Schizophrenia is a disorder with varied pathophysiology and heterogeneous treatment outcome across cultures.¹ Its course is highly variable, but it is often chronic with frequent relapses in the patients leading to increasing disabilities. Thus, the disorder has a significantly high cost to the patient in terms of personal suffering, on caregivers as a result of the shift of the burden of care from hospital to families and on the society in terms of direct, indirect and hidden cost from hospitalisation, lost productivity and stigma.² This is even more important in low- and middle-income countries (LMICs) where there are no national social welfare programmes or insurance schemes for patients with severe mental disorders; thus families and relatives of most patients with schizophrenia bear the major burden of mental illness.² Dillehey and colleagues defined the term ‘burden of care’ as a psychological state that ensues from the combination of physical, emotional, work and social pressure, such as economic restrictions that arise from taking care of a patient.³ A large body of evidence from both developing and developed countries agree that the burden on caregivers of patients with psychiatric disorders is enormous.^2,4,5 In Nigeria, Lasebikan et al.,⁶ Adeosun,⁷ Inogho et al.,⁸ Okafor et al.⁹ and Yusuf et al.¹⁰ have reported on the burden and correlates of caregiver burden amongst carers of patients with schizophrenia. Lasebikan et al.⁶ and Okafor et al.,⁹ for example, found that the prevalence of objective and subjective caregiver burden in Nigeria ranges from 85.3% to 90% and 84.2% to 88%, respectively. In addition, the common correlates reported were severity of patients symptoms, number of hospitalisations, number of relapses, monthly income of caregivers, caregivers level of education and employment status, patients’ functional status, duration of illness and being a female caregiver.^6,7,8,9,10 These authors agreed that there is need for a comprehensive intervention to reduce the burden of caregiving amongst carers of patients with chronic illnesses such as schizophrenia.^6,7,8,9,10 Some authors have proposed that one remedy for the situation would be to provide support to the families by implementing formal family interventions that are culturally congruent, socially appropriate, economical and widely applicable.^2,5 There seems to be widespread support for this recommendation with the need to support families by way of standardised family intervention packages (e.g. structured psychoeducation) being voiced by some Nigerian authors.^2,5

Improving the burden of caregiving for caregivers of patients with schizophrenia has been a challenge to mental health service providers.¹¹ In the past decades, many psychosocial interventions for supporting caregivers of patients with a mental disorder have been developed. One such programme is psychoeducation, which has been defined as a strategy of teaching patients and families about disorders, treatments, coping techniques and resources.¹² Other psychosocial interventions with evidence of effectiveness in schizophrenia include social skills training, cognitive behavioural therapy, cognitive remediation and social cognition training amongst others.¹³ Psychoeducation may be looked at as the application of psychological theories and practices to educate people to help them have more information to tackle their challenges more effectively.¹⁴ By teaching skills such as problem solving and communication, caregivers’ coping abilities would increase.¹⁵

A large body of controlled evidence has unequivocally demonstrated the efficacy of structured family-based intervention for schizophrenia patients and their caregivers.^11,12,16 These studies demonstrate that a relatively simple psychoeducation approach can be implemented in routine clinical settings and can have important effects. Structured psychoeducation intervention has emerged as superior to ‘care as usual’ in almost all studies.¹⁷ Thus, significant positive changes following structured family intervention have been observed in several areas including relapse and re-hospitalisation rates, psychotic symptoms, medication adherence, social functioning, relatives’ knowledge and attitudes, family burden, caregiver’s perception of support and their sense of self-efficacy.¹⁸ Progress made in the field of formal family interventions in the Western countries has not been replicated in developing countries such as Nigeria. This is important because of the differences in these settings. Firstly, mental health services in Western countries is accessed as close to the community as possible, whereas patients and carers in Nigeria travel long distances to access services in already congested tertiary centres.^19,20 Secondly, payment for mental health services in Nigeria is by out-of-pocket expenses by patients and their family caregivers unlike the wide insurance coverage in the developed countries.²¹ Thirdly, with the decline in support from the extended family, this support was thought to cushion the effect of caregiving in the traditional African society.²² The primary aim of this study was to compare the effectiveness of a structured psychoeducational intervention for caregivers of patients with schizophrenia, with ‘care as usual’ on caregivers’ burden.

The caregiver participants of both arms of the study were similar in all socio-demographic characteristics as shown in Table 1. Table 2 shows that the caregivers in both arms of the study were similar with regard to their score in the caregiver burden scale at baseline (p = 0.08). After the 4th, 8th and 12th week, the ZBI score of the intervention group decreased more than the ‘care as usual’ group with good to excellent effect size (Table 2).

Figure 1 shows the effect of structured psychoeducation and ‘care as usual’ on caregivers’ burden between the two arms of the study. The mean ZBI score for the intervention versus the control were 52.70 versus 53.93 at baseline, 46.91 versus 50.80 at week 4, 44.20 versus 50.24 at week 8 and 41.52 versus 50.67 at week 12 [F(1, 123) = 21.75, p ≤ 0.001, Partial Eta Squared = 0.39]. Post hoc comparison shows that there was a significant difference in the reduction of caregiver burden between the intervention and the control group across all the intervals of follow-up. Figure 2 shows the effect of the intervention on caregivers’ burden whilst controlling for caregivers’ employment status, patients’ disease severity and functional status. There was a significant difference in the mean reduction of the caregiver’s burden score [F (1,112) = 12.71, p = 0.001, effect size = 0.10) between the two arms whilst adjusting for cofounders although with weak effect size.

The study aimed to determine the effectiveness of a structured psychoeducation intervention for caregivers of patients with schizophrenia, compared with ‘care as usual’ on the burden of caregiving.

Informal caregiving is an integral part of the care of people with severe mental illness, but the support needs of those providing such care are not often met.²⁹ Carers focused intervention appear to improve the experience of caring and quality of life and reduce psychological distress of those caring for people with severe mental illness.²⁹ The major finding of this intervention study is that caregivers who received structured psychoeducation intervention had significantly decreased the burden of caregiving when compared with those who received ‘care as usual’ at the end of follow-up. This effect remained even after controlling for potential confounders such as employment status of the caregiver, severity of symptoms and psychosocial functioning of the patient. This result is consistent with previous reports that psychoeducation improves caregivers’ burden.^29,30,31 For example, Yesufu et al.²⁹ reported improvements in the experience of caring and quality of life and reduced psychological distress of those caring for people with severe mental illness after psychoeducation.²⁹ The mechanism by which psychoeducation intervention reduces caregivers’ burden is not clear. However, some authors have suggested that it does so through the indirect action of increasing knowledge, adherence and reduction of relapse and rehospitalisation.^17,32 For example, Janet et al.³¹ reported that psychoeducation intervention reduced caregivers’ burden through improvement in coping skills and enhanced empowerment in dealing with crises amongst caregivers of patients with schizophrenia.³¹ Similarly, Mannion et al.³³ reported improvement in coping strategies, personal distress and negative attitudes towards the affected relative in spouses of persons with serious mental illness after psychoeducation programme.

Contrary to the findings of the present study, some authors have reported no superior advantage between structured psychoeducation intervention and ‘care as usual’ in reducing caregivers’ burden.¹⁶ In a recent randomised-controlled trial on the impact of structured psychoeducation on patient and caregiver variables, Kulhara et al.³⁴ found that structured psychoeducation intervention did not significantly reduce caregivers’ burden or improve caregivers’ coping skills. These authors argue that knowledge about the illness for a caregiver alone is not sufficient in reducing the caregiver burden.^17,35 In other words, other confounding variables such as caregivers’ factors (e.g. level of education, employment status and time spent on the patient) and patients’ factors (i.e. the severity of symptoms and the functionality of the patient) are important mediators of caregivers’ burden.^17,32,36 This is indeed the case with the present study. When other variables such as caregivers’ employment status, patients’ severity of illness and functionality were controlled, the effect of psychoeducation remained significant although with a weak effect size. Thus, comprehensive carers’ interventions should be multidimensional: addressing both patients’ and caregivers’ difficulties.

Firstly, the study was limited to only 12 weeks, a longer period of follow-up would have enquired into the sustainability of the interventions with time. Secondly, the use of carers within the community as against carers of inpatients would have given a real-world picture of the effects of psychoeducation on carers’ burden. Thirdly, although not significant, it appears that the intervention arm had lower scores in the caregiver burden scale at the baseline.

Despite the given limitations, the study has some strengths. Firstly, the longitudinal design of this study allowed for multiple examination of the changes in caregivers’ burden over time. Secondly, the attrition rate was low (10.7%) compared with 34.6% reported by Onu et al.³⁷ in the same environment. Thirdly, the use of randomisation is still the gold-standard for such an intervention study and makes the result generalisable.

This study has provided preliminary evidence of the superior efficacy of structured psychoeducational intervention compared with ‘care as usual’ for South Eastern caregivers of patients with schizophrenia.