participants Interventions Outcomes Notes Navidian 2010 Methods Participants Interventions Outcomes Notes NCT01547026 Methods Participants Interventions Outcomes Notes NCT01601587 Methods Participants Interventions Outcomes Notes To be assessed. To be assessed. To be assessed. To be assessed.

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Nischk 2011 Methods Participants Interventions Outcomes Notes To be assessed.

Nordentoft 1999 b Methods Participants Interventions Outcomes Notes Rabovsky 2012 Methods Participants Interventions Outcomes Notes Ran 2002 Methods Participants Interventions Outcomes Notes To be assessed. To be assessed. To be assessed.

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Rotondi 2011 Methods Participants Interventions Outcomes Notes Schlosser 2011 Methods Participants Interventions Outcomes Notes Schlosser 2012 Methods Participants Interventions Outcomes Notes Schulze 2011 Methods Participants Interventions Outcomes Notes To be assessed. To be assessed. To be assessed. To be assessed.

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Sharif 2012 Methods Participants Interventions Outcomes Notes Shaygan 2011 Methods Participants Interventions Outcomes Notes Silverman 2011 Methods Participants Interventions Outcomes Notes To be assessed. To be assessed. To be assessed.

Silverman 2011a Methods Participants Interventions Outcomes Notes To be assessed.

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Smeerdijk 2010 Methods Participants Interventions Outcomes Notes Valencia 2012 Methods Participants Interventions Outcomes Notes To be assessed. To be assessed.

Zarafonitis 2012 Methods Participants Interventions Outcomes Notes To be assessed.

Characteristics of ongoing studies [ordered by study ID]
Kissling 2007 Trial name or title “How can rehospitalisations of patients with schizophrenia be avoided? A comparison between different compliance programs.” Allocation: randomised. Blinding: open label, placebo control. Diagnosis: schizophrenia Age: 18-67 years.

Methods

Participants

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Kissling 2007

(Continued)

Interventions

1. Psychoeducation by professionals vs placebo comparator. 2. Psychoeducation with video vs placebo comparator.

Outcomes Starting date Contact information September 2006 Dr Werner Kissling Technical University Munich, Germany. Estimated completion date: August 2010.

Notes

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DATA AND ANALYSES

Comparison 1. ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE
No. of studies 18 10 6 3 4 3 1 1400 781 282 No. of participants

Outcome or subgroup title 1 Compliance: 1a. With medication - non-compliance 1.1 short term 1.2 medium term 1.3 long term 2 Compliance: 1b. With medication - partial compliance 2.1 short term 2.2 medium term 3 Compliance: 1c. With medication - continuous outcomes - skewed data 3.1 single session - average compliance with medication (SAI sub-scale endpoint score, high = favourable) 3.2 three sessions - average compliance with medication (SAI sub-scale endpoint score, high = favourable) 4 Compliance: 2a. With follow up - loss to follow-up for any reason 4.1 medium term - loss to follow-up for any reason 4.2 long term - loss to follow-up for any reason (by 2 years) 4.3 long term - loss to follow-up for any reason (by 5 years or more) 5 Compliance: 2b. With follow-up - received intervention but left the study early 5.1 short term 5.2 medium term 5.3 long term 6 Compliance: 2c. With follow-up - allocated but never accepted treatment 6.1 medium term 7 Relapse: 1. Relapse for any reason

Statistical method Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Other data

Effect size Subtotals only 0.52 [0.40, 0.67] 0.36 [0.27, 0.49] 0.48 [0.31, 0.75] Subtotals only 0.64 [0.49, 0.85] 0.68 [0.39, 1.18] No numeric data

472 118

Other data

No numeric data

Other data

No numeric data

10

Risk Ratio (M-H, Fixed, 95% CI)

Subtotals only

8 3

949 420

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

1.00 [0.79, 1.26] 0.83 [0.62, 1.10]

2

172

Risk Ratio (M-H, Fixed, 95% CI)

0.77 [0.48, 1.23]

7

Risk Ratio (M-H, Fixed, 95% CI)

Subtotals only

2 4 2 2

87 319 206 213

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

3.04 [0.36, 25.67] 0.56 [0.29, 1.10] 0.63 [0.38, 1.04] 12.27 [2.58, 58.33]

2 16

213

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

12.27 [2.58, 58.33] Subtotals only
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7.1 medium term 7.2 long term 7.3 long term (at 5 years follow-up) 7.4 long term (at 7 years follow-up) 8 Relapse: 2. Relapse with readmission 8.1 medium term 8.2 long term 9 Knowledge: 1a. Average endpoint scale scores on various knowledge scales 9.1 short term - at end of intervention (KQ, high = favourable) 9.2 short term (KASQ, high = favourable) 9.3 short term (ITAQ, high = favourable) 9.4 short term (SKQ, high = favourable) 9.5 medium term (ITAQ, high = favourable) 9.6 medium term (KASQ, high = favourable) 9.7 long term (KQ, high = favourable) 10 Knowledge: 1b. Average change (UMQ, high = favourable, data skewed) 10.1 single session psychoeducation 10.2 three session psychoeducation 11 Knowledge: 2. Average endpoint scores on various insight scales 11.1 short term (SAUMD, high = poor) 11.2 medium term (RAQ, high = poor) 12 Knowledge: 3. Average endpoint score on illness-related attitudes - 4 months (KK, high = high expressed) 12.1 confidence in medication 12.2 confidence in physician 12.3 negative expectations toward medication as such

11 6 1 1 2 2 2 6

1214 790 124 48

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

0.70 [0.61, 0.81] 0.73 [0.62, 0.85] 0.89 [0.73, 1.08] 0.62 [0.42, 0.92] Subtotals only 0.77 [0.56, 1.07] 0.71 [0.56, 0.89] Subtotals only

206 206

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

1

75

Mean Difference (IV, Fixed, 95% CI)

-10.00 [-17.67, -6. 33] 0.20 [-2.12, 2.52] 5.53 [4.56, 6.49] -16.26 [-22.72, -9. 80] 4.83 [1.51, 8.15] 1.60 [-0.84, 4.04] -8.0 [-14.64, -1.36] No numeric data

1 3 1 1 1 1

71 295 19 73 61 75

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Other data

Other data Other data 3 217 Mean Difference (IV, Fixed, 95% CI)

No numeric data No numeric data -0.19 [-1.31, 0.93]

2 1 1

161 56

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

-0.63 [-1.86, 0.61] 1.80 [-0.85, 4.45] Subtotals only

1 1 1

75 75 75

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

-1.5 [-3.21, 0.21] -1.40 [-2.73, -0.07] -0.5 [-2.07, 1.07]

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12.4 susceptibility to illness and to relapse 12.5 attribution of illness to chance 12.6 attribution of guilt 12.7 fear of side effects of medication 13 Knowledge: 4. level of knowledge did not improve 14 Behaviour: Average score (NOSIE-30, endpoint, high = poor) 14.1 short term 14.2 medium term 14.3 long term 15 Social functioning: 1a. Average change scores on various scales - medium term (high = poor) 15.1 MRSS 15.2 SDSS 16 Social functioning: 1b. Average endpoint scores on various scales (high = poor) 16.1 short term - IPROS 16.2 short term - SAS 16.3 short term - SAS-II 16.4 short term - SDS 16.5 medium term - SDSS 17 Social functioning 1c. Average SAS, SFS, SNS scale scores skewed data (low = favourable) 18 Global functioning: 1. No clinically significant improvement 18.1 short term 18.2 medium term 18.3 long term 19 Global functioning: 2. Average endpoint scale score 19.1 short term - (GAF/GAS, high = good) 19.2 short term - (SLOF, high = good) 19.3 medium term (GAF/GAS, high = good) 19.4 medium term - (SLOF, high = good) 19.5 long term (GAS, high = good) - at 2 years 19.6 long term - (GAS, high = good) - at 5 years or more

1 1 1 1 2 3

75 75 75 75 216

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

0.60 [-0.78, 1.98] -0.70 [-2.30, 0.90] -0.80 [-2.07, 0.47] -1.60 [-2.74, -0.46] 0.13 [0.06, 0.28] Subtotals only

2 1 1 1

202 73 70

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

16.85 [11.90, 21.80] 14.0 [3.03, 24.97] 41.33 [31.02, 51.64] Subtotals only

1 1 5

118 118

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

13.68 [12.51, 14.85] 1.96 [1.83, 2.09] Subtotals only

1 3 1 3 1

116 378 19 378 85

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Other data

-6.64 [-11.02, -2.26] -8.53 [-10.50, -6.55] -0.10 [-0.37, 0.17] -5.60 [-7.55, -3.65] -3.74 [-6.05, -1.43] No numeric data

4

Risk Ratio (M-H, Fixed, 95% CI)

Subtotals only

2 2 2 5 1 1 4 1 1 2

208 178 132

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

0.61 [0.32, 1.13] 0.59 [0.43, 0.82] 0.70 [0.48, 1.04] Subtotals only -2.64 [-12.74, 7.46] 23.60 [11.88, 35.32] -5.44 [-8.51, -2.38] 46.40 [34.45, 58.35] -6.70 [-13.38, -0.02] -3.36 [-7.24, 0.52]

41 84 321 84 59 108

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20 Service utilisation: days in hospital 20.1 short term - days in hospital 20.2 medium term - days in hospital 21 Service utilisation: Days in hospital using ’acute services’ - during 18 months (data skewed) 22 Global state: 1. Average endpoint score - medium term (CGI, high = poor) 22.1 severity 22.2 change 23 Global state: 2. Increased medication dose by 25% 24 Global state: 3. Disability long term 25 Mental state: 1a. Global continuous - average total endpoint scale scores (high = poor) 25.1 short term (BPRS) 25.2 medium term (BPRS) 25.3 medium term (PANSS) 25.4 long term (BPRS - 1 ~ 2 year follow-up) 25.5 long term (BPRS - 7 year follow-up) 26 Mental state: 1b. Global continuous - average change scale scores - medium term (high = good) 26.1 GWB 26.2 SES 27 Mental state: 1c. Global continuous - average total endpoint scale scores - (BPRS, high = poor, data skewed) 28 Mental state: 2a. Specific binary - specific symptoms short term 28.1 anxiety 28.2 depression 29 Mental state: 2b. Specific continuous - average endpoint PANSS scores (high = poor) 29.1 short term - negative symptoms

2 2 1 200 84

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Other data

Subtotals only -3.23 [-5.44, -1.01] -8.4 [-10.44, -6.36] No numeric data

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1 1 1 1 17

61 61 20 86

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

0.50 [0.08, 0.92] -0.80 [-1.45, -0.15] 0.43 [0.15, 1.20] 0.29 [0.13, 0.64] Subtotals only

11 7 2 3 1 1

1107 760 163 370 48

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

-1.00 [-1.38, -0.63] -4.73 [-5.55, -3.91] -2.52 [-5.01, -0.04] -6.89 [-8.55, -5.23] -0.20 [-6.55, 6.15] Subtotals only

1 1

118 118

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Other data

10.89 [9.82, 11.96] 8.00 [7.77, 8.23] No numeric data

1

Risk Ratio (M-H, Fixed, 95% CI)

Subtotals only

1 1 1

146 146

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

0.49 [0.25, 0.93] 0.47 [0.25, 0.88] Subtotals only

1

71

Mean Difference (IV, Fixed, 95% CI)

0.40 [-1.98, 2.78]

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29.2 short term - positive symptoms 29.3 medium term - negative symptoms 29.4 medium term - positive symptoms 30 Expressed emotion: Participants with high EE relatives (FQ) 30.1 short term - at end of interventions 30.2 medium term - at 9-12 months 31 Quality of life: Average endpoint scores on various scales (high = favourable) 31.1 short term - GQOLI-74 31.2 short term - PGWB 31.3 medium term GQOLI-74 31.4 medium term - QOL 31.5 medium term - PGWB 32 Quality of life: Average endpoint scores on various scales (high = poor) 32.1 short term - FAD 32.2 short term - FBIS 32.3 medium term - FAD 32.4 medium term - FBIS 33 Satisfaction with mental health services: 1. Short term - average change score (VSS, high = good) 33.1 patients’ satisfaction 33.2 relatives’ satisfaction 34 Satisfaction with mental health services: 2. Average change - at 1 year (VSS Scale, high = good) 34.1 patients’ satisfaction with relatives’ involvement - mean change 34.2 relatives’ involvement satisfaction 34.3 relatives’ efficacy satisfaction 34.4 relatives’ intervention satisfaction 35 Satisfaction with mental health services: 3. Binary outcome 35.1 short term - unsatisfied

1 1 1 2 2 1 3

71 61 61

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

1.5 [-0.99, 3.99] 3.1 [0.16, 6.04] 2.40 [-0.46, 5.26] Subtotals only 0.84 [0.76, 0.94] 1.07 [0.64, 1.78] Subtotals only

282 46

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

1 1 1 1 1 3

62 71 62 108 61

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

0.63 [-0.79, 2.05] 2.0 [-6.08, 10.08] 2.13 [1.03, 3.23] -9.70 [-17.22, -2.18] 2.80 [-5.40, 11.00] Subtotals only

1 1 1 2 1

62 84 62 241

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

-0.42 [-5.45, 4.61] -4.70 [-7.19, -2.21] -6.79 [-11.67, -1.91] -6.24 [-7.80, -4.68] Subtotals only

1 1 1

32 17

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI)

-2.15 [-13.96, 9.66] -8.31 [-29.72, 13. 10] Subtotals only

1

30

Mean Difference (IV, Fixed, 95% CI)

-4.35 [-7.09, -1.61]

1 1 1 2 1

21 24 26 236 120

Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

-2.17 [-6.11, 1.77] -2.16 [-7.29, 2.97] -3.43 [-9.83, 2.97] 0.24 [0.12, 0.50] 0.11 [0.03, 0.46]

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35.2 medium term unsatisfied 36 Adverse event: Death 36.1 medium term 36.2 long term 37 Economic outcomes: Costs (US$ per person, data skewed) 37.1 acute hospital charges 37.2 ambulatory charges 37.3 total charges

1 4 2 2

116 626 282 344

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Other data Other data Other data Other data

0.4 [0.17, 0.96] 1.15 [0.31, 4.21] 0.90 [0.13, 6.35] 1.39 [0.24, 8.11] No numeric data No numeric data No numeric data No numeric data

Comparison 2. SUBGROUP ANALYSES 1. BRIEF PSYCHOEDUCATION/STANDARD PSYCHOEDUCATION vs STANDARD CARE
No. of studies 12 3 4 1 4 10 2 7 1 1 1 1 4 170 739 124 136 124 48 448 586 118 561 No. of participants

Outcome or subgroup title 1 Compliance: 1a. With medication - binary outcomes 1.1 short term non-compliance - brief 1.2 short term non-compliance - standard 1.3 medium term non-compliance - brief 1.4 medium term non-compliance - standard 2 Compliance: 2. With follow-up loss to follow-up for any reason 2.1 medium term - brief 2.2 medium term - standard 2.3 long term (by 2 years) brief 2.4 long term (by 2 years) standard 2.5 long term (by 5 years or more) - brief 2.6 long term (by 5 years or more) - standard 3 Compliance: 2a. with follow-up - received intervention but left the study early 3.1 short term - brief 3.2 short term - standard 3.3 long term - brief 3.4 long term - standard 4 Relapse: Relapse for any reason 4.1 relapse - medium term brief

Statistical method Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

Effect size Subtotals only 0.63 [0.41, 0.96] 0.41 [0.25, 0.67] 0.17 [0.05, 0.54] 0.44 [0.32, 0.62] Subtotals only 0.59 [0.37, 0.94] 1.13 [0.83, 1.55] 0.70 [0.43, 1.15] 0.97 [0.66, 1.42] 0.73 [0.44, 1.21] 1.0 [0.28, 3.54] Subtotals only

1 1 1 1 14 3

67 20 124 82 292

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

3.06 [0.17, 56.70] 3.0 [0.14, 65.90] 0.58 [0.33, 1.01] 0.83 [0.28, 2.52] Subtotals only 0.61 [0.43, 0.89]
107

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

4.2 relapse - medium term standard 4.3 relapse with readmission medium term - brief 4.4 relapse with readmission medium term - standard 4.5 relapse - long term - brief 4.6 relapse - long term standard 4.7 relapse with readmission long term - brief 4.8 relapse with readmission long term - standard

6 1 1 1 5 1 1

1011 124 82 124 666 124 82

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

0.87 [0.77, 0.99] 0.85 [0.59, 1.22] 0.6 [0.30, 1.21] 0.85 [0.59, 1.22] 0.70 [0.59, 0.84] 0.83 [0.64, 1.08] 0.53 [0.35, 0.82]

Comparison 3. SUBGROUP ANALYSES 2. GROUP PSYCHOEDUCATION/INDIVIDUAL PSYCHOEDUCATION vs STANDARD CARE
No. of studies 5 3 2 1 1 8 412 296 250 136 No. of participants

Outcome or subgroup title 1 Compliance: 1a. With medication - binary outcomes 1.1 short term non-compliance - group 1.2 short term non-compliance - individual 1.3 short term - partial compliance - group 1.4 short term - partial compliance - individual 2 Compliance: 2. With follow-up - leaving the study early/loss to follow-up 2.1 medium term - received intervention but left the study early - group 2.2 medium term - received intervention but left the study early - individual 2.3 medium term - loss to follow-up for any reason group 2.4 medium term - loss to follow-up for any reason individual 2.5 long term - loss to follow-up for any reason (by 2 years) - group

Statistical method Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

Effect size Subtotals only 0.26 [0.13, 0.52] 0.66 [0.39, 1.11] 0.76 [0.50, 1.16] 0.61 [0.41, 0.92] Subtotals only

2

213

Risk Ratio (M-H, Fixed, 95% CI)

0.52 [0.25, 1.06]

1

20

Risk Ratio (M-H, Fixed, 95% CI)

3.0 [0.14, 65.90]

4

367

Risk Ratio (M-H, Fixed, 95% CI)

0.86 [0.61, 1.20]

1

73

Risk Ratio (M-H, Fixed, 95% CI)

1.95 [0.18, 20.53]

1

124

Risk Ratio (M-H, Fixed, 95% CI)

0.70 [0.43, 1.15]

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2.6 long term - loss to follow-up for any reason (by 2 years) - individual 3 Relapse: Relapse for any reason 3.1 relapse - medium term group 3.2 relapse - medium term individual 3.3 relapse - long term - group 3.4 relapse - long term individual

2

296

Risk Ratio (M-H, Fixed, 95% CI)

0.90 [0.63, 1.29]

8 4 1 2 1

410 73 344 136

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

Subtotals only 0.74 [0.57, 0.96] 0.45 [0.19, 1.05] 0.81 [0.66, 0.99] 0.73 [0.57, 0.94]

Comparison 4. SENSITIVITY ANALYSIS - Chinese studies vs non-Chinese studies

Outcome or subgroup title 1 Compliance: 1a. With medication - non-compliance 1.1 long term 1.2 long term - Chinese studies 2 Compliance: 2a. With follow-up - loss to follow-up for any reason 2.1 medium term - loss to follow-up for any reason 2.2 medium term - loss to follow-up for any reason Chinese studies 2.3 long term - loss to follow-up for any reason (by 2 years) 2.4 long term - loss to follow-up for any reason (by 2 years) - Chinese studies 3 Compliance: 2b. With follow-up - received intervention but left the study early 3.1 medium term 3.2 medium term - Chinese studies 4 Relapse: 1. Relapse for any reason 4.1 medium term 4.2 medium term - Chinese studies 4.3 long term

No. of studies 3 3 3 10

No. of participants

Statistical method Risk Ratio (M-H, Fixed, 95% CI)

Effect size Subtotals only 0.48 [0.31, 0.75] 0.48 [0.31, 0.75] Subtotals only

282 282

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

8 8

949 949

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

1.00 [0.79, 1.26] 1.00 [0.79, 1.26]

3

420

Risk Ratio (M-H, Fixed, 95% CI)

0.83 [0.62, 1.10]

3

420

Risk Ratio (M-H, Fixed, 95% CI)

0.83 [0.62, 1.10]

4

Risk Ratio (M-H, Fixed, 95% CI)

Subtotals only

4 4 16 11 11 6

319 319

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

0.56 [0.29, 1.10] 0.56 [0.29, 1.10] Subtotals only 0.70 [0.61, 0.81] 0.70 [0.61, 0.81] 0.73 [0.62, 0.85]
109

1214 1214 790

Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

4.4 long term - Chinese studies

6

790

Risk Ratio (M-H, Fixed, 95% CI)

0.73 [0.62, 0.85]

Analysis 1.1. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 1 Compliance: 1a. With medication - non-compliance.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 1 Compliance: 1a. With medication - non-compliance

Study or subgroup

Treatment n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 short term Brief - Group 2006 Brief - Group 2007b Brief - Unclear 2005 Standard - Both 2006 Standard - Group 2004 Standard - Individual 03b Standard - Unclear 2007 Unclear - Both 2005 Unclear - Both 2007a Unclear - Individual 2008 2/30 3/51 24/143 9/50 4/125 7/68 0/50 5/43 6/60 12/80 3/30 7/51 36/143 12/50 25/125 9/68 3/50 10/43 14/60 20/80 2.2 % 5.0 % 25.8 % 8.6 % 17.9 % 6.5 % 2.5 % 7.2 % 10.0 % 14.3 % 0.67 [ 0.12, 3.71 ] 0.43 [ 0.12, 1.57 ] 0.67 [ 0.42, 1.06 ] 0.75 [ 0.35, 1.62 ] 0.16 [ 0.06, 0.45 ] 0.78 [ 0.31, 1.97 ] 0.14 [ 0.01, 2.70 ] 0.50 [ 0.19, 1.34 ] 0.43 [ 0.18, 1.04 ] 0.60 [ 0.31, 1.14 ]

Subtotal (95% CI)
Total events: 72 (Treatment), 139 (Control)

700

700

100.0 %

0.52 [ 0.40, 0.67 ]

Heterogeneity: Chi2 = 9.06, df = 9 (P = 0.43); I2 =1% Test for overall effect: Z = 4.91 (P < 0.00001) 2 medium term Brief - Both 2004 Standard - Both 2008 Standard - Both 2008b Standard - Group 2008 Standard - Unclear 2006 Unclear - Both 2007 3/59 6/79 17/45 6/99 7/58 7/52 18/59 14/78 34/45 15/99 18/58 26/50 14.3 % 11.2 % 27.1 % 11.9 % 14.3 % 21.1 % 0.17 [ 0.05, 0.54 ] 0.42 [ 0.17, 1.04 ] 0.50 [ 0.33, 0.75 ] 0.40 [ 0.16, 0.99 ] 0.39 [ 0.18, 0.86 ] 0.26 [ 0.12, 0.54 ]

Subtotal (95% CI)
Total events: 46 (Treatment), 125 (Control)

392

389

100.0 %

0.36 [ 0.27, 0.49 ]

0.1 0.2

0.5

1

2

5

10

Favours psychoeducation

Favours standard care

(Continued . . . )
Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 110

(. . .
Study or subgroup Treatment n/N Heterogeneity: Chi2 = 4.99, df = 5 (P = 0.42); I2 =0.0% Test for overall effect: Z = 6.76 (P < 0.00001) 3 long term Standard - Both 1996 Standard - Unclear 2005a Unclear - Individual 2008 7/41 0/20 16/80 2/41 9/20 37/80 4.1 % 19.6 % 76.3 % Control n/N Risk Ratio M-H,Fixed,95% CI Weight

Continued) Risk Ratio

M-H,Fixed,95% CI

3.50 [ 0.77, 15.85 ] 0.05 [ 0.00, 0.85 ] 0.43 [ 0.26, 0.71 ]

Subtotal (95% CI)
Total events: 23 (Treatment), 48 (Control)

141

141

100.0 %

0.48 [ 0.31, 0.75 ]

Heterogeneity: Chi2 = 9.23, df = 2 (P = 0.01); I2 =78% Test for overall effect: Z = 3.27 (P = 0.0011)

0.1 0.2

0.5

1

2

5

10

Favours psychoeducation

Favours standard care

Analysis 1.2. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 2 Compliance: 1b. With medication - partial compliance.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 2 Compliance: 1b. With medication - partial compliance

Study or subgroup

Psychoeducation n/N

Standard care n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 short term Standard - Group 2004 Standard - Individual 03b Unclear - Both 2005 28/125 22/68 8/43 37/125 36/68 17/43 41.1 % 40.0 % 18.9 % 0.76 [ 0.50, 1.16 ] 0.61 [ 0.41, 0.92 ] 0.47 [ 0.23, 0.97 ]

Subtotal (95% CI)

236

236

100.0 %

0.64 [ 0.49, 0.85 ]

Total events: 58 (Psychoeducation), 90 (Standard care) Heterogeneity: Chi2 = 1.34, df = 2 (P = 0.51); I2 =0.0% Test for overall effect: Z = 3.15 (P = 0.0017) 2 medium term

0.01

0.1

1

10

100

Favours experimental

Favours control

(Continued . . . )

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111

(. . .
Study or subgroup Psychoeducation n/N Brief - Both 2004 15/59 Standard care n/N 22/59 Risk Ratio M-H,Fixed,95% CI 100.0 % Weight

Continued) Risk Ratio

M-H,Fixed,95% CI 0.68 [ 0.39, 1.18 ]

Subtotal (95% CI)
Heterogeneity: not applicable Test for overall effect: Z = 1.37 (P = 0.17)

59

59

100.0 %

0.68 [ 0.39, 1.18 ]

Total events: 15 (Psychoeducation), 22 (Standard care)

0.01

0.1

1

10

100

Favours experimental

Favours control

Analysis 1.3. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 3 Compliance: 1c. With medication - continuous outcomes - skewed data. Compliance: 1c. With medication - continuous outcomes - skewed data

Study

Psychoed. mean Psychoed. SD

Psychoed. N

Standard mean

care Standard care SD Standard care N

single session - average compliance with medication (SAI sub-scale endpoint score, high = favourable) Brief - Individual 2.6 1996 1.2 22 2.1 1.3 20

three sessions - average compliance with medication (SAI sub-scale endpoint score, high = favourable) Brief - Individual 2.18 1996 1.3 22 2.1 1.3 20

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Analysis 1.4. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 4 Compliance: 2a. With follow up - loss to follow-up for any reason.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 4 Compliance: 2a. With follow up - loss to follow-up for any reason

Study or subgroup

Treatment n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 medium term - loss to follow-up for any reason Standard - Individual 03c Standard - Group 1988 Standard - Unclear 2006 Brief - Group 1999 Unclear - Group 1996 Standard - Both 2008 Brief - Group 1995 Standard - Unclear 1996 2/37 2/25 5/58 6/24 23/73 12/79 15/67 44/125 1/36 2/26 4/58 9/22 17/73 17/78 22/57 29/111 1.0 % 1.9 % 3.8 % 8.9 % 16.2 % 16.3 % 22.6 % 29.3 % 1.95 [ 0.18, 20.53 ] 1.04 [ 0.16, 6.83 ] 1.25 [ 0.35, 4.42 ] 0.61 [ 0.26, 1.44 ] 1.35 [ 0.79, 2.31 ] 0.70 [ 0.36, 1.36 ] 0.58 [ 0.33, 1.01 ] 1.35 [ 0.91, 2.00 ]

Subtotal (95% CI)

488

461

100.0 %

1.00 [ 0.79, 1.26 ]

Total events: 109 (Treatment), 101 (Control) Heterogeneity: Chi2 = 9.97, df = 7 (P = 0.19); I2 =30% Test for overall effect: Z = 0.01 (P = 0.99) 2 long term - loss to follow-up for any reason (by 2 years) Unclear - Individual 2008 Brief - Group 1995 Standard - Individual 03b 8/80 19/67 29/68 11/80 23/57 30/68 16.7 % 37.7 % 45.6 % 0.73 [ 0.31, 1.71 ] 0.70 [ 0.43, 1.15 ] 0.97 [ 0.66, 1.42 ]

Subtotal (95% CI)
Total events: 56 (Treatment), 64 (Control)

215

205

100.0 %

0.83 [ 0.62, 1.10 ]

Heterogeneity: Chi2 = 1.14, df = 2 (P = 0.57); I2 =0.0% Test for overall effect: Z = 1.29 (P = 0.20) 3 long term - loss to follow-up for any reason (by 5 years or more) Standard - Unclear 1996 Brief - Group 1995 4/24 19/67 4/24 22/57 14.4 % 85.6 % 1.00 [ 0.28, 3.54 ] 0.73 [ 0.44, 1.21 ]

Subtotal (95% CI)
Total events: 23 (Treatment), 26 (Control)

91

81

100.0 %

0.77 [ 0.48, 1.23 ]

Heterogeneity: Chi2 = 0.20, df = 1 (P = 0.66); I2 =0.0% Test for overall effect: Z = 1.08 (P = 0.28)

0.001 0.01 0.1 Favours treatment

1

10 100 1000 Favours control

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Analysis 1.5. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 5 Compliance: 2b. With follow-up - received intervention but left the study early.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 5 Compliance: 2b. With follow-up - received intervention but left the study early

Study or subgroup

Experimental n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 short term Brief - Individual 1996 Standard - Individual 93 3/47 1/10 0/20 0/10 58.2 % 41.8 % 3.06 [ 0.17, 56.70 ] 3.00 [ 0.14, 65.90 ]

Subtotal (95% CI)
Total events: 4 (Experimental), 0 (Control)

57

30

100.0 %

3.04 [ 0.36, 25.67 ]

Heterogeneity: Chi2 = 0.00, df = 1 (P = 0.99); I2 =0.0% Test for overall effect: Z = 1.02 (P = 0.31) 2 medium term Standard - Both 2004 Standard - Group 1988 Standard - Individual 93 Unclear - Group 1996 0/43 4/41 1/10 7/73 1/43 2/26 0/10 17/73 7.0 % 11.4 % 2.3 % 79.3 % 0.33 [ 0.01, 7.96 ] 1.27 [ 0.25, 6.44 ] 3.00 [ 0.14, 65.90 ] 0.41 [ 0.18, 0.93 ]

Subtotal (95% CI)

167

152

100.0 %

0.56 [ 0.29, 1.10 ]

Total events: 12 (Experimental), 20 (Control) Heterogeneity: Chi2 = 2.75, df = 3 (P = 0.43); I2 =0.0% Test for overall effect: Z = 1.69 (P = 0.091) 3 long term Brief - Group 1995 Standard - Both 1996 15/67 5/41 22/57 6/41 79.8 % 20.2 % 0.58 [ 0.33, 1.01 ] 0.83 [ 0.28, 2.52 ]

Subtotal (95% CI)

108

98

100.0 %

0.63 [ 0.38, 1.04 ]

Total events: 20 (Experimental), 28 (Control) Heterogeneity: Chi2 = 0.33, df = 1 (P = 0.56); I2 =0.0% Test for overall effect: Z = 1.82 (P = 0.068)

0.01

0.1

1

10

100

Favours psychoeducation

Favours standard care

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Analysis 1.6. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 6 Compliance: 2c. With follow-up - allocated but never accepted treatment.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 6 Compliance: 2c. With follow-up - allocated but never accepted treatment

Study or subgroup

Psychoeducation n/N

Standard care n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 medium term Standard - Group 1988 Unclear - Group 1996 6/41 16/73 1/26 0/73 71.0 % 29.0 % 3.80 [ 0.49, 29.83 ] 33.00 [ 2.02, 539.96 ]

Total (95% CI)

114

99

100.0 %

12.27 [ 2.58, 58.33 ]

Total events: 22 (Psychoeducation), 1 (Standard care) Heterogeneity: Chi2 = 1.72, df = 1 (P = 0.19); I2 =42% Test for overall effect: Z = 3.15 (P = 0.0016) Test for subgroup differences: Not applicable

0.001 0.01 0.1 Favours experimental

1

10 100 1000 Favours control

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Analysis 1.7. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 7 Relapse: 1. Relapse for any reason.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 7 Relapse: 1. Relapse for any reason

Study or subgroup

Treatment n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 medium term Brief - Group 1995a Brief - Group 1999 Brief - Group 2007 Standard - Both 2008b Standard - Group 1988 Standard - Individual 03c Standard - Unclear 1996 Standard - Unclear 2005 Standard - Unclear 2006 Unclear - Both 2007 Unclear - Both 2008 11/85 14/24 6/44 11/45 19/41 6/37 86/125 4/69 9/58 6/52 2/48 23/80 15/22 8/37 25/45 13/26 13/36 81/111 8/73 19/58 16/50 1/48 10.2 % 6.7 % 3.7 % 10.8 % 6.9 % 5.7 % 37.0 % 3.4 % 8.2 % 7.0 % 0.4 % 0.45 [ 0.23, 0.86 ] 0.86 [ 0.55, 1.33 ] 0.63 [ 0.24, 1.65 ] 0.44 [ 0.25, 0.78 ] 0.93 [ 0.56, 1.54 ] 0.45 [ 0.19, 1.05 ] 0.94 [ 0.80, 1.11 ] 0.53 [ 0.17, 1.68 ] 0.47 [ 0.23, 0.96 ] 0.36 [ 0.15, 0.85 ] 2.00 [ 0.19, 21.33 ]

Subtotal (95% CI)

628

586

100.0 %

0.70 [ 0.61, 0.81 ]

Total events: 174 (Treatment), 222 (Control) Heterogeneity: Chi2 = 24.27, df = 10 (P = 0.01); I2 =59% Test for overall effect: Z = 4.77 (P < 0.00001) 2 long term Brief - Group 1995 Standard - Both 1996 Standard - Both 2004 Standard - Group 2005 Standard - Individual 03b Standard - Unclear 2005 30/67 7/41 3/43 53/111 38/68 14/69 30/57 14/41 15/43 66/109 52/68 16/73 16.6 % 7.2 % 7.7 % 34.1 % 26.6 % 8.0 % 0.85 [ 0.59, 1.22 ] 0.50 [ 0.23, 1.11 ] 0.20 [ 0.06, 0.64 ] 0.79 [ 0.62, 1.01 ] 0.73 [ 0.57, 0.94 ] 0.93 [ 0.49, 1.75 ]

Subtotal (95% CI)

399

391

100.0 %

0.73 [ 0.62, 0.85 ]

Total events: 145 (Treatment), 193 (Control) Heterogeneity: Chi2 = 7.22, df = 5 (P = 0.20); I2 =31% Test for overall effect: Z = 4.01 (P = 0.000060) 3 long term (at 5 years follow-up) Brief - Group 1995 48/67 46/57
0.2 0.5 1 2 5

100.0 %

0.89 [ 0.73, 1.08 ]

Favours treatment

Favours control

(Continued . . . )

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(. . .
Study or subgroup Treatment n/N Control n/N Risk Ratio M-H,Fixed,95% CI Weight

Continued) Risk Ratio

M-H,Fixed,95% CI

Subtotal (95% CI)
Total events: 48 (Treatment), 46 (Control) Heterogeneity: not applicable Test for overall effect: Z = 1.18 (P = 0.24) 4 long term (at 7 years follow-up) Standard - Unclear 1996

67

57

100.0 %

0.89 [ 0.73, 1.08 ]

13/24

21/24

100.0 %

0.62 [ 0.42, 0.92 ]

Subtotal (95% CI)
Total events: 13 (Treatment), 21 (Control) Heterogeneity: not applicable Test for overall effect: Z = 2.36 (P = 0.018)

24

24

100.0 %

0.62 [ 0.42, 0.92 ]

0.2

0.5

1

2

5

Favours treatment

Favours control

Analysis 1.8. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 8 Relapse: 2. Relapse with readmission.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 8 Relapse: 2. Relapse with readmission

Study or subgroup

Psychoeducation n/N

Standard care n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 medium term Brief - Group 1995 Standard - Both 1996 30/67 9/41 30/57 15/41 68.4 % 31.6 % 0.85 [ 0.59, 1.22 ] 0.60 [ 0.30, 1.21 ]

Subtotal (95% CI)

108

98

100.0 %

0.77 [ 0.56, 1.07 ]

Total events: 39 (Psychoeducation), 45 (Standard care) Heterogeneity: Chi2 = 0.77, df = 1 (P = 0.38); I2 =0.0% Test for overall effect: Z = 1.56 (P = 0.12) 2 long term Brief - Group 1995 Standard - Both 1996 39/67 16/41 40/57 30/41 59.0 % 41.0 % 0.83 [ 0.64, 1.08 ] 0.53 [ 0.35, 0.82 ]

Subtotal (95% CI)

108

98

100.0 %

0.71 [ 0.56, 0.89 ]

Total events: 55 (Psychoeducation), 70 (Standard care) Heterogeneity: Chi2 = 3.08, df = 1 (P = 0.08); I2 =68% Test for overall effect: Z = 2.99 (P = 0.0028)

0.01

0.1

1

10

100

Favours psychoeducation

Favours standard care

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Analysis 1.9. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 9 Knowledge: 1a. Average endpoint scale scores on various knowledge scales.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 9 Knowledge: 1a. Average endpoint scale scores on various knowledge scales

Study or subgroup

Treatment N Mean(SD)

Control N Mean(SD)

Mean Difference IV,Fixed,95% CI

Weight

Mean Difference IV,Fixed,95% CI

1 short term - at end of intervention (KQ, high = favourable) Standard - Unclear 1996 51 -55 (11) 24 -43 (12) 100.0 % -12.00 [ -17.67, -6.33 ]

Subtotal (95% CI)
Heterogeneity: not applicable

51

24

100.0 % -12.00 [ -17.67, -6.33 ]

Test for overall effect: Z = 4.15 (P = 0.000034) 2 short term (KASQ, high = favourable) Standard - Group 2006 38 15.3 (4.7) 33 15.1 (5.2) 100.0 % 0.20 [ -2.12, 2.52 ]

Subtotal (95% CI)
Heterogeneity: not applicable

38

33

100.0 %

0.20 [ -2.12, 2.52 ]

Test for overall effect: Z = 0.17 (P = 0.87) 3 short term (ITAQ, high = favourable) Brief - Group 2009 Standard - Individual 03b Unclear - Both 2005 36 68 43 15.03 (5.33) 19 (4) 18.73 (3.59) 37 68 43 7.54 (6.15) 14 (4) 13.18 (4.05) 13.3 % 51.3 % 35.4 % 7.49 [ 4.85, 10.13 ] 5.00 [ 3.66, 6.34 ] 5.55 [ 3.93, 7.17 ]

Subtotal (95% CI)

147

148

100.0 %

5.53 [ 4.56, 6.49 ]

Heterogeneity: Chi2 = 2.72, df = 2 (P = 0.26); I2 =26% Test for overall effect: Z = 11.25 (P < 0.00001) 4 short term (SKQ, high = favourable) Standard - Individual 93 9 -48.56 (5.66) 10 -32.3 (8.55) 100.0 % -16.26 [ -22.72, -9.80 ]

Subtotal (95% CI)
Heterogeneity: not applicable

9

10

100.0 % -16.26 [ -22.72, -9.80 ]

Test for overall effect: Z = 4.93 (P < 0.00001) 5 medium term (ITAQ, high = favourable) Brief - Group 2009 36 14.64 (6.76) 37 9.81 (7.71) 100.0 % 4.83 [ 1.51, 8.15 ]

Subtotal (95% CI)
Heterogeneity: not applicable

36

37

100.0 %

4.83 [ 1.51, 8.15 ]

-20

-10

0

10

20

Favours standard care

Favours psychoeducation

(Continued . . . )

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(. . .
Study or subgroup Treatment N Test for overall effect: Z = 2.85 (P = 0.0044) 6 medium term (KASQ, high = favourable) Standard - Group 2006 36 16.2 (4.1) 25 14.6 (5.2) 100.0 % Mean(SD) Control N Mean(SD) Mean Difference IV,Fixed,95% CI Weight

Continued)

Mean Difference IV,Fixed,95% CI

1.60 [ -0.84, 4.04 ]

Subtotal (95% CI)
Heterogeneity: not applicable

36

25

100.0 %

1.60 [ -0.84, 4.04 ]

Test for overall effect: Z = 1.29 (P = 0.20) 7 long term (KQ, high = favourable) Standard - Unclear 1996 51 -54 (13) 24 -46 (14) 100.0 % -8.00 [ -14.64, -1.36 ]

Subtotal (95% CI)
Heterogeneity: not applicable

51

24

100.0 %

-8.00 [ -14.64, -1.36 ]

Test for overall effect: Z = 2.36 (P = 0.018) Test for subgroup differences: Chi2 = 103.82, df = 6 (P = 0.00), I2 =94%

-20

-10

0

10

20

Favours standard care

Favours psychoeducation

Analysis 1.10. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 10 Knowledge: 1b. Average change (UMQ, high = favourable, data skewed). Knowledge: 1b. Average change (UMQ, high = favourable, data skewed)

Study

Psychoed. mean Psychoed. SD

Psychoed. N

Standard mean

care Standard care SD Standard care N

single session psychoeducation Brief - Individual 6.4 1996 three session psychoeducation Brief - Individual 15.00 1996 7.4 22 1.0 2.8 20 5.9 22 1.0 2.8 20

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Analysis 1.11. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 11 Knowledge: 2. Average endpoint scores on various insight scales.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 11 Knowledge: 2. Average endpoint scores on various insight scales

Study or subgroup

Treatment N Mean(SD)

Control N Mean(SD)

Mean Difference IV,Fixed,95% CI

Weight

Mean Difference IV,Fixed,95% CI

1 short term (SAUMD, high = poor) Brief - Group 2007 Unclear - Both 2001 44 40 6.77 (2.56) 22.5 (9.6) 37 40 7.95 (3.2) 14.8 (12.8) 76.9 % 5.1 % -1.18 [ -2.46, 0.10 ] 7.70 [ 2.74, 12.66 ]

Subtotal (95% CI)

84

77

82.1 %

-0.63 [ -1.86, 0.61 ]

Heterogeneity: Chi2 = 11.55, df = 1 (P = 0.00068); I2 =91% Test for overall effect: Z = 0.99 (P = 0.32) 2 medium term (RAQ, high = poor) Standard - Group 2006 33 28.6 (4.1) 23 26.8 (5.5) 17.9 % 1.80 [ -0.85, 4.45 ]

Subtotal (95% CI)
Heterogeneity: not applicable

33

23

17.9 %

1.80 [ -0.85, 4.45 ]

Test for overall effect: Z = 1.33 (P = 0.18)

Total (95% CI)

117

100

100.0 %

-0.19 [ -1.31, 0.93 ]

Heterogeneity: Chi2 = 14.20, df = 2 (P = 0.00083); I2 =86% Test for overall effect: Z = 0.33 (P = 0.74) Test for subgroup differences: Chi2 = 2.65, df = 1 (P = 0.10), I2 =62%

-20

-10

0

10

20

Favours experimental

Favours control

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Analysis 1.12. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 12 Knowledge: 3. Average endpoint score on illness-related attitudes - 4 months (KK, high = high expressed).
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 12 Knowledge: 3. Average endpoint score on illness-related attitudes - 4 months (KK, high = high expressed)

Study or subgroup

Treatment N Mean(SD)

Control N Mean(SD)

Mean Difference IV,Fixed,95% CI

Weight

Mean Difference IV,Fixed,95% CI

1 confidence in medication Standard - Unclear 1996 50 -15.3 (3.3) 25 -13.8 (3.7) 100.0 % -1.50 [ -3.21, 0.21 ]

Subtotal (95% CI)
Heterogeneity: not applicable

50

25

100.0 %

-1.50 [ -3.21, 0.21 ]

Test for overall effect: Z = 1.71 (P = 0.086) 2 confidence in physician Standard - Unclear 1996 50 -12.2 (2.5) 25 -10.8 (2.9) 100.0 % -1.40 [ -2.73, -0.07 ]

Subtotal (95% CI)
Heterogeneity: not applicable

50

25

100.0 %

-1.40 [ -2.73, -0.07 ]

Test for overall effect: Z = 2.06 (P = 0.039) 3 negative expectations toward medication as such Standard - Unclear 1996 50 6.5 (3.2) 25 7 (3.3) 100.0 % -0.50 [ -2.07, 1.07 ]

Subtotal (95% CI)
Heterogeneity: not applicable

50

25

100.0 %

-0.50 [ -2.07, 1.07 ]

Test for overall effect: Z = 0.62 (P = 0.53) 4 susceptibility to illness and to relapse Standard - Unclear 1996 50 7.3 (2.6) 25 6.7 (3) 100.0 % 0.60 [ -0.78, 1.98 ]

Subtotal (95% CI)
Heterogeneity: not applicable

50

25

100.0 %

0.60 [ -0.78, 1.98 ]

Test for overall effect: Z = 0.85 (P = 0.39) 5 attribution of illness to chance Standard - Unclear 1996 50 8.4 (3.9) 25 9.1 (3) 100.0 % -0.70 [ -2.30, 0.90 ]

Subtotal (95% CI)
Heterogeneity: not applicable

50

25

100.0 %

-0.70 [ -2.30, 0.90 ]

Test for overall effect: Z = 0.86 (P = 0.39) 6 attribution of guilt Standard - Unclear 1996 50 3.6 (2.3) 25 4.4 (2.8) 100.0 % -0.80 [ -2.07, 0.47 ]

Subtotal (95% CI)
Heterogeneity: not applicable

50

25

100.0 %

-0.80 [ -2.07, 0.47 ]

Test for overall effect: Z = 1.24 (P = 0.22) 7 fear of side effects of medication Standard - Unclear 1996 50 7.3 (2.7) 25 8.9 (2.2)
-4 -2 0 2 4

100.0 %

-1.60 [ -2.74, -0.46 ]

Favours treatment

Favours control

(Continued . . . )

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(. . .
Study or subgroup Treatment N Mean(SD) Control N Mean(SD) Mean Difference IV,Fixed,95% CI Weight

Continued)

Mean Difference IV,Fixed,95% CI

Subtotal (95% CI)
Heterogeneity: not applicable

50

25

100.0 %

-1.60 [ -2.74, -0.46 ]

Test for overall effect: Z = 2.75 (P = 0.0060) Test for subgroup differences: Chi2 = 7.33, df = 6 (P = 0.29), I2 =18%

-4

-2

0

2

4

Favours treatment

Favours control

Analysis 1.13. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 13 Knowledge: 4. level of knowledge did not improve.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 13 Knowledge: 4. level of knowledge did not improve

Study or subgroup

Psychoeducation n/N

Standard care n/N 32/48 18/60

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

Unclear - Both 2008 Unclear - Unclear 2008

0/48 6/60

64.4 % 35.6 %

0.02 [ 0.00, 0.24 ] 0.33 [ 0.14, 0.78 ]

Total (95% CI)

108

108

100.0 %

0.13 [ 0.06, 0.28 ]

Total events: 6 (Psychoeducation), 50 (Standard care) Heterogeneity: Chi2 = 7.06, df = 1 (P = 0.01); I2 =86% Test for overall effect: Z = 5.11 (P < 0.00001) Test for subgroup differences: Not applicable

0.01

0.1

1

10

100

Favours psychoeducation

Favours standard care

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Analysis 1.14. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 14 Behaviour: Average score (NOSIE-30, endpoint, high = poor).
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 14 Behaviour: Average score (NOSIE-30, endpoint, high = poor)

Study or subgroup

Experimental N Mean(SD)

Control N Mean(SD)

Mean Difference IV,Fixed,95% CI

Weight

Mean Difference IV,Fixed,95% CI

1 short term Brief - Group 2007b Unclear - Group 2008 51 145.6 (14.7) 51 129 (12.8) 85.5 % 14.5 % 16.60 [ 11.25, 21.95 ] 18.32 [ 5.34, 31.30 ]

50 150.36 (33.96)

50 132.04 (32.24)

Subtotal (95% CI)

101

101

100.0 % 16.85 [ 11.90, 21.80 ]

Heterogeneity: Chi2 = 0.06, df = 1 (P = 0.81); I2 =0.0% Test for overall effect: Z = 6.68 (P < 0.00001) 2 medium term Standard - Individual 03c 37 188.34 (24.38) 36 174.34 (23.43) 100.0 % 14.00 [ 3.03, 24.97 ]

Subtotal (95% CI)
Heterogeneity: not applicable

37

36

100.0 %

14.00 [ 3.03, 24.97 ]

Test for overall effect: Z = 2.50 (P = 0.012) 3 long term Standard - Individual 03c 35 182.62 (23.62) 35 141.29 (20.25) 100.0 % 41.33 [ 31.02, 51.64 ]

Subtotal (95% CI)
Heterogeneity: not applicable

35

35

100.0 % 41.33 [ 31.02, 51.64 ]

Test for overall effect: Z = 7.86 (P < 0.00001) Test for subgroup differences: Chi2 = 19.13, df = 2 (P = 0.00), I2 =90%

-100

-50

0

50

100

Favours experimental

Favours control

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Analysis 1.15. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 15 Social functioning: 1a. Average change scores on various scales - medium term (high = poor).
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 15 Social functioning: 1a. Average change scores on various scales - medium term (high = poor)

Study or subgroup

Treatment N Mean(SD)

Control N Mean(SD)

Mean Difference IV,Fixed,95% CI

Weight

Mean Difference IV,Fixed,95% CI

1 MRSS Brief - Both 2004 59 15.07 (3.67) 59 1.39 (2.73) 100.0 % 13.68 [ 12.51, 14.85 ]

Subtotal (95% CI)
Heterogeneity: not applicable

59

59

100.0 %

13.68 [ 12.51, 14.85 ]

Test for overall effect: Z = 22.97 (P < 0.00001) 2 SDSS Brief - Both 2004 59 2.25 (0.45) 59 0.29 (0.22) 100.0 % 1.96 [ 1.83, 2.09 ]

Subtotal (95% CI)
Heterogeneity: not applicable

59

59

100.0 %

1.96 [ 1.83, 2.09 ]

Test for overall effect: Z = 30.06 (P < 0.00001) Test for subgroup differences: Chi2 = 382.76, df = 1 (P = 0.00), I2 =100%

-20

-10

0

10

20

Favours psychoeducation

Favours standard care

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Analysis 1.16. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 16 Social functioning: 1b. Average endpoint scores on various scales (high = poor).
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 16 Social functioning: 1b. Average endpoint scores on various scales (high = poor)

Study or subgroup

Experimental N Mean(SD)

Control N Mean(SD)

Mean Difference IV,Fixed,95% CI

Weight

Mean Difference IV,Fixed,95% CI

1 short term - IPROS Standard - Individual 03a 58 41.92 (12.58) 58 48.56 (11.47) 100.0 % -6.64 [ -11.02, -2.26 ]

Subtotal (95% CI)
Heterogeneity: not applicable

58

58

100.0 % -6.64 [ -11.02, -2.26 ]

Test for overall effect: Z = 2.97 (P = 0.0030) 2 short term - SAS Brief - Both 2004a Standard - Individual 03a Standard - Unclear 2006 74 58 58 40.64 (9.87) 46.08 (9.25) 31.9 (9.25) 72 58 58 46.75 (9.42) 41.96 (10.07) 57.69 (10.95) 39.8 % 31.5 % 28.7 % -6.11 [ -9.24, -2.98 ] 4.12 [ 0.60, 7.64 ] -25.79 [ -29.48, -22.10 ]

Subtotal (95% CI)

190

188

100.0 % -8.53 [ -10.50, -6.55 ]

Heterogeneity: Chi2 = 136.03, df = 2 (P<0.00001); I2 =99% Test for overall effect: Z = 8.46 (P < 0.00001) 3 short term - SAS-II Standard - Individual 93 9 2.88 (0.29) 10 2.98 (0.31) 100.0 % -0.10 [ -0.37, 0.17 ]

Subtotal (95% CI)
Heterogeneity: not applicable

9

10

100.0 %

-0.10 [ -0.37, 0.17 ]

Test for overall effect: Z = 0.73 (P = 0.47) 4 short term - SDS Brief - Both 2004a Standard - Individual 03a Standard - Unclear 2006 74 58 58 40.35 (9.47) 47.87 (9.56) 35.6 (8.65) 72 58 58 47.97 (10.75) 51.89 (9.15) 40.59 (10.23) 35.2 % 32.8 % 32.0 % -7.62 [ -10.91, -4.33 ] -4.02 [ -7.43, -0.61 ] -4.99 [ -8.44, -1.54 ]

Subtotal (95% CI)

190

188

100.0 %

-5.60 [ -7.55, -3.65 ]

Heterogeneity: Chi2 = 2.40, df = 2 (P = 0.30); I2 =17% Test for overall effect: Z = 5.62 (P < 0.00001) 5 medium term - SDSS Standard - Both 2008b 44 5.27 (0.35) 41 9.01 (7.54) 100.0 % -3.74 [ -6.05, -1.43 ]

Subtotal (95% CI)
Heterogeneity: not applicable

44

41

100.0 %

-3.74 [ -6.05, -1.43 ]

Test for overall effect: Z = 3.17 (P = 0.0015) Test for subgroup differences: Chi2 = 112.88, df = 4 (P = 0.00), I2 =96%

-50

-25

0

25

50

Favours psychoeducation

Favours standard care

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Analysis 1.17. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 17 Social functioning 1c. Average SAS, SFS, SNS scale scores - skewed data (low = favourable). Social functioning 1c. Average SAS, SFS, SNS scale scores - skewed data (low = favourable)

Study

Scale

Experimental N

Exp. mean + SD 2.40 + 1.30

Control N 62

Control mean + SD 2.60 + 1.30

Unclear - Group Social Adjustment 52 1996 Scale II at end of study Unclear - Group Social Functioning 50 1996 Schedule score at 3 months Unclear - Group To52 1996 tal number of contacts (SNS, modified): post treatment Unclear - Group Total 50 1996 number of contacts (SNS, modified): at 3 months follow-up

2.00 + 1.10

58

2.50 + 1.20

16.80 + 8.60

60

13.10 + 10.30

17.50 + 10.70

56

13.50 + 10.80

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Analysis 1.18. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 18 Global functioning: 1. No clinically significant improvement.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 18 Global functioning: 1. No clinically significant improvement

Study or subgroup

Treatment n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 short term Standard - Unclear 1988 Standard - Unclear 2006 7/37 5/58 20/55 6/58 72.8 % 27.2 % 0.52 [ 0.24, 1.10 ] 0.83 [ 0.27, 2.58 ]

Subtotal (95% CI)
Total events: 12 (Treatment), 26 (Control)

95

113

100.0 %

0.61 [ 0.32, 1.13 ]

Heterogeneity: Chi2 = 0.46, df = 1 (P = 0.50); I2 =0.0% Test for overall effect: Z = 1.58 (P = 0.11) 2 medium term Standard - Both 2004 Standard - Unclear 1988 16/43 14/37 35/43 25/55 63.5 % 36.5 % 0.46 [ 0.30, 0.69 ] 0.83 [ 0.50, 1.38 ]

Subtotal (95% CI)
Total events: 30 (Treatment), 60 (Control)

80

98

100.0 %

0.59 [ 0.43, 0.82 ]

Heterogeneity: Chi2 = 3.26, df = 1 (P = 0.07); I2 =69% Test for overall effect: Z = 3.22 (P = 0.0013) 3 long term Standard - Unclear 1988 Standard - Unclear 2005a 17/37 4/20 28/55 12/20 65.2 % 34.8 % 0.90 [ 0.58, 1.39 ] 0.33 [ 0.13, 0.86 ]

Subtotal (95% CI)
Total events: 21 (Treatment), 40 (Control)

57

75

100.0 %

0.70 [ 0.48, 1.04 ]

Heterogeneity: Chi2 = 3.64, df = 1 (P = 0.06); I2 =73% Test for overall effect: Z = 1.75 (P = 0.081)

0.1 0.2

0.5

1

2

5

10

Favours treatment

Favours control

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Analysis 1.19. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 19 Global functioning: 2. Average endpoint scale score.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 19 Global functioning: 2. Average endpoint scale score

Study or subgroup

Treatment N Mean(SD)

Control N Mean(SD)

Mean Difference IV,Fixed,95% CI

Weight

Mean Difference IV,Fixed,95% CI

1 short term - (GAF/GAS, high = good) Brief - Group 1999 22 -53.27 (17.83) 19 -50.63 (15.18) 100.0 % -2.64 [ -12.74, 7.46 ]

Subtotal (95% CI)
Heterogeneity: not applicable

22

19

100.0 %

-2.64 [ -12.74, 7.46 ]

Test for overall effect: Z = 0.51 (P = 0.61) 2 short term - (SLOF, high = good) Standard - Group 2007 42 148.7 (25.8) 42 125.1 (28.9) 100.0 % 23.60 [ 11.88, 35.32 ]

Subtotal (95% CI)
Heterogeneity: not applicable

42

42

100.0 % 23.60 [ 11.88, 35.32 ]

Test for overall effect: Z = 3.95 (P = 0.000079) 3 medium term - (GAF/GAS, high = good) Brief - Group 1995 Brief - Group 1999 Standard - Group 2006 Standard - Unclear 1996 26 22 36 79 -56.1 (13) -62.91 (16.34) 47.6 (13.2) -78 (14.5) 35 18 25 80 -57.8 (8.3) -55.39 (16.35) 53.7 (11.5) -68 (17.5) 28.9 % 9.1 % 24.2 % 37.8 % 1.70 [ -4.00, 7.40 ] -7.52 [ -17.70, 2.66 ] -6.10 [ -12.34, 0.14 ] -10.00 [ -14.99, -5.01 ]

Subtotal (95% CI)

163

158

100.0 %

-5.44 [ -8.51, -2.38 ]

Heterogeneity: Chi2 = 9.43, df = 3 (P = 0.02); I2 =68% Test for overall effect: Z = 3.48 (P = 0.00051) 4 medium term - (SLOF, high = good) Standard - Group 2007 42 165.5 (28.1) 42 119.1 (27.8) 100.0 % 46.40 [ 34.45, 58.35 ]

Subtotal (95% CI)
Heterogeneity: not applicable

42

42

100.0 % 46.40 [ 34.45, 58.35 ]

Test for overall effect: Z = 7.61 (P < 0.00001) 5 long term (GAS, high = good) - at 2 years Brief - Group 1995 25 -65.2 (13.7) 34 -58.5 (11.8) 100.0 % -6.70 [ -13.38, -0.02 ]

Subtotal (95% CI)
Heterogeneity: not applicable

25

34

100.0 % -6.70 [ -13.38, -0.02 ]

Test for overall effect: Z = 1.97 (P = 0.049) 6 long term - (GAS, high = good) - at 5 years or more Brief - Group 1995 Standard - Unclear 1996 25 24 -59.8 (9.1) 61.7 (19.3) 35 24 -56 (6.9) 62.8 (14.4)
-50 -25 0 25 50

83.8 % 16.2 %

-3.80 [ -8.04, 0.44 ] -1.10 [ -10.73, 8.53 ]

Favours standard care

Favours psychoeducation

(Continued . . . )

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(. . .
Study or subgroup Treatment N Mean(SD) Control N Mean(SD) Mean Difference IV,Fixed,95% CI Weight

Continued)

Mean Difference IV,Fixed,95% CI

Subtotal (95% CI)

49

59

100.0 %

-3.36 [ -7.24, 0.52 ]

Heterogeneity: Chi2 = 0.25, df = 1 (P = 0.62); I2 =0.0% Test for overall effect: Z = 1.70 (P = 0.089) Test for subgroup differences: Chi2 = 88.51, df = 5 (P = 0.00), I2 =94%

-50

-25

0

25

50

Favours standard care

Favours psychoeducation

Analysis 1.20. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 20 Service utilisation: days in hospital.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 20 Service utilisation: days in hospital

Study or subgroup

Psychoeducation N Mean(SD)

Standard care N Mean(SD)

Mean Difference IV,Fixed,95% CI

Weight

Mean Difference IV,Fixed,95% CI

1 short term - days in hospital Standard - Group 2007 Standard - Unclear 2006 42 14.1 (5.1) 42 19.1 (6.1) 85.0 % 15.0 % -5.00 [ -7.40, -2.60 ] 6.80 [ 1.08, 12.52 ]

58 75.38 (15.21)

58 68.58 (16.21)

Subtotal (95% CI)

100

100

100.0 % -3.23 [ -5.44, -1.01 ]

Heterogeneity: Chi2 = 13.89, df = 1 (P = 0.00019); I2 =93% Test for overall effect: Z = 2.85 (P = 0.0043) 2 medium term - days in hospital Standard - Group 2007 42 12.4 (4.3) 42 20.8 (5.2) 100.0 % -8.40 [ -10.44, -6.36 ]

Subtotal (95% CI)
Heterogeneity: not applicable

42

42

100.0 % -8.40 [ -10.44, -6.36 ]

Test for overall effect: Z = 8.07 (P < 0.00001) Test for subgroup differences: Chi2 = 11.32, df = 1 (P = 0.00), I2 =91%

-100

-50

0

50

100

Favours psychoeducation

Favours standard care

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Analysis 1.21. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 21 Service utilisation: Days in hospital using ’acute services’ - during 18 months (data skewed). Service utilisation: Days in hospital using ’acute services’ - during 18 months (data skewed)

Study

Psychoed. mean Psychoed. SD

Psychoed. N

Standard mean 27.9

care Standard care SD Standard care N

Standard - Both 37.2 1996

33.3

41

12.6

41

Analysis 1.22. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 22 Global state: 1. Average endpoint score - medium term (CGI, high = poor).
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 22 Global state: 1. Average endpoint score - medium term (CGI, high = poor)

Study or subgroup

Favours control N Mean(SD)

Control N Mean(SD)

Mean Difference IV,Fixed,95% CI

Weight

Mean Difference IV,Fixed,95% CI

1 severity Standard - Group 2006 36 4.4 (0.7) 25 3.9 (0.9) 100.0 % 0.50 [ 0.08, 0.92 ]

Subtotal (95% CI)
Heterogeneity: not applicable

36

25

100.0 %

0.50 [ 0.08, 0.92 ]

Test for overall effect: Z = 2.33 (P = 0.020) 2 change Standard - Group 2006 36 2.7 (1.6) 25 3.5 (1) 100.0 % -0.80 [ -1.45, -0.15 ]

Subtotal (95% CI)
Heterogeneity: not applicable

36

25

100.0 % -0.80 [ -1.45, -0.15 ]

Test for overall effect: Z = 2.40 (P = 0.016) Test for subgroup differences: Chi2 = 10.76, df = 1 (P = 0.00), I2 =91%

-4

-2

0

2

4

Favours psychoeducation

Favours standard care

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Analysis 1.23. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 23 Global state: 2. Increased medication dose by 25%.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 23 Global state: 2. Increased medication dose by 25%

Study or subgroup

Treatment n/N

Control n/N 7/10

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

Standard - Individual 93

3/10

100.0 %

0.43 [ 0.15, 1.20 ]

Total (95% CI)
Total events: 3 (Treatment), 7 (Control) Heterogeneity: not applicable Test for overall effect: Z = 1.61 (P = 0.11)

10

10

100.0 %

0.43 [ 0.15, 1.20 ]

Test for subgroup differences: Not applicable

0.01

0.1

1

10

100

Favours psychoeducation

Favours standard care

Analysis 1.24. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 24 Global state: 3. Disability - long term.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 24 Global state: 3. Disability - long term

Study or subgroup

Treatment n/N

Control n/N 21/43

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

Standard - Both 2004

6/43

100.0 %

0.29 [ 0.13, 0.64 ]

Total (95% CI)
Total events: 6 (Treatment), 21 (Control) Heterogeneity: not applicable

43

43

100.0 %

0.29 [ 0.13, 0.64 ]

Test for overall effect: Z = 3.06 (P = 0.0022) Test for subgroup differences: Not applicable

0.01

0.1

1

10

100

Favours psychoeducation

Favours standard care

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Analysis 1.25. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 25 Mental state: 1a. Global - continuous - average total endpoint scale scores (high = poor).
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 25 Mental state: 1a. Global - continuous - average total endpoint scale scores (high = poor)

Study or subgroup

Treatment N Mean(SD)

Control N Mean(SD)

Mean Difference IV,Fixed,95% CI

Weight

Mean Difference IV,Fixed,95% CI

1 short term (BPRS) Brief - Group 2006 Standard - Both 2008a Standard - Both 2008b Standard - Group 2004 Standard - Group 2007 Standard - Individual 03a Standard - Individual 03b Standard - Individual 03c Standard - Individual 93 Unclear - Both 2005 Unclear - Individual 2008 30 30 44 125 42 58 68 35 9 43 72 20.63 (4.3) 20.4 (3.8) 30.01 (7.95) 21.87 (4.45) 10 (4) 21.59 (4.19) 22 (7) 24.6 (7.1) 1.03 (0.55) 26.87 (8.43) 24.3 (4.1) 30 30 41 125 42 58 68 35 10 43 69 23.33 (4.15) 23.8 (7.9) 28.53 (7.61) 23.94 (5.12) 10.5 (4.1) 24.03 (5.14) 29 (7) 24.3 (7.2) 1.09 (0.49) 28.1 (7.19) 29.6 (5.2) 3.1 % 1.4 % 1.3 % 10.0 % 4.7 % 4.8 % 2.5 % 1.3 % 63.7 % 1.3 % 5.9 % -2.70 [ -4.84, -0.56 ] -3.40 [ -6.54, -0.26 ] 1.48 [ -1.83, 4.79 ] -2.07 [ -3.26, -0.88 ] -0.50 [ -2.23, 1.23 ] -2.44 [ -4.15, -0.73 ] -7.00 [ -9.35, -4.65 ] 0.30 [ -3.05, 3.65 ] -0.06 [ -0.53, 0.41 ] -1.23 [ -4.54, 2.08 ] -5.30 [ -6.85, -3.75 ]

Subtotal (95% CI)

556

551

100.0 %

-1.00 [ -1.38, -0.63 ]

Heterogeneity: Chi2 = 83.48, df = 10 (P<0.00001); I2 =88% Test for overall effect: Z = 5.22 (P < 0.00001) 2 medium term (BPRS) Brief - Group 2003 Standard - Both 2004 Standard - Both 2008 Standard - Both 2008b Standard - Group 2007 Standard - Individual 03c Standard - Unclear 1996 68 43 79 44 42 35 79 20.61 (4.65) 19.12 (5.28) 23.2 (4.4) 28.12 (7.46) 9.7 (4.8) 32.3 (8.3) 26 (7.7) 52 42 78 41 42 35 80 25.97 (3.22) 30.86 (10.57) 27.2 (5.1) 33.85 (9.72) 10.9 (4.9) 38.5 (10.2) 32 (12.1) 33.8 % 5.3 % 30.2 % 4.9 % 15.6 % 3.5 % 6.8 % -5.36 [ -6.77, -3.95 ] -11.74 [ -15.31, -8.17 ] -4.00 [ -5.49, -2.51 ] -5.73 [ -9.43, -2.03 ] -1.20 [ -3.27, 0.87 ] -6.20 [ -10.56, -1.84 ] -6.00 [ -9.15, -2.85 ]

Subtotal (95% CI)

390

370

100.0 %

-4.73 [ -5.55, -3.91 ]

Heterogeneity: Chi2 = 29.01, df = 6 (P = 0.00006); I2 =79% Test for overall effect: Z = 11.32 (P < 0.00001) 3 medium term (PANSS) Standard - Group 2006 36 30.9 (7.5) 25 30.8 (8.1)
-10 -5 0 5 10

38.4 %

0.10 [ -3.91, 4.11 ]

Favours psychoeducation

Favours standard care

(Continued . . . )

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(. . .
Study or subgroup Treatment N Unclear - Both 2007 52 Mean(SD) 40.9 (8.83) Control N 50 Mean(SD) 45.06 (7.45) Mean Difference IV,Fixed,95% CI 61.6 % Weight

Continued)

Mean Difference IV,Fixed,95% CI -4.16 [ -7.33, -0.99 ]

Subtotal (95% CI)

88

75

100.0 %

-2.52 [ -5.01, -0.04 ]

Heterogeneity: Chi2 = 2.67, df = 1 (P = 0.10); I2 =63% Test for overall effect: Z = 1.99 (P = 0.046) 4 long term (BPRS - 1 ˜ 2 year follow-up) Standard - Individual 03c Standard - Unclear 1996 Unclear - Individual 2008 35 79 72 32.3 (8.3) 26 (7.7) 27.2 (5.1) 35 80 69 38.5 (10.2) 32 (12.1) 34.7 (7.8) 14.5 % 27.8 % 57.7 % -6.20 [ -10.56, -1.84 ] -6.00 [ -9.15, -2.85 ] -7.50 [ -9.69, -5.31 ]

Subtotal (95% CI)

186

184

100.0 %

-6.89 [ -8.55, -5.23 ]

Heterogeneity: Chi2 = 0.70, df = 2 (P = 0.70); I2 =0.0% Test for overall effect: Z = 8.14 (P < 0.00001) 5 long term (BPRS - 7 year follow-up) Standard - Unclear 1996 24 32.7 (12) 24 32.9 (10.4) 100.0 % -0.20 [ -6.55, 6.15 ]

Subtotal (95% CI)
Heterogeneity: not applicable

24

24

100.0 %

-0.20 [ -6.55, 6.15 ]

Test for overall effect: Z = 0.06 (P = 0.95) Test for subgroup differences: Chi2 = 103.11, df = 4 (P = 0.00), I2 =96%

-10

-5

0

5

10

Favours psychoeducation

Favours standard care

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Analysis 1.26. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 26 Mental state: 1b. Global - continuous - average change scale scores - medium term (high = good).
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 26 Mental state: 1b. Global - continuous - average change scale scores - medium term (high = good)

Study or subgroup

Treatment N Mean(SD)

Control N Mean(SD)

Mean Difference IV,Fixed,95% CI

Weight

Mean Difference IV,Fixed,95% CI

1 GWB Brief - Both 2004 59 13.13 (1.78) 59 2.24 (3.81) 100.0 % 10.89 [ 9.82, 11.96 ]

Subtotal (95% CI)
Heterogeneity: not applicable

59

59

100.0 %

10.89 [ 9.82, 11.96 ]

Test for overall effect: Z = 19.89 (P < 0.00001) 2 SES Brief - Both 2004 59 9.11 (0.77) 59 1.11 (0.48) 100.0 % 8.00 [ 7.77, 8.23 ]

Subtotal (95% CI)
Heterogeneity: not applicable

59

59

100.0 %

8.00 [ 7.77, 8.23 ]

Test for overall effect: Z = 67.72 (P < 0.00001) Test for subgroup differences: Chi2 = 26.63, df = 1 (P = 0.00), I2 =96%

-20

-10

0

10

20

Favours standard care

Favours psychoeducation

Analysis 1.27. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 27 Mental state: 1c. Global - continuous - average total endpoint scale scores - (BPRS, high = poor, data skewed). Mental state: 1c. Global - continuous - average total endpoint scale scores - (BPRS, high = poor, data skewed)

Study

Length of follow- Psychoed. N up at end of study (8 22 weeks) at 1 year 22

Exp. mean + SD

Control N

Control mean + SD

Brief - Group 1999

11.41±7.91

19

13.50±9.54

Brief - Group 1999 Brief - Group 2009

8.86±6.19 5.69±7.91

18 37

10.50±7.37 8.81±9.58

at end of study (3 36 months) at 1 year 36

Brief - Group 2009

4.5±5.11

37

8.81±9.12

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Analysis 1.28. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 28 Mental state: 2a. Specific - binary - specific symptoms - short term.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 28 Mental state: 2a. Specific - binary - specific symptoms - short term

Study or subgroup

Experimental n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 anxiety Brief - Both 2004a 11/74 22/72 100.0 % 0.49 [ 0.25, 0.93 ]

Subtotal (95% CI)
Total events: 11 (Experimental), 22 (Control) Heterogeneity: not applicable Test for overall effect: Z = 2.18 (P = 0.029) 2 depression Brief - Both 2004a

74

72

100.0 %

0.49 [ 0.25, 0.93 ]

11/74

23/72

100.0 %

0.47 [ 0.25, 0.88 ]

Subtotal (95% CI)
Total events: 11 (Experimental), 23 (Control) Heterogeneity: not applicable Test for overall effect: Z = 2.34 (P = 0.019)

74

72

100.0 %

0.47 [ 0.25, 0.88 ]

0.01

0.1

1

10

100

Favours psychoeducation

Favours standard care

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Analysis 1.29. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 29 Mental state: 2b. Specific - continuous - average endpoint PANSS scores (high = poor).
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 29 Mental state: 2b. Specific - continuous - average endpoint PANSS scores (high = poor)

Study or subgroup

Treatment N Mean(SD)

Control N Mean(SD)

Mean Difference IV,Fixed,95% CI

Weight

Mean Difference IV,Fixed,95% CI

1 short term - negative symptoms Standard - Group 2006 38 15.7 (5.1) 33 15.3 (5.1) 100.0 % 0.40 [ -1.98, 2.78 ]

Subtotal (95% CI)
Heterogeneity: not applicable

38

33

100.0 %

0.40 [ -1.98, 2.78 ]

Test for overall effect: Z = 0.33 (P = 0.74) 2 short term - positive symptoms Standard - Group 2006 38 16.5 (5) 33 15 (5.6) 100.0 % 1.50 [ -0.99, 3.99 ]

Subtotal (95% CI)
Heterogeneity: not applicable

38

33

100.0 %

1.50 [ -0.99, 3.99 ]

Test for overall effect: Z = 1.18 (P = 0.24) 3 medium term - negative symptoms Standard - Group 2006 36 18 (6.9) 25 14.9 (4.8) 100.0 % 3.10 [ 0.16, 6.04 ]

Subtotal (95% CI)
Heterogeneity: not applicable

36

25

100.0 %

3.10 [ 0.16, 6.04 ]

Test for overall effect: Z = 2.07 (P = 0.039) 4 medium term - positive symptoms Standard - Group 2006 36 16.6 (6) 25 14.2 (5.3) 100.0 % 2.40 [ -0.46, 5.26 ]

Subtotal (95% CI)
Heterogeneity: not applicable

36

25

100.0 %

2.40 [ -0.46, 5.26 ]

Test for overall effect: Z = 1.65 (P = 0.10) Test for subgroup differences: Chi2 = 2.28, df = 3 (P = 0.52), I2 =0.0%

-10

-5

0

5

10

Favours experimental

Favours control

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Analysis 1.30. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 30 Expressed emotion: Participants with high EE relatives (FQ).
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 30 Expressed emotion: Participants with high EE relatives (FQ)

Study or subgroup

Treatment n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 short term - at end of interventions Brief - Group 1999 Standard - Unclear 1996 10/24 100/125 14/22 102/111 11.9 % 88.1 % 0.65 [ 0.37, 1.16 ] 0.87 [ 0.78, 0.97 ]

Subtotal (95% CI)

149

133

100.0 %

0.84 [ 0.76, 0.94 ]

Total events: 110 (Treatment), 116 (Control) Heterogeneity: Chi2 = 1.09, df = 1 (P = 0.30); I2 =8% Test for overall effect: Z = 3.00 (P = 0.0027) 2 medium term - at 9-12 months Brief - Group 1999 14/24 12/22 100.0 % 1.07 [ 0.64, 1.78 ]

Subtotal (95% CI)
Total events: 14 (Treatment), 12 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.26 (P = 0.80)

24

22

100.0 %

1.07 [ 0.64, 1.78 ]

0.1 0.2

0.5

1

2

5

10

Favours psychoeducation

Favours standard care

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Analysis 1.31. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 31 Quality of life: Average endpoint scores on various scales (high = favourable).
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 31 Quality of life: Average endpoint scores on various scales (high = favourable)

Study or subgroup

Treatment N Mean(SD)

Control N Mean(SD)

Mean Difference IV,Fixed,95% CI

Weight

Mean Difference IV,Fixed,95% CI

1 short term - GQOLI-74 Brief - Group 2007a 30 17.35 (2.56) 32 16.72 (3.13) 100.0 % 0.63 [ -0.79, 2.05 ]

Subtotal (95% CI)
Heterogeneity: not applicable

30

32

100.0 %

0.63 [ -0.79, 2.05 ]

Test for overall effect: Z = 0.87 (P = 0.38) 2 short term - PGWB Standard - Group 2006 38 -70.9 (17.1) 33 -72.9 (17.5) 100.0 % 2.00 [ -6.08, 10.08 ]

Subtotal (95% CI)
Heterogeneity: not applicable

38

33

100.0 %

2.00 [ -6.08, 10.08 ]

Test for overall effect: Z = 0.49 (P = 0.63) 3 medium term - GQOLI-74 Brief - Group 2007a 30 18.45 (2.25) 32 16.32 (2.17) 100.0 % 2.13 [ 1.03, 3.23 ]

Subtotal (95% CI)
Heterogeneity: not applicable

30

32

100.0 %

2.13 [ 1.03, 3.23 ]

Test for overall effect: Z = 3.79 (P = 0.00015) 4 medium term - QOL Unclear - Group 1996 51 -67.9 (20.7) 57 -58.2 (19) 100.0 % -9.70 [ -17.22, -2.18 ]

Subtotal (95% CI)
Heterogeneity: not applicable

51

57

100.0 %

-9.70 [ -17.22, -2.18 ]

Test for overall effect: Z = 2.53 (P = 0.012) 5 medium term - PGWB Standard - Group 2006 36 75.9 (17) 25 73.1 (15.4) 100.0 % 2.80 [ -5.40, 11.00 ]

Subtotal (95% CI)
Heterogeneity: not applicable

36

25

100.0 %

2.80 [ -5.40, 11.00 ]

Test for overall effect: Z = 0.67 (P = 0.50) Test for subgroup differences: Chi2 = 11.30, df = 4 (P = 0.02), I2 =65%

-20

-10

0

10

20

Favours control

Favours psychoeducation

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Analysis 1.32. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 32 Quality of life: Average endpoint scores on various scales (high = poor).
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 32 Quality of life: Average endpoint scores on various scales (high = poor)

Study or subgroup

Treatment N Mean(SD)

Control N Mean(SD)

Mean Difference IV,Fixed,95% CI

Weight

Mean Difference IV,Fixed,95% CI

1 short term - FAD Brief - Group 2007a 30 71.26 (9.83) 32 71.68 (10.37) 100.0 % -0.42 [ -5.45, 4.61 ]

Subtotal (95% CI)
Heterogeneity: not applicable

30

32

100.0 %

-0.42 [ -5.45, 4.61 ]

Test for overall effect: Z = 0.16 (P = 0.87) 2 short term - FBIS Standard - Group 2007 42 25.1 (4.8) 42 29.8 (6.7) 100.0 % -4.70 [ -7.19, -2.21 ]

Subtotal (95% CI)
Heterogeneity: not applicable

42

42

100.0 %

-4.70 [ -7.19, -2.21 ]

Test for overall effect: Z = 3.70 (P = 0.00022) 3 medium term - FAD Brief - Group 2007a 30 63.13 (9.86) 32 69.92 (9.74) 100.0 % -6.79 [ -11.67, -1.91 ]

Subtotal (95% CI)
Heterogeneity: not applicable

30

32

100.0 % -6.79 [ -11.67, -1.91 ]

Test for overall effect: Z = 2.73 (P = 0.0064) 4 medium term - FBIS Standard - Both 2008 Standard - Group 2007 79 42 13.7 (5.6) 21.4 (6) 78 42 18.9 (6.2) 30.2 (7.5) 71.2 % 28.8 % -5.20 [ -7.05, -3.35 ] -8.80 [ -11.70, -5.90 ]

Subtotal (95% CI)

121

120

100.0 %

-6.24 [ -7.80, -4.68 ]

Heterogeneity: Chi2 = 4.20, df = 1 (P = 0.04); I2 =76% Test for overall effect: Z = 7.84 (P < 0.00001) Test for subgroup differences: Chi2 = 5.44, df = 3 (P = 0.14), I2 =45%

-20

-10

0

10

20

Favours psychoeducation

Favours standard care

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Analysis 1.33. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 33 Satisfaction with mental health services: 1. Short term - average change score (VSS, high = good).
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 33 Satisfaction with mental health services: 1. Short term - average change score (VSS, high = good)

Study or subgroup

Treatment N Mean(SD)

Control N Mean(SD)

Mean Difference IV,Fixed,95% CI

Weight

Mean Difference IV,Fixed,95% CI

1 patients’ satisfaction Brief - Group 1999 18 -9.47 (17.46) 14 -7.32 (16.48) 100.0 % -2.15 [ -13.96, 9.66 ]

Subtotal (95% CI)
Heterogeneity: not applicable

18

14

100.0 %

-2.15 [ -13.96, 9.66 ]

Test for overall effect: Z = 0.36 (P = 0.72) 2 relatives’ satisfaction Brief - Group 1999 10 -9.56 (28.73) 7 -1.25 (16.05) 100.0 % -8.31 [ -29.72, 13.10 ]

Subtotal (95% CI)
Heterogeneity: not applicable

10

7

100.0 %

-8.31 [ -29.72, 13.10 ]

Test for overall effect: Z = 0.76 (P = 0.45) Test for subgroup differences: Chi2 = 0.24, df = 1 (P = 0.62), I2 =0.0%

-50

-25

0

25

50

Favours standard care

Favours psychoeducation

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Analysis 1.34. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 34 Satisfaction with mental health services: 2. Average change - at 1 year (VSS Scale, high = good).
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 34 Satisfaction with mental health services: 2. Average change - at 1 year (VSS Scale, high = good)

Study or subgroup

Treatment N Mean(SD)

Control N Mean(SD)

Mean Difference IV,Fixed,95% CI

Weight

Mean Difference IV,Fixed,95% CI

1 patients’ satisfaction with relatives’ involvement - mean change Brief - Group 1999 15 -4.47 (3.13) 15 -0.12 (4.42) 100.0 % -4.35 [ -7.09, -1.61 ]

Subtotal (95% CI)
Heterogeneity: not applicable

15

15

100.0 %

-4.35 [ -7.09, -1.61 ]

Test for overall effect: Z = 3.11 (P = 0.0019) 2 relatives’ involvement satisfaction Brief - Group 1999 11 -1.34 (5.77) 10 0.83 (3.19) 100.0 % -2.17 [ -6.11, 1.77 ]

Subtotal (95% CI)
Heterogeneity: not applicable

11

10

100.0 %

-2.17 [ -6.11, 1.77 ]

Test for overall effect: Z = 1.08 (P = 0.28) 3 relatives’ efficacy satisfaction Brief - Group 1999 12 -1.51 (6.47) 12 0.65 (6.35) 100.0 % -2.16 [ -7.29, 2.97 ]

Subtotal (95% CI)
Heterogeneity: not applicable

12

12

100.0 %

-2.16 [ -7.29, 2.97 ]

Test for overall effect: Z = 0.83 (P = 0.41) 4 relatives’ intervention satisfaction Brief - Group 1999 13 -2.83 (9.54) 13 0.6 (6.91) 100.0 % -3.43 [ -9.83, 2.97 ]

Subtotal (95% CI)
Heterogeneity: not applicable

13

13

100.0 %

-3.43 [ -9.83, 2.97 ]

Test for overall effect: Z = 1.05 (P = 0.29) Test for subgroup differences: Chi2 = 1.06, df = 3 (P = 0.79), I2 =0.0%

-20

-10

0

10

20

Favours standard care

Favours psychoeducation

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Analysis 1.35. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 35 Satisfaction with mental health services: 3. Binary outcome.
Review: Psychoeducation for schizophrenia

Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 35 Satisfaction with mental health services: 3. Binary outcome

Study or subgroup

Psychoeducation n/N

Standard care n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 short term - unsatisfied Unclear - Unclear 2008 2/60 18/60 54.5 % 0.11 [ 0.03, 0.46 ]

Subtotal (95% CI)
Heterogeneity: not applicable Test for overall effect: Z = 3.04 (P = 0.0024) 2 medium term - unsatisfied Standard - Unclear 2006

60

60

54.5 %

0.11 [ 0.03, 0.46 ]

Total events: 2 (Psychoeducation), 18 (Standard care)

6/58

15/58

45.5 %

0.40 [ 0.17, 0.96 ]

Subtotal (95% CI)
Heterogeneity: not applicable Test for overall effect: Z = 2.05 (P = 0.040)

58

58

45.5 %

0.40 [ 0.17, 0.96 ]

Total events: 6 (Psychoeducation), 15 (Standard care)

Total (95% CI)

118

118

100.0 %

0.24 [ 0.12, 0.50 ]

Total events: 8 (Psychoeducation), 33 (Standard care) Heterogeneity: Chi2 = 2.43, df = 1 (P = 0.12); I2 =59% Test for overall effect: Z = 3.80 (P = 0.00014) Test for subgroup differences: Chi2 = 2.28, df = 1 (P = 0.13), I2 =56%

0.01

0.1

1

10

100

Favours psychoeducation

Favours standard care

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Analysis 1.36. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 36 Adverse event: Death.
Review: Psychoeducation for schizophrenia Comparison: 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE Outcome: 36 Adverse event: Death

Study or subgroup

Treatment n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 medium term Brief - Group 1999 Standard - Unclear 1996 0/24 1/125 1/22 0/111 37.4 % 12.7 % 0.31 [ 0.01, 7.16 ] 2.67 [ 0.11, 64.80 ]

Subtotal (95% CI)
Total events: 1 (Treatment), 1 (Control)

149

133

50.0 %

0.90 [ 0.13, 6.35 ]

Heterogeneity: Chi2 = 0.89, df = 1 (P = 0.34); I2 =0.0% Test for overall effect: Z = 0.10 (P = 0.92) 2 long term Brief - Group 1995 Standard - Group 2005 1/67 2/111 1/57 1/109 25.8 % 24.1 % 0.85 [ 0.05, 13.30 ] 1.96 [ 0.18, 21.35 ]

Subtotal (95% CI)
Total events: 3 (Treatment), 2 (Control)

178

166

50.0 %

1.39 [ 0.24, 8.11 ]

Heterogeneity: Chi2 = 0.20, df = 1 (P = 0.65); I2 =0.0% Test for overall effect: Z = 0.36 (P = 0.72)

Total (95% CI)
Total events: 4 (Treatment), 3 (Control)

327

299

100.0 %

1.15 [ 0.31, 4.21 ]

Heterogeneity: Chi2 = 1.18, df = 3 (P = 0.76); I2 =0.0% Test for overall effect: Z = 0.21 (P = 0.84) Test for subgroup differences: Chi2 = 0.10, df = 1 (P = 0.75), I2 =0.0%

0.005

0.1

1

10

200

Favours treatment

Favours control

Analysis 1.37. Comparison 1 ANY FORM OF PSYCHOEDUCATION vs STANDARD CARE, Outcome 37 Economic outcomes: Costs (US$ per person, data skewed). Economic outcomes: Costs (US$ per person, data skewed)

Study

Psychoed. mean Psychoed. SD

Psychoed. N

Standard mean

care Standard care SD Standard care N

acute hospital charges Standard - Both 6537 1996 ambulatory charges 17248.0 41 7863 12038 41

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Economic outcomes: Costs (US$ per person, data skewed)

(Continued)

Standard - Both 6488 1996 total charges Standard - Both 13025 1996

4332.8

41

5212

3500.1

41

16358.4

41

13075

12000

41

Analysis 2.1. Comparison 2 SUBGROUP ANALYSES 1. BRIEF PSYCHOEDUCATION/STANDARD PSYCHOEDUCATION vs STANDARD CARE, Outcome 1 Compliance: 1a. With medication - binary outcomes.
Review: Psychoeducation for schizophrenia Comparison: 2 SUBGROUP ANALYSES 1. BRIEF PSYCHOEDUCATION/STANDARD PSYCHOEDUCATION vs STANDARD CARE Outcome: 1 Compliance: 1a. With medication - binary outcomes

Study or subgroup

Treatment n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 short term - non-compliance - brief Brief - Group 2006 Brief - Group 2007b Brief - Unclear 2005 2/30 3/51 24/143 3/30 7/51 36/143 6.5 % 15.2 % 78.3 % 0.67 [ 0.12, 3.71 ] 0.43 [ 0.12, 1.57 ] 0.67 [ 0.42, 1.06 ]

Subtotal (95% CI)
Total events: 29 (Treatment), 46 (Control)

224

224

100.0 %

0.63 [ 0.41, 0.96 ]

Heterogeneity: Chi2 = 0.40, df = 2 (P = 0.82); I2 =0.0% Test for overall effect: Z = 2.15 (P = 0.032) 2 short term - non-compliance - standard Standard - Both 2006 Standard - Group 2004 Standard - Individual 03b Standard - Unclear 2007 9/50 4/125 7/68 0/50 12/50 25/125 9/68 3/50 24.2 % 50.5 % 18.2 % 7.1 % 0.75 [ 0.35, 1.62 ] 0.16 [ 0.06, 0.45 ] 0.78 [ 0.31, 1.97 ] 0.14 [ 0.01, 2.70 ]

Subtotal (95% CI)
Total events: 20 (Treatment), 49 (Control)

293

293

100.0 %

0.41 [ 0.25, 0.67 ]

Heterogeneity: Chi2 = 7.86, df = 3 (P = 0.05); I2 =62% Test for overall effect: Z = 3.56 (P = 0.00037) 3 medium term - non-compliance - brief Brief - Both 2004 3/59 18/59
0.1 0.2 0.5 1 2 5 10

100.0 %

0.17 [ 0.05, 0.54 ]

Favours treatment

Favours control

(Continued . . . )

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(. . .
Study or subgroup Treatment n/N Control n/N Risk Ratio M-H,Fixed,95% CI Weight

Continued) Risk Ratio

M-H,Fixed,95% CI

Subtotal (95% CI)
Total events: 3 (Treatment), 18 (Control) Heterogeneity: not applicable Test for overall effect: Z = 3.01 (P = 0.0026) 4 medium term - non-compliance - standard Standard - Both 2008 Standard - Both 2008b Standard - Group 2008 Standard - Unclear 2006

59

59

100.0 %

0.17 [ 0.05, 0.54 ]

6/79 17/45 6/99 7/58

14/78 34/45 15/99 18/58

17.4 % 41.9 % 18.5 % 22.2 %

0.42 [ 0.17, 1.04 ] 0.50 [ 0.33, 0.75 ] 0.40 [ 0.16, 0.99 ] 0.39 [ 0.18, 0.86 ]

Subtotal (95% CI)
Total events: 36 (Treatment), 81 (Control)

281

280

100.0 %

0.44 [ 0.32, 0.62 ]

Heterogeneity: Chi2 = 0.49, df = 3 (P = 0.92); I2 =0.0% Test for overall effect: Z = 4.82 (P < 0.00001)

0.1 0.2

0.5

1

2

5

10

Favours treatment

Favours control

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Analysis 2.2. Comparison 2 SUBGROUP ANALYSES 1. BRIEF PSYCHOEDUCATION/STANDARD PSYCHOEDUCATION vs STANDARD CARE, Outcome 2 Compliance: 2. With follow-up - loss to follow-up for any reason.
Review: Psychoeducation for schizophrenia

Comparison: 2 SUBGROUP ANALYSES 1. BRIEF PSYCHOEDUCATION/STANDARD PSYCHOEDUCATION vs STANDARD CARE Outcome: 2 Compliance: 2. With follow-up - loss to follow-up for any reason

Study or subgroup

Treatment n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 medium term - brief Brief - Group 1995 Brief - Group 1999 15/67 6/24 22/57 9/22 71.7 % 28.3 % 0.58 [ 0.33, 1.01 ] 0.61 [ 0.26, 1.44 ]

Subtotal (95% CI)
Total events: 21 (Treatment), 31 (Control)

91

79

100.0 %

0.59 [ 0.37, 0.94 ]

Heterogeneity: Chi2 = 0.01, df = 1 (P = 0.92); I2 =0.0% Test for overall effect: Z = 2.23 (P = 0.025) 2 medium term - standard Standard - Both 2004 Standard - Both 2008 Standard - Group 1988 Standard - Individual 03c Standard - Individual 93 Standard - Unclear 1996 Standard - Unclear 2006 0/43 12/79 2/25 2/37 1/10 44/125 5/58 1/43 17/78 2/26 1/36 0/10 29/111 4/58 2.6 % 30.1 % 3.5 % 1.8 % 0.9 % 54.1 % 7.0 % 0.33 [ 0.01, 7.96 ] 0.70 [ 0.36, 1.36 ] 1.04 [ 0.16, 6.83 ] 1.95 [ 0.18, 20.53 ] 3.00 [ 0.14, 65.90 ] 1.35 [ 0.91, 2.00 ] 1.25 [ 0.35, 4.42 ]

Subtotal (95% CI)
Total events: 66 (Treatment), 54 (Control)

377

362

100.0 %

1.13 [ 0.83, 1.55 ]

Heterogeneity: Chi2 = 3.96, df = 6 (P = 0.68); I2 =0.0% Test for overall effect: Z = 0.78 (P = 0.44) 3 long term (by 2 years) - brief Brief - Group 1995 19/67 23/57 100.0 % 0.70 [ 0.43, 1.15 ]

Subtotal (95% CI)
Total events: 19 (Treatment), 23 (Control) Heterogeneity: not applicable Test for overall effect: Z = 1.40 (P = 0.16) 4 long term (by 2 years) - standard Standard - Individual 03b

67

57

100.0 %

0.70 [ 0.43, 1.15 ]

29/68

30/68

100.0 %

0.97 [ 0.66, 1.42 ]

Subtotal (95% CI)
Total events: 29 (Treatment), 30 (Control) Heterogeneity: not applicable

68

68

100.0 %

0.97 [ 0.66, 1.42 ]

0.1 0.2

0.5

1

2

5

10

Favours treatment

Favours control

(Continued . . . )

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(. . .
Study or subgroup Treatment n/N Test for overall effect: Z = 0.17 (P = 0.86) 5 long term (by 5 years or more) - brief Brief - Group 1995 19/67 22/57 100.0 % Control n/N Risk Ratio M-H,Fixed,95% CI Weight

Continued) Risk Ratio

M-H,Fixed,95% CI

0.73 [ 0.44, 1.21 ]

Subtotal (95% CI)
Total events: 19 (Treatment), 22 (Control) Heterogeneity: not applicable Test for overall effect: Z = 1.20 (P = 0.23) 6 long term (by 5 years or more) - standard Standard - Unclear 1996

67

57

100.0 %

0.73 [ 0.44, 1.21 ]

4/24

4/24

100.0 %

1.00 [ 0.28, 3.54 ]

Subtotal (95% CI)
Total events: 4 (Treatment), 4 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.0 (P = 1.0)

24

24

100.0 %

1.00 [ 0.28, 3.54 ]

0.1 0.2

0.5

1

2

5

10

Favours treatment

Favours control

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Analysis 2.3. Comparison 2 SUBGROUP ANALYSES 1. BRIEF PSYCHOEDUCATION/STANDARD PSYCHOEDUCATION vs STANDARD CARE, Outcome 3 Compliance: 2a. with follow-up - received intervention but left the study early.
Review: Psychoeducation for schizophrenia

Comparison: 2 SUBGROUP ANALYSES 1. BRIEF PSYCHOEDUCATION/STANDARD PSYCHOEDUCATION vs STANDARD CARE Outcome: 3 Compliance: 2a. with follow-up - received intervention but left the study early

Study or subgroup

Treatment n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 short term - brief Brief - Individual 1996 3/47 0/20 100.0 % 3.06 [ 0.17, 56.70 ]

Subtotal (95% CI)
Total events: 3 (Treatment), 0 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.75 (P = 0.45) 2 short term - standard Standard - Individual 93

47

20

100.0 %

3.06 [ 0.17, 56.70 ]

1/10

0/10

100.0 %

3.00 [ 0.14, 65.90 ]

Subtotal (95% CI)
Total events: 1 (Treatment), 0 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.70 (P = 0.49) 3 long term - brief Brief - Group 1995

10

10

100.0 %

3.00 [ 0.14, 65.90 ]

15/67

22/57

100.0 %

0.58 [ 0.33, 1.01 ]

Subtotal (95% CI)
Total events: 15 (Treatment), 22 (Control) Heterogeneity: not applicable Test for overall effect: Z = 1.93 (P = 0.054) 4 long term - standard Standard - Both 1996

67

57

100.0 %

0.58 [ 0.33, 1.01 ]

5/41

6/41

100.0 %

0.83 [ 0.28, 2.52 ]

Subtotal (95% CI)
Total events: 5 (Treatment), 6 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.32 (P = 0.75)

41

41

100.0 %

0.83 [ 0.28, 2.52 ]

0.002

0.1

1

10

500

Favours experimental

Favours control

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Analysis 2.4. Comparison 2 SUBGROUP ANALYSES 1. BRIEF PSYCHOEDUCATION/STANDARD PSYCHOEDUCATION vs STANDARD CARE, Outcome 4 Relapse: Relapse for any reason.
Review: Psychoeducation for schizophrenia

Comparison: 2 SUBGROUP ANALYSES 1. BRIEF PSYCHOEDUCATION/STANDARD PSYCHOEDUCATION vs STANDARD CARE Outcome: 4 Relapse: Relapse for any reason

Study or subgroup

Treatment n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 relapse - medium term - brief Brief - Group 1995a Brief - Group 1999 Brief - Group 2007 11/85 14/24 6/44 23/80 15/22 8/37 49.3 % 32.6 % 18.1 % 0.45 [ 0.23, 0.86 ] 0.86 [ 0.55, 1.33 ] 0.63 [ 0.24, 1.65 ]

Subtotal (95% CI)
Total events: 31 (Treatment), 46 (Control)

153

139

100.0 %

0.61 [ 0.43, 0.89 ]

Heterogeneity: Chi2 = 3.03, df = 2 (P = 0.22); I2 =34% Test for overall effect: Z = 2.59 (P = 0.0096) 2 relapse - medium term - standard Standard - Both 2008b Standard - Group 1988 Standard - Group 1988 Standard - Individual 03c Standard - Unclear 1996 Standard - Unclear 1996 Standard - Unclear 2005 Standard - Unclear 2006 11/45 12/25 19/41 6/37 86/125 69/125 4/69 9/58 25/45 13/26 13/26 13/36 81/111 50/111 8/73 19/58 10.8 % 5.5 % 6.8 % 5.7 % 36.9 % 22.8 % 3.3 % 8.2 % 0.44 [ 0.25, 0.78 ] 0.96 [ 0.55, 1.68 ] 0.93 [ 0.56, 1.54 ] 0.45 [ 0.19, 1.05 ] 0.94 [ 0.80, 1.11 ] 1.23 [ 0.95, 1.59 ] 0.53 [ 0.17, 1.68 ] 0.47 [ 0.23, 0.96 ]

Subtotal (95% CI)

525

486

100.0 %

0.87 [ 0.77, 0.99 ]

Total events: 216 (Treatment), 222 (Control) Heterogeneity: Chi2 = 18.98, df = 7 (P = 0.01); I2 =63% Test for overall effect: Z = 2.05 (P = 0.041) 3 relapse with readmission - medium term - brief Brief - Group 1995 30/67 30/57 100.0 % 0.85 [ 0.59, 1.22 ]

Subtotal (95% CI)
Total events: 30 (Treatment), 30 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.87 (P = 0.38)

67

57

100.0 %

0.85 [ 0.59, 1.22 ]

4 relapse with readmission - medium term - standard Standard - Both 1996 9/41 15/41 100.0 % 0.60 [ 0.30, 1.21 ]

Subtotal (95% CI)
Total events: 9 (Treatment), 15 (Control)

41

41

100.0 %

0.60 [ 0.30, 1.21 ]

0.2

0.5

1

2

5

Favours treatment

Favours control

(Continued . . . )

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149

(. . .
Study or subgroup Treatment n/N Heterogeneity: not applicable Test for overall effect: Z = 1.42 (P = 0.15) 5 relapse - long term - brief Brief - Group 1995 30/67 30/57 100.0 % Control n/N Risk Ratio M-H,Fixed,95% CI Weight

Continued) Risk Ratio

M-H,Fixed,95% CI

0.85 [ 0.59, 1.22 ]

Subtotal (95% CI)
Total events: 30 (Treatment), 30 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.87 (P = 0.38) 6 relapse - long term - standard Standard - Both 1996 Standard - Both 2004 Standard - Group 2005 Standard - Individual 03b Standard - Unclear 2005

67

57

100.0 %

0.85 [ 0.59, 1.22 ]

7/41 3/43 53/111 38/68 14/69

14/41 15/43 66/109 52/68 16/73

8.6 % 9.2 % 40.8 % 31.9 % 9.5 %

0.50 [ 0.23, 1.11 ] 0.20 [ 0.06, 0.64 ] 0.79 [ 0.62, 1.01 ] 0.73 [ 0.57, 0.94 ] 0.93 [ 0.49, 1.75 ]

Subtotal (95% CI)

332

334

100.0 %

0.70 [ 0.59, 0.84 ]

Total events: 115 (Treatment), 163 (Control) Heterogeneity: Chi2 = 6.79, df = 4 (P = 0.15); I2 =41% Test for overall effect: Z = 4.01 (P = 0.000060) 7 relapse with readmission - long term - brief Brief - Group 1995 39/67 40/57 100.0 % 0.83 [ 0.64, 1.08 ]

Subtotal (95% CI)
Total events: 39 (Treatment), 40 (Control) Heterogeneity: not applicable Test for overall effect: Z = 1.39 (P = 0.17)

67

57

100.0 %

0.83 [ 0.64, 1.08 ]

8 relapse with readmission - long term - standard Standard - Both 1996 16/41 30/41 100.0 % 0.53 [ 0.35, 0.82 ]

Subtotal (95% CI)
Total events: 16 (Treatment), 30 (Control) Heterogeneity: not applicable Test for overall effect: Z = 2.90 (P = 0.0038)

41

41

100.0 %

0.53 [ 0.35, 0.82 ]

0.2

0.5

1

2

5

Favours treatment

Favours control

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

150

Analysis 3.1. Comparison 3 SUBGROUP ANALYSES 2. GROUP PSYCHOEDUCATION/INDIVIDUAL PSYCHOEDUCATION vs STANDARD CARE, Outcome 1 Compliance: 1a. With medication - binary outcomes.
Review: Psychoeducation for schizophrenia Comparison: 3 SUBGROUP ANALYSES 2. GROUP PSYCHOEDUCATION/INDIVIDUAL PSYCHOEDUCATION vs STANDARD CARE Outcome: 1 Compliance: 1a. With medication - binary outcomes

Study or subgroup

Psychoeducation n/N

Standard care n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 short term - non-compliance - group Brief - Group 2006 Brief - Group 2007b Standard - Group 2004 2/30 3/51 4/125 3/30 7/51 25/125 8.6 % 20.0 % 71.4 % 0.67 [ 0.12, 3.71 ] 0.43 [ 0.12, 1.57 ] 0.16 [ 0.06, 0.45 ]

Subtotal (95% CI)

206

206

100.0 %

0.26 [ 0.13, 0.52 ]

Total events: 9 (Psychoeducation), 35 (Standard care) Heterogeneity: Chi2 = 2.60, df = 2 (P = 0.27); I2 =23% Test for overall effect: Z = 3.76 (P = 0.00017) 2 short term - non-compliance - individual Standard - Individual 03b Unclear - Individual 2008 7/68 12/80 9/68 20/80 31.0 % 69.0 % 0.78 [ 0.31, 1.97 ] 0.60 [ 0.31, 1.14 ]

Subtotal (95% CI)

148

148

100.0 %

0.66 [ 0.39, 1.11 ]

Total events: 19 (Psychoeducation), 29 (Standard care) Heterogeneity: Chi2 = 0.20, df = 1 (P = 0.65); I2 =0.0% Test for overall effect: Z = 1.57 (P = 0.12) 3 short term - partial compliance - group Standard - Group 2004 28/125 37/125 100.0 % 0.76 [ 0.50, 1.16 ]

Subtotal (95% CI)
Heterogeneity: not applicable Test for overall effect: Z = 1.29 (P = 0.20) 4 short term - partial compliance - individual Standard - Individual 03b

125

125

100.0 %

0.76 [ 0.50, 1.16 ]

Total events: 28 (Psychoeducation), 37 (Standard care)

22/68

36/68

100.0 %

0.61 [ 0.41, 0.92 ]

Subtotal (95% CI)
Heterogeneity: not applicable Test for overall effect: Z = 2.35 (P = 0.019)

68

68

100.0 %

0.61 [ 0.41, 0.92 ]

Total events: 22 (Psychoeducation), 36 (Standard care)

0.1 0.2

0.5

1

2

5

10

Favours psychoeducation

Favours standard

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151

Analysis 3.2. Comparison 3 SUBGROUP ANALYSES 2. GROUP PSYCHOEDUCATION/INDIVIDUAL PSYCHOEDUCATION vs STANDARD CARE, Outcome 2 Compliance: 2. With follow-up - leaving the study early/loss to follow-up.
Review: Psychoeducation for schizophrenia

Comparison: 3 SUBGROUP ANALYSES 2. GROUP PSYCHOEDUCATION/INDIVIDUAL PSYCHOEDUCATION vs STANDARD CARE Outcome: 2 Compliance: 2. With follow-up - leaving the study early/loss to follow-up

Study or subgroup

Treatment n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 medium term - received intervention but left the study early - group Standard - Group 1988 Unclear - Group 1996 4/41 7/73 2/26 17/73 12.6 % 87.4 % 1.27 [ 0.25, 6.44 ] 0.41 [ 0.18, 0.93 ]

Subtotal (95% CI)
Total events: 11 (Treatment), 19 (Control)

114

99

100.0 %

0.52 [ 0.25, 1.06 ]

Heterogeneity: Chi2 = 1.47, df = 1 (P = 0.23); I2 =32% Test for overall effect: Z = 1.80 (P = 0.072) 2 medium term - received intervention but left the study early - individual Standard - Individual 93 1/10 0/10 100.0 % 3.00 [ 0.14, 65.90 ]

Subtotal (95% CI)
Total events: 1 (Treatment), 0 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.70 (P = 0.49)

10

10

100.0 %

3.00 [ 0.14, 65.90 ]

3 medium term - loss to follow-up for any reason - group Brief - Group 1995 Brief - Group 1999 Standard - Group 1988 Unclear - Group 1996 15/67 6/24 2/25 23/73 22/57 9/22 2/26 17/73 45.6 % 18.0 % 3.8 % 32.6 % 0.58 [ 0.33, 1.01 ] 0.61 [ 0.26, 1.44 ] 1.04 [ 0.16, 6.83 ] 1.35 [ 0.79, 2.31 ]

Subtotal (95% CI)
Total events: 46 (Treatment), 50 (Control)

189

178

100.0 %

0.86 [ 0.61, 1.20 ]

Heterogeneity: Chi2 = 5.33, df = 3 (P = 0.15); I2 =44% Test for overall effect: Z = 0.91 (P = 0.36) 4 medium term - loss to follow-up for any reason - individual Standard - Individual 03c 2/37 1/36 100.0 % 1.95 [ 0.18, 20.53 ]

Subtotal (95% CI)
Total events: 2 (Treatment), 1 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.55 (P = 0.58)

37

36

100.0 %

1.95 [ 0.18, 20.53 ]

5 long term - loss to follow-up for any reason (by 2 years) - group Brief - Group 1995 19/67 23/57 100.0 % 0.70 [ 0.43, 1.15 ]

Subtotal (95% CI)

67

57
0.001 0.01 0.1 Favours treatment 1 10 100 1000 Favours control

100.0 %

0.70 [ 0.43, 1.15 ]

(Continued . . . )

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152

(. . .
Study or subgroup Treatment n/N Total events: 19 (Treatment), 23 (Control) Heterogeneity: not applicable Test for overall effect: Z = 1.40 (P = 0.16) 6 long term - loss to follow-up for any reason (by 2 years) - individual Standard - Individual 03b Unclear - Individual 2008 29/68 8/80 30/68 11/80 73.2 % 26.8 % Control n/N Risk Ratio M-H,Fixed,95% CI Weight

Continued) Risk Ratio

M-H,Fixed,95% CI

0.97 [ 0.66, 1.42 ] 0.73 [ 0.31, 1.71 ]

Subtotal (95% CI)
Total events: 37 (Treatment), 41 (Control)

148

148

100.0 %

0.90 [ 0.63, 1.29 ]

Heterogeneity: Chi2 = 0.37, df = 1 (P = 0.54); I2 =0.0% Test for overall effect: Z = 0.56 (P = 0.57)

0.001 0.01 0.1 Favours treatment

1

10 100 1000 Favours control

Analysis 3.3. Comparison 3 SUBGROUP ANALYSES 2. GROUP PSYCHOEDUCATION/INDIVIDUAL PSYCHOEDUCATION vs STANDARD CARE, Outcome 3 Relapse: Relapse for any reason.
Review: Psychoeducation for schizophrenia

Comparison: 3 SUBGROUP ANALYSES 2. GROUP PSYCHOEDUCATION/INDIVIDUAL PSYCHOEDUCATION vs STANDARD CARE Outcome: 3 Relapse: Relapse for any reason

Study or subgroup

Treatment n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 relapse - medium term - group Brief - Group 1995a Brief - Group 1999 Brief - Group 2007 Standard - Group 1988 Standard - Group 1988 11/85 14/24 6/44 12/25 19/41 23/80 15/22 8/37 13/26 13/26 30.9 % 20.4 % 11.3 % 16.6 % 20.7 % 0.45 [ 0.23, 0.86 ] 0.86 [ 0.55, 1.33 ] 0.63 [ 0.24, 1.65 ] 0.96 [ 0.55, 1.68 ] 0.93 [ 0.56, 1.54 ]

Subtotal (95% CI)
Total events: 62 (Treatment), 72 (Control)

219

191

100.0 %

0.74 [ 0.57, 0.96 ]

Heterogeneity: Chi2 = 4.39, df = 4 (P = 0.36); I2 =9% Test for overall effect: Z = 2.27 (P = 0.023)

0.2

0.5

1

2

5

Favours treatment

Favours control

(Continued . . . )

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

153

(. . .
Study or subgroup Treatment n/N 2 relapse - medium term - individual Standard - Individual 03c 6/37 13/36 100.0 % Control n/N Risk Ratio M-H,Fixed,95% CI Weight

Continued) Risk Ratio

M-H,Fixed,95% CI

0.45 [ 0.19, 1.05 ]

Subtotal (95% CI)
Total events: 6 (Treatment), 13 (Control) Heterogeneity: not applicable Test for overall effect: Z = 1.84 (P = 0.065) 3 relapse - long term - group Brief - Group 1995 Standard - Group 2005

37

36

100.0 %

0.45 [ 0.19, 1.05 ]

30/67 53/111

30/57 66/109

32.7 % 67.3 %

0.85 [ 0.59, 1.22 ] 0.79 [ 0.62, 1.01 ]

Subtotal (95% CI)
Total events: 83 (Treatment), 96 (Control)

178

166

100.0 %

0.81 [ 0.66, 0.99 ]

Heterogeneity: Chi2 = 0.12, df = 1 (P = 0.73); I2 =0.0% Test for overall effect: Z = 2.04 (P = 0.042) 4 relapse - long term - individual Standard - Individual 03b 38/68 52/68 100.0 % 0.73 [ 0.57, 0.94 ]

Subtotal (95% CI)
Total events: 38 (Treatment), 52 (Control) Heterogeneity: not applicable Test for overall effect: Z = 2.47 (P = 0.014)

68

68

100.0 %

0.73 [ 0.57, 0.94 ]

0.2

0.5

1

2

5

Favours treatment

Favours control

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

154

Analysis 4.1. Comparison 4 SENSITIVITY ANALYSIS - Chinese studies vs non-Chinese studies, Outcome 1 Compliance: 1a. With medication - non-compliance.
Review: Psychoeducation for schizophrenia

Comparison: 4 SENSITIVITY ANALYSIS - Chinese studies vs non-Chinese studies Outcome: 1 Compliance: 1a. With medication - non-compliance

Study or subgroup

Treatment n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 long term Standard - Both 1996 Standard - Unclear 2005a Unclear - Individual 2008 7/41 0/20 16/80 2/41 9/20 37/80 4.1 % 19.6 % 76.3 % 3.50 [ 0.77, 15.85 ] 0.05 [ 0.00, 0.85 ] 0.43 [ 0.26, 0.71 ]

Subtotal (95% CI)
Total events: 23 (Treatment), 48 (Control)

141

141

100.0 %

0.48 [ 0.31, 0.75 ]

Heterogeneity: Chi2 = 9.23, df = 2 (P = 0.01); I2 =78% Test for overall effect: Z = 3.27 (P = 0.0011) 2 long term - Chinese studies Standard - Both 1996 Standard - Unclear 2005a Unclear - Individual 2008 7/41 0/20 16/80 2/41 9/20 37/80 4.1 % 19.6 % 76.3 % 3.50 [ 0.77, 15.85 ] 0.05 [ 0.00, 0.85 ] 0.43 [ 0.26, 0.71 ]

Subtotal (95% CI)
Total events: 23 (Treatment), 48 (Control)

141

141

100.0 %

0.48 [ 0.31, 0.75 ]

Heterogeneity: Chi2 = 9.23, df = 2 (P = 0.01); I2 =78% Test for overall effect: Z = 3.27 (P = 0.0011)

0.1 0.2

0.5

1

2

5

10

Favours psychoeducation

Favours standard care

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

155

Analysis 4.2. Comparison 4 SENSITIVITY ANALYSIS - Chinese studies vs non-Chinese studies, Outcome 2 Compliance: 2a. With follow-up - loss to follow-up for any reason.
Review: Psychoeducation for schizophrenia

Comparison: 4 SENSITIVITY ANALYSIS - Chinese studies vs non-Chinese studies Outcome: 2 Compliance: 2a. With follow-up - loss to follow-up for any reason

Study or subgroup

Treatment n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 medium term - loss to follow-up for any reason Standard - Individual 03c Standard - Group 1988 Standard - Unclear 2006 Brief - Group 1999 Unclear - Group 1996 Standard - Both 2008 Brief - Group 1995 Standard - Unclear 1996 2/37 2/25 5/58 6/24 23/73 12/79 15/67 44/125 1/36 2/26 4/58 9/22 17/73 17/78 22/57 29/111 1.0 % 1.9 % 3.8 % 8.9 % 16.2 % 16.3 % 22.6 % 29.3 % 1.95 [ 0.18, 20.53 ] 1.04 [ 0.16, 6.83 ] 1.25 [ 0.35, 4.42 ] 0.61 [ 0.26, 1.44 ] 1.35 [ 0.79, 2.31 ] 0.70 [ 0.36, 1.36 ] 0.58 [ 0.33, 1.01 ] 1.35 [ 0.91, 2.00 ]

Subtotal (95% CI)

488

461

100.0 %

1.00 [ 0.79, 1.26 ]

Total events: 109 (Treatment), 101 (Control) Heterogeneity: Chi2 = 9.97, df = 7 (P = 0.19); I2 =30% Test for overall effect: Z = 0.01 (P = 0.99) 2 medium term - loss to follow-up for any reason - Chinese studies Standard - Individual 03c Standard - Group 1988 Standard - Unclear 2006 Brief - Group 1999 Unclear - Group 1996 Standard - Both 2008 Brief - Group 1995 Standard - Unclear 1996 2/37 2/25 5/58 6/24 23/73 12/79 15/67 44/125 1/36 2/26 4/58 9/22 17/73 17/78 22/57 29/111 1.0 % 1.9 % 3.8 % 8.9 % 16.2 % 16.3 % 22.6 % 29.3 % 1.95 [ 0.18, 20.53 ] 1.04 [ 0.16, 6.83 ] 1.25 [ 0.35, 4.42 ] 0.61 [ 0.26, 1.44 ] 1.35 [ 0.79, 2.31 ] 0.70 [ 0.36, 1.36 ] 0.58 [ 0.33, 1.01 ] 1.35 [ 0.91, 2.00 ]

Subtotal (95% CI)

488

461

100.0 %

1.00 [ 0.79, 1.26 ]

Total events: 109 (Treatment), 101 (Control) Heterogeneity: Chi2 = 9.97, df = 7 (P = 0.19); I2 =30% Test for overall effect: Z = 0.01 (P = 0.99) 3 long term - loss to follow-up for any reason (by 2 years) Unclear - Individual 2008 Brief - Group 1995 8/80 19/67 11/80 23/57
0.001 0.01 0.1 Favours treatment 1 10 100 1000 Favours control

16.7 % 37.7 %

0.73 [ 0.31, 1.71 ] 0.70 [ 0.43, 1.15 ]

(Continued . . . )

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156

(. . .
Study or subgroup Treatment n/N Standard - Individual 03b 29/68 Control n/N 30/68 Risk Ratio M-H,Fixed,95% CI 45.6 % Weight

Continued) Risk Ratio

M-H,Fixed,95% CI 0.97 [ 0.66, 1.42 ]

Subtotal (95% CI)
Total events: 56 (Treatment), 64 (Control)

215

205

100.0 %

0.83 [ 0.62, 1.10 ]

Heterogeneity: Chi2 = 1.14, df = 2 (P = 0.57); I2 =0.0% Test for overall effect: Z = 1.29 (P = 0.20) 4 long term - loss to follow-up for any reason (by 2 years) - Chinese studies Unclear - Individual 2008 Brief - Group 1995 Standard - Individual 03b 8/80 19/67 29/68 11/80 23/57 30/68 16.7 % 37.7 % 45.6 % 0.73 [ 0.31, 1.71 ] 0.70 [ 0.43, 1.15 ] 0.97 [ 0.66, 1.42 ]

Subtotal (95% CI)
Total events: 56 (Treatment), 64 (Control)

215

205

100.0 %

0.83 [ 0.62, 1.10 ]

Heterogeneity: Chi2 = 1.14, df = 2 (P = 0.57); I2 =0.0% Test for overall effect: Z = 1.29 (P = 0.20)

0.001 0.01 0.1 Favours treatment

1

10 100 1000 Favours control

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

157

Analysis 4.3. Comparison 4 SENSITIVITY ANALYSIS - Chinese studies vs non-Chinese studies, Outcome 3 Compliance: 2b. With follow-up - received intervention but left the study early.
Review: Psychoeducation for schizophrenia

Comparison: 4 SENSITIVITY ANALYSIS - Chinese studies vs non-Chinese studies Outcome: 3 Compliance: 2b. With follow-up - received intervention but left the study early

Study or subgroup

Experimental n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 medium term Standard - Both 2004 Standard - Group 1988 Standard - Individual 93 Unclear - Group 1996 0/43 4/41 1/10 7/73 1/43 2/26 0/10 17/73 7.0 % 11.4 % 2.3 % 79.3 % 0.33 [ 0.01, 7.96 ] 1.27 [ 0.25, 6.44 ] 3.00 [ 0.14, 65.90 ] 0.41 [ 0.18, 0.93 ]

Subtotal (95% CI)

167

152

100.0 %

0.56 [ 0.29, 1.10 ]

Total events: 12 (Experimental), 20 (Control) Heterogeneity: Chi2 = 2.75, df = 3 (P = 0.43); I2 =0.0% Test for overall effect: Z = 1.69 (P = 0.091) 2 medium term - Chinese studies Standard - Both 2004 Standard - Group 1988 Standard - Individual 93 Unclear - Group 1996 0/43 4/41 1/10 7/73 1/43 2/26 0/10 17/73 7.0 % 11.4 % 2.3 % 79.3 % 0.33 [ 0.01, 7.96 ] 1.27 [ 0.25, 6.44 ] 3.00 [ 0.14, 65.90 ] 0.41 [ 0.18, 0.93 ]

Subtotal (95% CI)

167

152

100.0 %

0.56 [ 0.29, 1.10 ]

Total events: 12 (Experimental), 20 (Control) Heterogeneity: Chi2 = 2.75, df = 3 (P = 0.43); I2 =0.0% Test for overall effect: Z = 1.69 (P = 0.091)

0.01

0.1

1

10

100

Favours psychoeducation

Favours standard care

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158

Analysis 4.4. Comparison 4 SENSITIVITY ANALYSIS - Chinese studies vs non-Chinese studies, Outcome 4 Relapse: 1. Relapse for any reason.
Review: Psychoeducation for schizophrenia

Comparison: 4 SENSITIVITY ANALYSIS - Chinese studies vs non-Chinese studies Outcome: 4 Relapse: 1. Relapse for any reason

Study or subgroup

Treatment n/N

Control n/N

Risk Ratio M-H,Fixed,95% CI

Weight

Risk Ratio M-H,Fixed,95% CI

1 medium term Brief - Group 1995a Brief - Group 1999 Brief - Group 2007 Standard - Both 2008b Standard - Group 1988 Standard - Individual 03c Standard - Unclear 1996 Standard - Unclear 2005 Standard - Unclear 2006 Unclear - Both 2007 Unclear - Both 2008 11/85 14/24 6/44 11/45 19/41 6/37 86/125 4/69 9/58 6/52 2/48 23/80 15/22 8/37 25/45 13/26 13/36 81/111 8/73 19/58 16/50 1/48 10.2 % 6.7 % 3.7 % 10.8 % 6.9 % 5.7 % 37.0 % 3.4 % 8.2 % 7.0 % 0.4 % 0.45 [ 0.23, 0.86 ] 0.86 [ 0.55, 1.33 ] 0.63 [ 0.24, 1.65 ] 0.44 [ 0.25, 0.78 ] 0.93 [ 0.56, 1.54 ] 0.45 [ 0.19, 1.05 ] 0.94 [ 0.80, 1.11 ] 0.53 [ 0.17, 1.68 ] 0.47 [ 0.23, 0.96 ] 0.36 [ 0.15, 0.85 ] 2.00 [ 0.19, 21.33 ]

Subtotal (95% CI)

628

586

100.0 %

0.70 [ 0.61, 0.81 ]

Total events: 174 (Treatment), 222 (Control) Heterogeneity: Chi2 = 24.27, df = 10 (P = 0.01); I2 =59% Test for overall effect: Z = 4.77 (P < 0.00001) 2 medium term - Chinese studies Brief - Group 1995a Brief - Group 1999 Brief - Group 2007 Standard - Both 2008b Standard - Group 1988 Standard - Individual 03c Standard - Unclear 1996 Standard - Unclear 2005 Standard - Unclear 2006 Unclear - Both 2007 11/85 14/24 6/44 11/45 19/41 6/37 86/125 4/69 9/58 6/52 23/80 15/22 8/37 25/45 13/26 13/36 81/111 8/73 19/58 16/50
0.2 0.5 1 2 5

10.2 % 6.7 % 3.7 % 10.8 % 6.9 % 5.7 % 37.0 % 3.4 % 8.2 % 7.0 %

0.45 [ 0.23, 0.86 ] 0.86 [ 0.55, 1.33 ] 0.63 [ 0.24, 1.65 ] 0.44 [ 0.25, 0.78 ] 0.93 [ 0.56, 1.54 ] 0.45 [ 0.19, 1.05 ] 0.94 [ 0.80, 1.11 ] 0.53 [ 0.17, 1.68 ] 0.47 [ 0.23, 0.96 ] 0.36 [ 0.15, 0.85 ]

Favours treatment

Favours control

(Continued . . . )

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

159

(. . .
Study or subgroup Treatment n/N Unclear - Both 2008 2/48 Control n/N 1/48 Risk Ratio M-H,Fixed,95% CI 0.4 % Weight

Continued) Risk Ratio

M-H,Fixed,95% CI 2.00 [ 0.19, 21.33 ]

Subtotal (95% CI)

628

586

100.0 %

0.70 [ 0.61, 0.81 ]

Total events: 174 (Treatment), 222 (Control) Heterogeneity: Chi2 = 24.27, df = 10 (P = 0.01); I2 =59% Test for overall effect: Z = 4.77 (P < 0.00001) 3 long term Brief - Group 1995 Standard - Both 1996 Standard - Both 2004 Standard - Group 2005 Standard - Individual 03b Standard - Unclear 2005 30/67 7/41 3/43 53/111 38/68 14/69 30/57 14/41 15/43 66/109 52/68 16/73 16.6 % 7.2 % 7.7 % 34.1 % 26.6 % 8.0 % 0.85 [ 0.59, 1.22 ] 0.50 [ 0.23, 1.11 ] 0.20 [ 0.06, 0.64 ] 0.79 [ 0.62, 1.01 ] 0.73 [ 0.57, 0.94 ] 0.93 [ 0.49, 1.75 ]

Subtotal (95% CI)

399

391

100.0 %

0.73 [ 0.62, 0.85 ]

Total events: 145 (Treatment), 193 (Control) Heterogeneity: Chi2 = 7.22, df = 5 (P = 0.20); I2 =31% Test for overall effect: Z = 4.01 (P = 0.000060) 4 long term - Chinese studies Brief - Group 1995 Standard - Both 1996 Standard - Both 2004 Standard - Group 2005 Standard - Individual 03b Standard - Unclear 2005 30/67 7/41 3/43 53/111 38/68 14/69 30/57 14/41 15/43 66/109 52/68 16/73 16.6 % 7.2 % 7.7 % 34.1 % 26.6 % 8.0 % 0.85 [ 0.59, 1.22 ] 0.50 [ 0.23, 1.11 ] 0.20 [ 0.06, 0.64 ] 0.79 [ 0.62, 1.01 ] 0.73 [ 0.57, 0.94 ] 0.93 [ 0.49, 1.75 ]

Subtotal (95% CI)

399

391

100.0 %

0.73 [ 0.62, 0.85 ]

Total events: 145 (Treatment), 193 (Control) Heterogeneity: Chi2 = 7.22, df = 5 (P = 0.20); I2 =31% Test for overall effect: Z = 4.01 (P = 0.000060)

0.2

0.5

1

2

5

Favours treatment

Favours control

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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ADDITIONAL TABLES
Table 1. Chinese studies vs full analysis (sensitivity analyses)

Primary outcome Compliance Relapse

China Experimental 19/174 44/353

China Control 22/172 90/347

China RR (CI)

Full analysis Experimental

Full analysis Control 101/461 22/586

Full analysis RR (CI) 1.00 (0.79-1.26) 0.7 (0.61-0.81)

0.85 (0.48-1.51) 109/488 0.48 (0.35-0.66) 174/628

Table 2. English studies vs full analysis (sensitivity analyses)

Primary outcome Compliance Relapse

English Experimental 90/314 130/275

English Control 79/289 132/239

English RR (CI) 1.04 (0.8-1.34)

Full analysis Experimental 109/488

Full analysis Control 101/461 22/586

Full analysis RR (CI) 1.00 (0.79-1.26) 0.7 (0.61-0.81)

0.85 (0.73-0.99) 174/628

Table 3. Suggested design of study

Methods

Allocation: randomised, fully explicit description of methods of randomisation and allocation concealment. Blinding: single, tested. Setting: community rather than hospital. Duration: 12 weeks treatment, and then follow-up to at least 52 weeks Diagnosis: schizophrenia (ICD). N = 300.* Age: adults. Sex: both. 1. Psychoeducation. N = 150. 2. Standard care. N = 150. General: time to all-cause treatment failure marked by its discontinuation, relapse, general impression of clinician (CGI), career/other, compliance with treatment, healthy days. Mental state: BPRS and PANSS. Global state: CGI (Clinical Global Impression). Quality of life. QOL (Quality of Life Questionnaire). Family burden: FBQ (Family Burden Questionnaire). Social functioning: return to everyday living for 80% of time.* Adverse events: any adverse event recorded. Economic outcomes. * Powered to be able to identify a difference of ~ 20% between groups for primary outcome with adequate degree of certainty

Participants

Interventions

Outcomes

Notes

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APPENDICES Appendix 1. Methods section of original review
Criteria for considering studies for this review Types of studies All relevant randomised controlled trials. Quasi-randomised trials, using, for example, alternation as the method of randomisation, were excluded. Types of participants People suffering from severe non-affective mental disorders such as schizophrenia and schizophreniform, schizoaffective or schizotypal disorders, and including those with multiple diagnoses. Types of interventions 1. All didactic interventions of psychoeducation or patient teaching involving individuals or groups were included. Psychoeducational interventions were defined as any group or individual programme involving interaction between information provider and patient. These programmes address the illness from a multidimensional viewpoint, including familial, social, biological and pharmacological perspectives. Patients are provided with support, information and management strategies. Programmes of 10 sessions or less were considered as ’brief ’, and 11 or more as ’standard’ for the purposes of this review. Interventions including elements of behavioural training, such as social skills or life skills training, as well as education performed by patient peers, were excluded from this review. Staff education studies were also excluded. 2. Standard care was defined as the normal level of psychiatric care provided in the area where the trial was carried out. Types of outcome measures Primary outcomes 1. Patient compliance, defined as: 1.1 compliance with medication; 1.2 compliance with follow-up. 2. Relapse. Secondary outcomes 1. Level of knowledge: 1.1 improvement of understanding of his/her illness and need for treatment; 1.2 level of knowledge about expected and undesired effects of medication. 2. Behavioural outcomes: 2.1 level of psychiatric symptoms; 2.2 symptom control skills; 2.3 problem-solving skills; 2.4 social skills. 3. Family members’ level of knowledge: 3.1 family members’ understanding of medication and psychiatric illness. 4. Service utilisation: 4.1 use of outpatient treatment; 4.2 length of hospitalisation. 5. Health economic outcomes: 5.1 treatment costs.
Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 162

Data collection and analysis 1. Selection of trials The search for trials was performed independently by two reviewers. Potentially relevant abstracts were identified and full papers were assessed for inclusion and methodological quality. Any disagreement was resolved by discussion. 2. Quality assessment Trials were allocated to three quality categories by each reviewer, as described in the Cochrane Collaboration Reviewers’ Handbook (Clarke 2000). When disputes arose as to which category a trial was allocated, again, resolution was attempted by discussion. When this was not possible and further information was necessary to clarify into which category to allocate the trial, data was not entered and the trial was allocated to the list of those awaiting assessment. Only trials in Category A or B were included in the review. 3. Data management 3.1 Data extraction This was performed independently by at least two reviewers and the authors of trials were contacted to provide missing data where possible. 3.2 Intention-to-treat analysis Data were excluded from studies where more than 50% of participants in any group were lost to follow-up. A sensitivity analysis was performed to assess the impact of this decision. In studies with less than 50% dropout rate, withdrawals were considered as negative outcome. 4. Data analysis 4.1 Binary data For binary outcomes an estimation of the relative risk (RR) and its 95% confidence interval (CI) was calculated. The weighted number needed to treat statistic (NNT) was also calculated. The chi-squared test for heterogeneity was used to establish heterogeneity, as well as visual inspection of graphs. When heterogeneity (P < 0.1) occurred, the reviewers tried to establish if there were reasons for true heterogeneity. If studies were found to be comparable in spite of heterogeneous outcomes, a random effects model was used in statistical calculations. 4.2 Continuous data 4.2.1 Skewed data: continuous data on clinical and social outcomes are often not normally distributed. To avoid the pitfall of applying parametric tests to non-parametric data, the following standards were applied to all data before inclusion: i. standard deviations and means were reported in the paper or were obtainable from the authors; ii. when a scale started from a finite number (such as 0), the standard deviation, when multiplied by 2, was less than the mean (as otherwise the mean was unlikely to be an appropriate measure of the centre of the distribution (Altman 1996)). Endpoint scores on scales often have a finite start and end point and this rule can be applied to them. 4.2.2 Summary statistic: for continuous outcomes a weighted mean difference (WMD) or a standardised mean difference (SMD) between groups was estimated. Again, if heterogeneity was found a random effects model was used. A post-hoc decision was made to pool the GAF scale (APA 1994) and its virtually similar earlier version, the GAS scale (Endicott 1976), using WMD statistics. 4.2.3 Valid scales: continuous data from rating scales were included only if the measuring instrument had been described in a peerreviewed journal and the instrument was either a self report or completed by an independent rater or relative (not the therapist). 4.2.4 Endpoint versus change data: where possible, endpoint data were presented and if both endpoint and change data were available for the same outcomes, then only the former were reported in this review. 5. Addressing publication bias Data from all identified and selected trials were entered into a funnel graph (trial effect against trial size) in an attempt to investigate the likelihood of overt publication bias (Egger 1997). 6. Sensitivity analyses A sensitivity analysis was performed to assess the impact of the reviewers’ decision to exclude trials with more than 50% loss of participants.

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Appendix 2. 2001 Search
2001 update (Pekkala 2002) To update this review the searches were repeated in January 2001 and in May 2001. The search in January 2001 yielded 213 citations and 235 in May 2001, of which both 200 were quickly rejected as not relevant for the following mutually exclusive reasons: duplicate references, not a randomised controlled trial, participants were not people with schizophrenia, the intervention was not psychoeducation defined as interaction between information provider and patient or the control intervention was not standard care defined as the normal level of psychiatric care provided in the area where the trial was carried out. No new trials were identified for the comparison of psychoeducation vs. standard care. In this process four ongoing studies were recognised by the reviewers to be relevant and were included in the section of ongoing studies. Six papers awaiting assessment were translated and rejected as not relevant, one study (Cormier 1995) was moved to the excluded studies section due to lack of usable data. Secondary reports of included studies were found and added to the list of references. The total number of studies that matched with the reviewers’ inclusion criteria closely enough to be mentioned in either the included studies or excluded studies section was 28. One paper is awaiting assessment until the additional information is obtained. The review cites 18 studies dating from 1983 to 1998 in the excluded studies section and 10 studies dating from 1988 to 1999 in the included studies section. The results of the review have not changed.

Appendix 3. 1999 Search
Original 1999 search (Pekkala 2002) The original searches in 1999 yielded 583 electronic records, of which 495 were rejected during the first inspection. The other 88 papers were ordered, inspected and 58 were quickly rejected as not relevant. The remaining 30 papers were considered. During this process a further four studies were recognised by the reviewers to be relevant.

Appendix 4. 2010 Search
Update 2010 - Cochrane Schizophrenia Group Trials Register (February 2010) We searched the register using the phrase: [*Psychoeducat* in interventions of STUDY] This register is compiled by systematic searches of major databases, handsearches and conference proceedings (see Group Module).

WHAT’S NEW
Last assessed as up-to-date: 19 April 2010.

Date 28 November 2012

Event Amended

Description Update search of Cochrane Schizophrenia Group’s Trial Register (see Search methods for identification of studies), 27 studies added to awaiting classification.

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HISTORY
Protocol first published: Issue 2, 1999 Review first published: Issue 4, 2000

Date 28 April 2011

Event

Description

New citation required but conclusions have not Results from 2010 search added weight to previous changed results but did not substantially change previous conclusions New search has been performed Update search results incorporated into review. All included data were double checked and analysis performed

3 May 2010

30 April 2008

New citation required but conclusions have not Substantive amendment changed New citation required but conclusions have not First update changed New citation required and conclusions have changed First version of this review

2 July 2002

25 November 1999

CONTRIBUTIONS OF AUTHORS
1. Original review Eila Pekkala - initiation of the review, protocol production, searching, data extraction, analysis, data interpretation and writing the final report. Lars Bertil Merinder - protocol production, analysis, data interpretation and writing the final report of the original review. 2. 2010 update Jun Xia - selected studies, extracted data and wrote up report during the 2010 update. Madhvi R Belgamwa - extracted and input English trial data during 2010 update. Lars Bertil Merinder - extracted data of English trials and handled all queries relating to trials from the original review.

DECLARATIONS OF INTEREST
None.

Psychoeducation for schizophrenia (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

165

SOURCES OF SUPPORT Internal sources
• Department of Psychiatry, Porvoo Hospital, Finland. • Department of Psychiatric Demography, Institute of Basic Psychiatric Research, University Hospital of Aarhus, Denmark.

External sources
• Finnish Office for Health Technology Assessment (FinOHTA), Finland.

DIFFERENCES BETWEEN PROTOCOL AND REVIEW
1. Wording of protocol We have substantively reworded the protocol of this review. We think that this rewording represents an improvement in clarity but, also, that it did not substantively change the procedures by which we undertook the review. For the record the methods section of the previous version of this review is reproduced in Appendix 1. 2. Additional outcomes Many studies found in the 2010 update search reported data on outcomes such as social function, mental state, adverse event etc, which were not listed in the original protocol. But we feel that these outcome data are of significant clinical value and important to this review. Therefore, we amended the original protocol and added/supplemented the following secondary outcomes: social function, global function, global state, mental state, expressed emotion, quality of life, satisfaction with care and adverse events.

NOTES
This review has undergone anonymous external peer review by two experts in the field.

INDEX TERMS Medical Subject Headings (MeSH)
Awareness; Family; Patient Compliance; Patient Education as Topic [∗ methods]; Psychotic Disorders [rehabilitation]; Randomized Controlled Trials as Topic; Schizophrenia [∗ rehabilitation]; Schizophrenic Psychology

MeSH check words
Female; Humans; Male

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...The man who loved flowers When you meet a normal person at a normal event, you talk to them and everything they say seems normal. They laugh at your jokes, they comment on the weather, they complain about politicians and how they should lower the taxes, as I said a normal person. But after they have left the event is everything about them still normal? This is a story about a young guy from New York who to everyone seems normal guy who has found the love of his life, but actually is a grieving killer who kills woman when they tell him that they are not his soul mate Norma who died 10 years ago. This is Steven King’s “The man who loved flowers”. The story takes place in New York of May 1963, and the setting is very happy. The opening sequence tells us how everybody seemed to be smiling, the air was soft and beautiful, and that this was one of those nights where people who love the city would love this night. To add to the setting the main character is also very happy and very much in love. Because of the happy setting, you feel safe when you read it and you think of the main character as the “good guy”. His happy outer has en effect on the setting for example he makes the old woman at l. 13-17 p. 1, where because of the positive vibes he expresses makes her think of dancing and how spring is beautiful and so on. She begins to have happy thoughts. Even on l. 6 – 13 p. 2, when the radio is talking about how a lot of awful things are happening in the world it doesn’t change...

Words: 831 - Pages: 4

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Psycho

...Psycho 1 This essay will provide a semiotic and psychoanalytical analysis of the Alfred Hitchcock film Psycho with the help of theories of Dr. Sigmund Freud, it will also be stressing some of the critical differences between men and women when it comes to power. The theme of this movie contains a young woman who steals $40,000 from her employer's client, and ends up on a peculiar journey of terror when she meets a troubled young motel manager who is controlled by his mother. Patrick McGilligan (2003) said that the Bates character was based on Wisconsin serial killer Ed Gein, who may have had an incestuous relationship with his mother. (McGilligan, 2003. Page 579) One of the most important signifiers in the movie is money. Cash is the early desire that leads the main character, a banker named Marion Crane (portrayed by the actress Janet Leigh), toward a path that leads her to her own self ruin. What is indicated is the control that money and gluttony have over all humans, and how one has serious consequence for surrendering to its control. Looking at an exemplary structure made up of the want to marry her boyfriend, but not having the money needed to do so, Crane comes up with a solution that has presented itself. A very wealthy oil businessperson comes in and asks Crane to put $40,000 cash in the bank. (Berger, p. 24) When headed to the bank, Crane begins to imagine how the cash could help ease her stifled wants to leave a boring job and set......

Words: 1649 - Pages: 7