Assessment of expressed emotion in family members of patients with schizophrenia in a selected Medical College Hospital , Assam

Background: Schizophrenia is a severe form of mental disorder which is chronic and disabling in nature. Family members of schizophrenia patients often show negative attitude with higher range of expressed emotion (EE) towards their relative as they experience signifi cant stress in coping with caring such patients. Material and methods: The present study was conducted to assess EE of family members of patients with schizophrenia. The study setting was outpatient department and psychiatric ward of Assam Medical College Hospital, Dibrugarh. Hundred schizophrenia patients and 100 family members were included in the study through purposive sampling technique. Tools used in the study were sociodemographic and clinical datasheet of patient, socio-demographic datasheet of family member, and Family Attitude Scale. Results: Majority of family members (79%) had low level of EE. Their EE had signifi cant association with age of onset of illness. EE was higher when schizophrenia started before 20 years of patient’s age. Age and marital status of the family members had signifi cant associations with their EE. It increased along with increased age of the family members whereas majority of the younger family members had low level of EE. Married family members had higher level of EE. Conclusion: There is need for psychosocial nursing intervention for the family members of schizophrenia patients to help them cope with their stress.


Introduction
Schizophrenia is severe and chronic mental disorder.It occurs in all class, colour, and religion globally.26.3 million people in the world suff ered from schizophrenia.[1] It was one of the most common causes of disability (16.7 million people of all ages were disabled in the world).In India, 4.3-8.7 million people suff ered from this illness.[2] Family members are the direct care providers.Taking care of schizophrenia is very stressful due to its chronic and disabling nature, poor outcome, and varied symptoms.Besides that economic burden, lack of support system, inadequate information on the illness, negative attitude, and stigma from society-all act as stressors on the family members.In turn, they start to show negative attitude to the patients in the form of high expressed emotion (EE).Specifi c characteristics of family-patient interactions and their associations have been observed by researchers and found that it has importance in the course and prognosis of mental illnesses.And this adverse family interaction or environment is termed as EE.Criticisms by family members, hostile and emotionally over involved behaviours towards the patients are regarded as high EE.Many research studies have proved that high EE by family members towards the patient is one of the strong predictors of relapse in schizophrenia.[3][4][5][6][7] One study reported that among all the components of EE, critical comment was an indicator of prognosis in the course of schizophrenia.[8] Th ere are many studies conducted on EE of family members of schizophrenia patients around the world.Few are as follows.
Suhail et al. [9] found that Pakistani relatives showed higher levels of EE as compared to those reported from many other countries.Th e relatives had more hostility (57%), and emotional overinvolvement (EOI) (45%).Th e researchers found that most of the women who were mothers had high emotional over involvement.
Another study conducted in Pakistan by Ikram et al. [10] found that 75% Pakistani relatives had high EE, critical comment 3.8%, hostility 59%, warmth 3.33%, positive remarks 1.17%, and emotional over involvement 53%.When the researchers compared these fi ndings cross culturally with studies from many other countries they found higher levels of overall index of EE in Pakistani.Th ey also found that Pakistani relatives were more hostile and emotionally over involved as compared to many other countries.
Bogojevic et al. [11] found that EE of family members of 71.4% of patients who experienced clinical worsening was high before and during long-term hospitalisation.Th is was more in case of parents (62.5%), and more frequently for mothers.Illness course was better in case of patients having low EE by family members.
In another study, the levels of family burden, family interactions, and EE in fi rst episode psychosis patients were assessed and it was seen that EE was high in half of the keyrelatives.[12] Hence, the literature reviewed gives an overview of the importance of family member's or caregiver's EE on the course and prognosis of the illness.No study was found done in Assam and the northeast part of India.

Material and methods
Th e research approach of the present study was nonexperimental, descriptive, cross-sectional, and survey type.Th e aim of the present study was to assess EE in family members of patients with schizophrenia in a selected Medical College Hospital, Assam.Th e objectives of the study were: i.To assess EE of family members of patients with schizophrenia ii.To fi nd association of EE of family members with sociodemographic variables of patients iii.To fi nd association of EE of family members with clinical variables of patients iv.To fi nd association of EE of family members and their socio-demographic variables

Study setting
Th e study was conducted in the outpatient department (OPD) and psychiatric ward of Assam Medical College Hospital (AMCH), Dibrugarh which is the premier and oldest medical institution in northeastern India.It is the tertiary medical referral centre for upper part of Assam and neighbouring states, including Arunachal Pradesh.

Time period
Th e study was done during January 2014 to January 2016.

Defi nition of the population
In this study, the population consisted of family members accompanying the patients with schizophrenia taking treatment from outpatient and indoor services of the selected hospital during the period of data collection.

Study variables
• Dependent variables: EE of family members of patients with schizophrenia.• Extraneous variables: Selected variables under sociodemographic profi le and clinical/illness profi le of patients and socio-demographic variables of family members.

Inclusion criteria
• Family members of patients suff ering from schizophrenia for more than one year • Family members who were directly involved in the care of the patient • Family members staying with the patient for more than one year • Both genders • Family members of adult age group • Th ose who understoond the nature of the study and give consent.

Exclusion criteria
• Family members suff ering from mental illness • Family members not staying with the patients and not directly involved in the care giving.

Sample size
Hundred family members of 100 patients who fulfi lled the sampling criteria defi ned in the study.
Sampling design: Purposive sampling technique was used in this research study.
Collection of data: Th e data collection was done from the family members of patients suff ering from schizophrenia visiting OPD and psychiatric ward settings of AMCH, Dibrugarh aft er getting institutional ethical clearance and permission, and by interviewing the participants aft er obtaining their formal written permission.

Tools used in the study
1. Socio-demographic and clinical datasheet of patient 2. Socio-demographic datasheet of family member 3. Family Attitude Scale (FAS) [13] Th e tool numbers one and two were semi-structured, developed by the researcher.FAS is a standard tool developed by Kavanagh et al. [13] Th ere are 30 items.Scoring is done on Likert scale from zero to four.Total score is 120.High score on the scale denotes high expressed emotion.Earlier studies had reported that optimum cutoff score of 60 and above in family members predicted relapse in the patients.[14] Th is tool was translated into Assamese-the vernacular language, pilot tested (reliability=0.96),and used in this study.

Findings related to socio-demographic profi le of patients
Mean age of the patients was 32.02 years (standard deviation [SD]=10.10).

Findings related to illness profi le of the patients
Table 2 shows that majority of the patients' (45%) illness started between 21-32 years of life followed by below 20 years in 38%.Th e duration of illness of majority of the patients (60%) was one to fi ve years.Majority of the patients included in the study were admitted to hospital for treatment of this illness for less than fi ve times (89%).Nine four per cent of the patients were from indoor setting whereas only six per cent were taking treatment from OPD. Majority of the patients stopped medicines (46%), 36% were irregular, and only 18% patients were regular on medication.Cost of medicines of patients' treatment was equal between Rs. 100-500 (42%) and Rs.501-1000 (41%).In most of the patients, treatment expenditure was borne by fathers (31%) followed by husbands (22%).

Findings related to socio-demographic profi le of family members
Mean age of the family members was 43.06 years (SD=12.97).

Findings related to EE of family members
Mean score of EE of family members (n=100) was 39.59 (median=34, mode=23) with SD=20.43 which can be assumed as low EE (maximum total FAS score=120).Seventy nine per cent family members had low EE.Only 21% had high level of EE.
Table 4 shows that there were no signifi cant association among the socio-demographic variables of patients and level of EE of family members (p>0.05).
Table 5 shows that duration of illness, medication status, current treatment setting, cost of medicine per month, and who bears the treatment expenditure did not have any signifi cant association with EE level.But age of onset (p=0.020 which is <0.05) and number of hospitalisation for the illness (p=0.004 which is <0.05) had signifi cant association with EE of family members.
Table 6 shows that there were signifi cant associations of EE of family members with their age and marital status.Family members' gender, educational level, occupation, monthly income, religion, language, domicile, ethnicity, relationship with patient, type of family, duration of stay with patient, contact per day with patient did not have signifi cant association with level of EE (p>0.05).

Socio-demographic variables of patients
Patients' mean age in the present study was 32.02 years (SD=10.10).In support, few study fi ndings also reported more or less similar mean ages of patients, e.g.30.13 years (SD=9.14)by Mottaghipour et al., [4] 33.5 years (SD=8.5)by Nirmala et al., [15] and 29.6 years (SD=7.9)by Kopelowicz et al. [16] Th erefore, it can be said that the present study fi ndings also refl ect the worldwide epidemiology of schizophrenia that it aff ects people at their early ages.
In the present study, most of patients were high school (37%) educated.In support, Bharti [17] and Dorian et al. [18] also reported similar fi ndings.
Th ere were more married patients in the present study (53%).Similar fi ndings were reported by another study.[15] In contrast, few studies reported that majority of the patients in their study were unmarried.[5,7,16] Most of the patients in the study were unemployed and did not have any income.Previous studies also revealed similar fi ndings.[4,5,19] Th ese fi nding are refl ecting the universal picture of the illness-its debilitating and burdensome nature.
In the present study, age of onset of the illness in most of the patients (45%) was during 21-32 years of their life.Similarly, Kopelowics et al. [16] found mean age of onset of the illness was 23.5 years (SD=5.9).Another study [19] reported mean age of onset of illness was 30.2 years (SD=11.3).

Socio-demographic variables of family members
Mean age of the family members in the present study was 43.06 years (SD=12.97).Similar fi ndings were reported   [20] Th e family members in the present study were almost of equal gender.It may be due to the fact that females are given equal status in Assamese society.Specially, women of upper part of Assam are seen to take equal responsibility in agriculture, household activities, etc. like men.
Th ere was more number of mothers in the family members in the present study.Diff erent researchers also reported mothers as their major group of subjects in their studies.[5,7,8,10,16,19,20] It refl ects that mothers of all human being are same in showing their love and caring attitude towards their sick children.
In the present study, 90% of the family members were staying with the patient for more than ten years and 75% family members had more than ten hours of contact per day with the patient.It shows that the family members of the present study were close relatives and spent quite a long time with the patients.

EE of family members
Th e present study revealed that mean score of EE of family members was 39.59 (SD=20.43)which can be regarded as low EE.When EE was categorised into low EE and high EE group, it was seen that 79% family members had low EE and only 21% had high level of EE.In support of these fi ndings, Kopelowicz et al. [16] found that maximum number of the key relatives (67%) in their study had low EE.Dorian et al. [18] also reported that only 19% of the caregivers were high in EE.In contrast, most of the studies conducted earlier provide evidences of high EE in family members or caregivers.[5,6,9,10,15,19,20] Th e present study fi ndings indicate that Assamese people had more acceptance and caring attitude towards mentally ill relative.Th eir acceptance was expressed verbally by themselves during the interviews with the researcher.Th is might be the cause of having lower level of EE towards the patients.A pervious study also reported that the caregivers having low EE had higher overall acceptance.[18] In a review study, Brady and McCain[21] found that studies conducted in Non-westernised countries like Asian, African, Middle Eastern Countries reported fi ndings which EE=Expressed emotion, df=Degree of freedom, NS=Statistically not signifi cant at 0.05 level were suggestive of some positive aspects associated with living with a family member who had schizophrenia.

Association of EE of family members with socio-demographic variables of patients
Th e present study fi ndings did not reveal any signifi cant association of the socio-demographic variables of patients and level of EE of family members.Similarly, Nirmala et al. [15] found no association of age, marital relationship of patients with EE of family members.Another study [4] reported no association of family type, place of residence, gender, marital status, and employment status of patients with EE.Bharti [17] also found no signifi cant association of EE of family members with age, sex, religion, education, residence, socioeconomic status, except marital status.She found that patients who were single perceived higher criticism.
In contrast, fi ndings of Carrà et al. [22] revealed signifi cant association of EE of relatives and education of patients.In case of educated patients, EE level of relatives was low.

Association of EE of family members with clinical variables of the patients
In the present study, the age of onset of the illness had signifi cant associations with EE.EE of the family members was lower for the patients whose illness started aft er 33 years of their lives.Early onset of the illness might have caused care burden due to long term duration causing increased EE of the family members.On the contrary, researchers of a study [19] reported that length of illness, age of onset of the illness, and severity of symptoms were not associated with high level EE.
In the present study, duration of illness, medication status, current treatment setting, cost of medicine per month, and who bears the treatment expenditure did not have any signifi cant association with EE level.Similarly, a study done in India also reported no association of duration of illness of patient with EE. [15] King and Dixon [7] also found that high EE did not have association with medication compliance of the patients.Ng [23] reported that the length of the patient's illness history, i.e., the number of years in which the patient has been diagnosed and treated for schizophrenia was not  Th e present study fi ndings also showed that EE was signifi cantly associated with marital status of the family members.Married family members had higher levels of EE towards their relative patients.It may be due to the fact that the married family members already had responsibility towards their family and an added responsibility of caring a schizophrenia patient lead to more stress in them, therefore they end up showing their frustration on the patients.In contrast, a study found no association of marital status of caregivers with their EE towards the patient.[4] In the present study, family members' gender, educational level, occupation, monthly income, religion, language, domicile, ethnicity, relationship with patient, type of family, duration of stay with patient, and contact per day with patient were not associated with level of EE (p>0.05).In support of this, Mottaghipour et al. [4] also found that caregivers' gender, type of family, place of residence, and employment status was not associated with EE.King and Dixon [7] found no association between amount of contact and high EE.
One important fi nding of the current study is that there was no association of EE with relationship of family members with the patient.Only one study supported this fi nding.[4] On the other hand, few studies done previously reported having association of diff erent types of family members/caregivers and EE.For example, Pourmand et al. [5] reported that mothers (58%) and fathers (32%) had high EE.Cutting et al. [24] also found that parents had higher EOI ratings.Ng [23] found that patients reported highest level of EE from sibling caregiver type followed by parents and spouses.

Implication
Th e fi ndings of the study may be useful for the mental health professionals for planning family oriented psychosocial interventions.

Limitation
Th e study was done on family members who attended inpatient and outpatient services of AMCH, Dibrugarh; therefore, the data cannot be generalised.Th e samples were selected using purposive sampling method; therefore, the sample is not representative of families of all schizophrenia patients.

Conclusions
EE of family members is an important issue in schizophrenia as it has direct relationship with severity of the illness, its course, and prognosis.Assessment of EE in family members is helpful in identifying experience of distress and burden in the family members or caregivers as a primary step for family intervention.Although the present study reported low level of EE in maximum family members, there is need for psychosocial nursing care for every family members of schizophrenia patient which in turn will reduce the relapse rate, help them to eff ectively cope with the stress of managing the mentally ill family member at home.

Table 4 :
Association between EE of family members with socio-demographic variables of patients (n=100)

Table 5 :
Association of EE of family members with clinical variables of the patients (n=100) OJPAS OJPASTM TM | 2016 Nov 20 [Epub ahead of print] | 2016 Nov 20 [Epub ahead of print]

Table 6 :
Association of EE of family members with their socio-demographic variables (n=100) EE=Expressed emotion, df=Degree of freedom, S=Statistically signifi cant at 0.05 level, NS=Statistically not signifi cant at 0.05 level related to the level of family's emotional involvement, nor the level of family's criticism.