Family and Patient Psychoeducation for Severe Mental Disorder in Iran: A Review.

Objective: There are evidence-based practices in the field of family and patient psychoeducation for patients suffering from severe mental disorders. However, given the variation in resources and cultural contexts, implementation of these services, especially in low and middle-income countries is faced with challenges. This study aimed to review articles on family and patient psychoeducation of severe mental disorders in Iran and to find the characteristics of the main components necessary for the implementation of such practices in clinical settings. Method : All published studies on family and patient psychoeducation for severe mental disorders (schizophrenia, schizoaffective, and bipolar disorder) conducted in Iran were searched up to May 2018; and key features and findings of each study were extracted and presented. Results: Forty-eight studies were included in this review, of which 27 were randomized controlled trials, and 20 were quasi-experimental. One study was an implementation and service development report. The main findings of these studies were a significant decrease in relapse rate and/or rehospitalization rate and a significant decrease of burden and distress of families. Conclusion: Despite a wide diversity in approaches, this review showed that different psychosocial interventions in which psychoeducation is one of their core and main components have promising results, demonstrating the significance of this intervention in Iranian mental health research. In our opinion, based on evidence, even with limited resources, it is no longer acceptable to deprioritize some forms of psychoeducation for patients and their families in clinical settings.

There are evidence-based practices in the field of family and patient psychoeducation for patients suffering from severe mental disorder (SMD). Clinical trials and systematic reviews have demonstrated that psychoeducation significantly reduces relapse and rehospitalization rates in patients with SMD as well as burden and stress level of caregivers (1,2,3). However, family and patient psychoeducation are not widely implemented in routine clinical practices, even in developed countries (4). The main issues to be considered in the implementation of psychoeducation in routine clinical practices are staff skills, training, and follow-up supervision, applicability of the intervention to the service users, economic costs, and mental health team's values and preferences (5,6). Furthermore, implementation of these services, especially in low and middle-income countries (LMICs), is faced with challenges, given the variation in resources and cultural contexts. Education of participants, followup, and acceptability of services are few examples of barriers to feasibility that are mentioned in different articles (7). Limited qualitative studies conducted in this area in Iran revealed that families of patients struggle with the lack of information on illnesses and how to deal with different issues related to them, while stigma is still a major concern for them (8,9). In an overview of the first episode psychosis research in Iran, few studies related to aftercare services and psychosocial interventions showed promising results in reduction of relapse rates, distress level of relatives, and negative experience of caregivers (10). Iran J Psychiatry 2019; 14: 1: 84-108 Bipolar disorder occurs in 1% to 3.7% and schizophrenia in 1% of the general population (11,12). The exact number of people suffering from SMD and their families is not available. There are about 60 million people in Iran from early adolescence to old age. Considering there are at least 4 people in a family, it is evident that a vast number of people are affected by SMD . For the past two decades, several studies have been conducted in the realm of patient and family psychoeducation in Iran. Finding information on different aspects of participants and programs, including level of education, type of intervention, and study design, can provide a framework for the implementation of such programs in routine clinical settings in LMICs. This article aimed to review studies on family and patient psychoeducation of SMD in Iran and to find the characteristics of the main components necessary for the implementation of such practices in clinical settings. Demographic data of participants and different aspects of intervention used in psychoeducational research can highlight the need for future research and can also be used as a roadmap for mental health services.

Materials and Methods
All published studies on family and patient psychoeducation for SMD (schizophrenia, schizoaffective, and bipolar disorder) conducted in Iran were searched up to May 2018. The electronic search was performed using PubMed, Scopus, Magiran, SID, PsychInfo, and Google Scholar. The following keywords in English and Farsi were used: psychoeducational family/patient intervention, family/patient psychoeducation, family/patient interventions, family/patient education and caregivers' education/psychoeducation, combined with severe mental disorder/illness, schizophrenia, and schizoaffective bipolar disorder. The included papers were written in Farsi and English. Further, cross-reference searching for the purpose of obtaining more relevant studies was conducted. All studies on patient or family psychoeducation in SMD in Iran were included for this review. However, studies that developed a guideline were excluded. Both authors reviewed relevant studies and extracted data. Any disagreement was resolved by discussion. Where possible, authors of original papers were contacted for additional data. This review should not be considered as a systematic review, but rather as a review and description of key variables of studies supporting the implementation of psychoeducation for families and patients in routine clinical practice . Key features and findings of each study were extracted and presented in two tables. Data extracted on study characteristics included city of study, sample size, diagnosis, patients' gender, relationship of family members to patient, family members' education level, length and number of sessions, use of structured manual, attrition rate, type of intervention, personnel delivering intervention, study design, outcome measures, and main findings (family/patient).
To collect information on different aspects of psychoeducational intervention from each paper, the following categorizations were employed to extract data on each variable:  When different sections of a research were published in more than one paper, they were grouped together under 1 study with different dates/references.  Sample size included the number of patients and/or family members participating in studies. The size of different arms of study were also reported if indicated in the paper .  Patients' gender was reported by percentage or number, the same as the original paper. Classification of the level of education in family members differed in studies and was presented by percentage or the majority of cases.  Length of psychoeducational sessions showed the duration of psychoeducational intervention. Length of each session and number of psychoeducational sessions were also reported .  Reporting of the use of structured manual variable was fitted into different categories. If the psychoeducational intervention was administered according to a manual, the manual reference was mentioned. If the content of the intervention was described based on each session, then "content of sessions described" was mentioned. Otherwise "information not given" was used. When pamphlets or other written materials were reported for psychoeducation, the phrase of "written information is given" was used.  Given the wide diversity in reporting the attrition rate, it was stated the same as the original paper. Attrition rate included pre-and post-analysis dropout rates, response rate, and retention rate.  With regards to type of intervention, all interventions other than "treatment as usual" (TAU) were listed. TAU usually comprised pharmacological treatment and inactive follow-up visits. Different interventions, including home visit/home care, social skills training, multiple family group" (MFG) psychoeducation, patient group psychoeducation, psychosocial rehabilitation, individual psychoeducation, telephone follow-up (TFU) and discharge planning, were reported .  Whenever personnel delivering interventions based on different psychoeducational programs were mentioned in an article, they were included in this paper.  Outcome measures used in each research as well as the main results of different interventions for patients and family members were reviewed. Main results were reported only where there were significant differences in outcome measures.
Four studies only provided written information for educational purposes (25,31,32,64,68). MFG psychoeducation was the most common psychoeducational intervention and was conducted in 31 studies (Table 1). In 16 studies, family psychoeducation was conducted during home visits. Furthermore, patients were present in all family psychoeducational sessions provided at home. Five studies focused on patient psychoeducation and did not provide family psychoeducation (36,42,56,72,79). In the majority of the studies, psychoeducation was delivered along with other interventions, such as active follow-up, home visit, social skills training, crisis management, or psychosocial rehabilitation. Except for 1 study, in which family members were trained and worked as case managers (31,32), other studies involved trained professionals for delivering psychoeducation . One study reported service development (76), therefore, had no outcome report in Table 2. Measures and scales that have been translated into Farsi and used in the studies are listed in Table 2. All studies found improvement in some outcome measures. In 16 studies, a significant decrease in relapse rate or rehospitalization rate was reported in the experimental group (13, 15, 18-21, 26, 31, 32, 44-46, 51, 55-57, 61, 62, 64, 68, 72). Further, 18 studies reported a significant decrease of burden and distress of families (22, 23, 25, 27-29, 31-33, 38-41, 47-50, 53, 54, 58, 65, 68, 69-71, 76).

Discussion
This is the first review of patient and family psychoeducation for patients suffering from SMD in Iran. Despite wide diversity in approaches, this review shows that different psychosocial interventions, with psychoeducation as one of their core and main component, have promising results, demonstrating the significance of this intervention in Iran's mental health research. In 47% of the included studies, the diagnosis of patients was schizophrenia, however, the prevalence and number of beds in main psychiatric wards do not reflect the same statistics. Historically, family and patient psychoeducation first began with providing education to patients and families of patients suffering from schizophrenia. With a limited number of studies on patients suffering from bipolar disorder and first episode psychosis, there is a need to develop more specific psychoeducation interventions for these groups of families and their patients . The content of psychoeducation sessions in Iran was similar to programs in other parts of the world (2,3,11). Most articles mentioned adaptation from other references. Few papers detailed the content of the sessions based on each session or provided a structured manual reference. The point that needs to be considered is that the content of the information provided was brief due to the limited time of personnel and resources .

Family and Patient Psychoeducation in Iran
MFG psychoeducation was presented without the presence of the patient. Cultural context plays a role in this format as families do not speak freely in front of the patients. Patients live with their families in Iran and families are the main caregivers, which is similar to other LMICs (80). With the exception of 6 studies (21,42,56,72,76,79), which provided structured patient psychoeducation, other studies were conducted during home visits offered some form of education to family and their patient. When psychoeducation is delivered at home, program fidelity becomes a major issue. At home, there is less adherence to the protocol in terms of content and time spent for psychoeducation (63). The prevalence of SMD is approximately the same for men and women. However, most participants in psychoeducation were male patients (27 studies out of 34 included studies that reported gender). Although the inpatient bed distribution is about 60% male to 40% female in psychiatric hospitals in Iran (personal communication with the Ministry of Health), research participants' gender distribution still reflects a larger gap. Therefore, an investigation into the reasons why female patients' participation rates are lower is important. For example, does stigma play a part in the gender participation rate (76)? Or, why do research samples include more male patients? On the other hand, the main caregivers were females, similar to other studies (3). For these reasons, looking into the involvement of male family members requires special attention. These considerations could increase participation rates in psychoeducation intervention, and hence provide better outcomes for patients and family members. Studies were conducted at the capital cities of different provinces in Iran (12 provinces out of 31 provinces in Iran), and the majority were conducted in Tehran, the capital city of Iran. Some important questions are how many of the centers provide these services as a routine clinical practice? And how sustainable are psychoeducation programs ? The specialty of those who delivered the services varied. In all studies, the intervention was delivered by professionals, except in 1 study in which family members delivered aftercare services, including psychoeducation (32). Keeping in mind that there are limited resources for family education, this seems to be another option for caregiving families, especially since it is also tested in different cultural settings (81). Duration of psychoeducation in studies reviewed in this article ranged from 1 session to 14. In a number of studies in which aftercare/home visits were provided, the education provided to patients and families was mentioned. However, the format and duration of each session were not reported, which makes it difficult to reach any conclusions. To be able to continue to support and help patients and their families for a longer time, booster sessions and self-help groups are recommended within planning psychoeducation programs for families and patients in community settings .
The list of outcome measures shows a number of questionnaires that were used in different studies, which have been translated and validated for use in Farsi. A set of the same questionnaires for patients as well as their families exist, which were administered in the studies and can be useful for future research in this area. The main significant results are listed in Table 2 for outcomes of family and patient psychoeducation. Although the design of most studies was quasiexperimental, with no randomization, results showed the same trend as other research conducted in these areas in other parts of the world (1, 2, 11). Attrition rate is an important factor in planning the implementation of a program in clinical settings. Social and cultural issues can play a major role in the number of dropouts. Studies that were reviewed here reported attrition rates based on different definitions. Therefore, it is difficult to make a summary of the data. On the other hand, for each study that reported attrition rates, the number lied within an acceptable range compared to other research in this field. Research shows that culturally adapted interventions were more efficacious than the usual treatment in proportion to the degree of adaptation (82). Psychoeducation is offered in different formats and packages in community settings. Given the mixed method and the use of other interventions beside the psychoeducation, which were employed by the majority of studies included in this paper, it is difficult to make a generalized inference of the results. Also, we cannot infer that the outcomes are attributed to psychoeducation per se. However, significant results are promising with regards to a number of important variables that were measured as outcomes for included studies. Some of these include a low rate of relapse and rehospitalization for patients (in 16 studies) as well as the decrease of the level of burden and distress of caregivers (in 18 studies). Another important issue to consider regarding the implementation of a psychoeducation program is the cost-effectiveness of such interventions. Three studies conducted in this area showed a lower cost in intervention groups (48,64,61).

Limitation
The strength of this study is reviewing all interventions with psychoeducation as part of the package offered to patients and their families. Capturing all the core elements of psychoeducation intervention for patients suffering from SMD and their families is another strength of this study, which is useful in planning services .
One limitation of this review is the lack of reported information on a number of variables, such as the educational level of caregivers, the relationship of caregivers to patients, the number of people who conducted the psychoeducational sessions and their professional capacity in several of the included studies. These variables are important in planning socially and culturally adaptable psychoeducation programs with limited resources. Another limitation is that the review did not include the research results of unpublished theses and dissertations topics in this area.

Implications
The main purpose of this review was to gather information on studies conducted in Iran to provide a roadmap for the implementation of psychoeducational programs for patients suffering from SMD and their families. This information can be used as an example for other LMICs. Our review has a promising capacity in the area of patient and family psychoeducation in Iran. However, the main issue is still the implementation of such programs. Few pilot studies conducted in the newly developed community mental health centers in Iran show promising trends for the future (83). However, the important question that still remains is how many family and patient psychoeducation programs are part of ongoing routine clinical practice in Iran's mental health system. One of the barriers to feasibility in LMICs is the educational level of participants in psychoeducational intervention (7). In studies that provided information on the level of education, there is a percentage of participants with no or minimum literacy level (8 studies). A number of studies required at least a few years of education for the patient/family to be able to participate in the study (Table 1). In reality, that is not the case for all the patients or families. This is an important issue that should not prevent them from getting the help and support they need to cope with the illness. Brief psychoeducational interventions in which patients and family members are provided with support and information about medication, the illness, and management strategies improve compliance, decrease relapse, and decrease readmission rates. This outcome is consistent in a number of studies included in the review as well as in other references (9). To overcome difficulties in the implementation of psychoeducation interventions considering the limited resources, the incorporation of a level approach can be one useful way to involve patients and families. Initial contact, assessment, and general education built on the patient and families' acceptability of services and the engagement process can decrease attrition rates (84). Discharge planning, as well as one session of psychoeducation during hospitalization are two examples of a leveled approach, which can facilitate further involvement with mental health services (33,46).
There is a lack of information regarding training and supervision of mental health professionals while conducting psychoeducational sessions in most of the included studies. One study focused on service development with detailed information on training and supervision (76). Unfortunately, this is another important variable missing in the translation of program findings into practice in real-world settings. Translating research findings into "real world" settings and improving the context of interventions plays a central role in the implementation process. To promote large-scale use and sustainability of an intervention, factors that describe various aspects of how the implementation of a program occurs and which important strategies facilitate the delivery are essential (85). Unfortunately, a number of included studies did not provide information on a number of key variables of psychoeducation which was part of their intervention. Based on studies included in this review, the majority of participants were male and the majority of the caregivers were female. Also, based on the results, low educational level should be considered in planning educational programs. Further, it was found that different methods of psychoeducation and mixed interventions are being used to provide psychoeducation to patients and their families. A number of possible contents are available in Farsi for psychoeducational sessions. In more than 40 studies, different mental health professionals were involved who could actively participate in capacity building and implementing psychoeducational intervention into routine practice in their workplace.

Conclusion
This review included all studies that mentioned psychoeducation as part of their intervention. Although there are differences in the format and structure of education offered to families and their patients, the common factors of psychoeducation intervention provide a broad framework for future research as well as planning psychoeducation in community settings. To plan the implementation of family and patient psychoeducation, this review provides a basic structure including information extracted from studies on caregivers, interventions, manuals, and mental health personnel. This article has reviewed studies with a focus on the context and factors affecting implementation, such as the educational level of consumers and their families or the relationship of the main caregiver, which is important for the future planning of psychoeducational programs .

Family and Patient Psychoeducation in Iran
Pragmatic and qualitative evaluations of appropriately adopted interventions that focus on feasibility and acceptance are necessary, given the promising outcome of studies published in Iran and other countries. Using information to guide the decision-making process for the service delivery of psychoeducation intervention for patients and their families is a priority for mental health services. In our opinion, based on evidence, even with limited resources, it is no longer acceptable to deprioritize some forms of psychoeducation for patients and their families in clinical settings . Future research with a focus on the implementation process and service development is much needed to facilitate the availability of psychoeducation to all patients suffering from SMD and their families in mental health settings in Iran.