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Management Brief No. 51

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Management eBriefs
Issue 51June 2012

A Systematic Review: Family Involved Psychosocial Treatments for Adult Mental Health Conditions

Since 2008, VA's authority to provide family services for Veterans' mental healthcare has expanded, creating a need to identify efficacious and promising family-involved interventions for improving Veterans' mental health outcomes. Prior reviews have traditionally focused on one condition at a time, thereby limiting a synthesis of the evidence for all mental health conditions. Moreover, prior reviews are potentially less relevant to VA populations due to their focus on studies conducted in non-Veteran or in non-US populations.

Recently, investigators at the VA Evidence-Based Synthesis Program site in Minneapolis, MN conducted a systematic review of the literature to evaluate whether (and which) family-involved treatments improve patient outcomes–and whether (and which) family-involved treatments are superior to alternative interventions; particularly patient-only treatments. Primary outcomes included mental health outcomes and couple/family functioning for patients with mental health conditions. Other outcomes included treatment adherence, use of mental healthcare, patient satisfaction, and social support for patients. Investigators reviewed randomized controlled trials and systematic reviews conducted in the United States and published from 1996 to November 2011 in order to help answer the following key questions.

Question #1
What is the efficacy of family-involved interventions in improving outcomes for adult patients with mental health conditions? (i.e., How do family-involved psychosocial treatments compare to no psychosocial treatment, waitlist, or medication management only?)

Low strength of evidence was found indicating the following family interventions for specific disorders improved selected patient outcomes or intermediate process outcomes (e.g., treatment utilization), compared to waitlist/drug treatment. Although some studies reported positive findings, the number of studies was too small and results not consistent enough to support strong conclusions.

  • Substance Use Disorders (1 trial): Family involvement in aftercare planning for patients going through detox does not improve substance use, but it does improve rates at which patients initiate substance use treatment following a hospital stay for detox.
  • Bipolar Disorder (2 trials): Family therapy
    • Neither general family therapy nor a disorder-specific family therapy, delivered in multiple family groups, improved recovery rates over medication management alone.
    • Marital psychoeducational therapy led to higher global functioning and greater medication adherence, but not to significant differences in symptoms of bipolar disorder.
    • Among participants with high levels of family impairment,
      • Disorder specific psycho-educational group-family therapy led to fewer depressive episodes per year, 14% percent less time in a mood episode, and nearly two fewer mood episodes per year.
      • General family therapy led to 0.9 fewer depressive episodes per year; additional comparisons were non-significant.
  • Schizophrenia (No new trials examined): Behavioral family therapy and supportive family therapy were established as efficacious for reducing rates of relapse and hospitalization prior to the timeframe of studies included in our review.
  • PTSD (1 trial): Support groups for family members designed to increase engagement in services for Bosnian refugees with PTSD resulted in a greater average number of patient mental health visits than those assigned to waitlist.
  • Sexual Functioning (2 trials): Couples sex therapy, in addition to medication for erectile dysfunction, led to greater satisfaction with treatment than for those assigned to medication alone. Differences between conditions on erectile functioning up to two months after treatment were not significant. A second trial found no significant benefits to couples cognitive behavioral sex therapy plus medication versus medication alone.
  • Depression (1 trial): Brief, disorder-specific, cognitive behavioral couples therapy significantly improved depression symptoms and marital satisfaction over waitlist for most comparisons in a small RCT.
  • Binge Eating Disorder (1 trial): Group cognitive behavioral therapy (CBT) for binge eating disorder–with or without spouse involvement–resulted in better symptom improvement than waitlist.

Question #2
What is the effectiveness of family-involved interventions compared to alternative interventions in improving outcomes for adult patients with mental health conditions? (i.e., How do family-involved interventions compare to any individually-oriented psychosocial intervention, or to any alternative family-involved intervention?)

  • Family-involved treatments for mental health conditions were as effective as, or more effective than, alternative psychotherapies, with two exceptions.
    • The addition of 6 months of disorder-specific behavioral family therapy after 2 months of exposure therapy for PTSD led to greater drop-out rates than exposure therapy alone or waitlist.
    • Male opioid users with pregnant partners who participated in a combination of motivational enhancement, case management, contingency management, and psycho-educational couple therapy reported greater heroin use than patients in usual care.
  • With the exception of trials examining two different interventions (CRAFT and BCT for substance use), many of the trials comparing family therapies to an equally intensive, alternative family or individual therapy found no significant differences.
    • Behavioral couple therapy (BCT), a disorder-specific therapy, resulted in lower rates of substance use and greater relationship adjustment than individually-oriented treatments for drug use and alcohol use in both male and female patients.
    • Community Reinforcement and Family Training (CRAFT), a disorder-specific and partner-assisted intervention, conducted solely with the family members of individuals with substance use disorders (SUDs), led to better rates of treatment initiation among individuals with SUDs than alternative family interventions.

Future Research
Most studies were of fair quality (10 good, 20 fair, 9 poor), and more than half (n=22) examined family interventions for substance use disorders. The authors suggest the biggest need in future research is for high-quality RCTs of family interventions with Veterans (only 3 of the 39 studies in this review reported Veteran status of participants). In particular, studies are needed (especially in conditions beyond substance use disorders) that compare family/couples interventions to interventions directed solely at patients, in order to evaluate the incremental effectiveness of family/couple therapies.

Operations Note
This topic was suggested by Sonja Batten, Ph.D., Deputy Chief Consultant for Specialty Mental Health, VA Office of Mental Health Services, and is primarily intended to help refine VA clinical guidelines by providing information as to whether family treatments improve the outcomes of Veterans receiving care for mental health conditions. Dr. Batten stated, "This review provides us with important information about what is known from carefully controlled trials of family-involved mental health interventions; at the same time, it highlights just how much we still need to learn in order to guide effective interventions for Veterans and their loved ones."

A Cyberseminar on this ESP Report was held on June 18, 2012. You may access the archived version at any time on the HSR&D Cyberseminar web page.

This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers -- and to disseminate these reports throughout VA.

Meis L, Griffin J, Greer N, Jensen A. Carlyle M, MacDonald R, Rutks I, and Wilt T. Family Involved Psychosocial Treatments for Adult Mental Health Conditions: A Review of the Evidence. VA-ESP Project #09-009; 2012.

View the full report online: (intranet only)

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Read past HSR&D Management e-Briefs on the HSR&D website.

This Management eBrief is a product of the HSR&D Evidence Synthesis Program (ESP). ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers - and to disseminate these reports throughout VA.

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