The Mindfulness-Based Psychoeducation Program for Chinese Patients With Schizophrenia

Many patients with schizophrenia continue to experience disabling residual symptoms, impaired social and occupational functioning, and a high risk of relapse in community rehabilitation. Clinical trials on a few psychosocial interventions, such as psychoeducation programs, have provided evidence of their effectiveness in improving patients’ relapse rates and severity and knowledge about the illness (1). Although recent literature reviews have indicated that different models of psychosocial intervention for schizophrenia are effective in reducing patients’ relapse rate and improving medication adherence, the effects of these interventions on patients’ psychosocial health condition and insights into illness and its treatment have been inconsistent and modest (2). Other limitations of psychosocial intervention studies include few multisite trials with a wide range of health outcomes, small sample sizes, and high attrition rates (3,4). Nevertheless, an integrated program for schizophrenia care, with medication, skills training, and cognitive-behavioral therapy, is another recent approach that has been used with significant effects on symptom severity (5).

A few integrated schizophrenia care programs, such as the Schizophrenia Care Management program in China (6,7) and medication management intervention for early-stage schizophrenia in Europe (2), have reported significant improvements on patients’ functioning and relapse. However, only a few intervention studies have also focused on changing patients’ negative thoughts and feelings toward the illness and on their relationship to the suffering caused by those thoughts by using the mindfulness-based stress reduction (MBSR) program (8,9). These mindfulness-based interventions, aimed at enhancing nonjudgmental and self-regulated attention as well as acceptance and control of current perceptual and cognitive symptoms, are effective in improving psychosocial functioning and control of distressing thoughts in severe depression (8). A clinical trial of a ten-session mindfulness training and home practice for 22 psychotic patients indicated that the intervention group significantly improved clinical functioning and control of psychotic symptoms, such as distressing voices and paranoia (9). Further clinical trial is recommended to test the longer-term effects (lasting more than one year) of mindfulness-based intervention on reducing patient relapse and improving functioning and insights into the illness (9). Therefore, this trial was designed to test the effects of a mindfulness-based psychoeducation program (MBPP) for Chinese patients with schizophrenia on their symptom severity, illness insight, and psychosocial functioning.

Methods

The study was a multicenter controlled trial that used a repeated-measures design. It was undertaken in Hong Kong between April 2010 and February 2012 and was approved by the University Research Ethics Committee. A total of 1,082 Chinese patients with schizophrenia who were attending three outpatient clinics were eligible for the study, and 337 (31%) agreed to participate. Of these, 96 (29%) were randomly selected for participation. Based on recent psychoeducation studies (2,6,7), this sample size was required to detect any significant difference between the groups with repeated measures at a 5% significance level with a power of 90% and 25% potential attrition (10).

The inclusion criteria for these outpatients were being at least 18 years old and having received (in the past five years) a diagnosis of schizophrenia based on DSM-IV criteria. Similar to other mindfulness-based programs that are effective for people with a few episodes of major depression, the MBPP was tested for effectiveness with patients whose schizophrenia had endured less than five years, with the goal of reducing the likelihood of relapse or further psychotic episodes. After their written consent had been obtained after a full explanation of the study, the participants were assigned randomly to receive usual care or the MBPP plus usual care.

The purpose of MBPP is to enhance patients’ understanding of schizophrenia, its treatment, and the community services available to them; increase patients’ insight into their illness and its symptoms; and improve their acceptance and control of psychotic symptoms, particularly hallucinations and delusions. The program comprises 12 biweekly, two-hour group sessions (five to six patients per group). MBPP is based on the psychoeducation programs by Chien and Lee (7) and Lehman and colleagues (3), as well as on the MBSR program by Kabat-Zinn and colleagues (11), and was designed to teach patients to become more aware of and to relate differently to their disorganized and unreal thoughts, feelings, and sensations, rather than relying on them as accurate reactions to the real world. The MBPP consists of seven components that span three phases. Phase 1 comprises program orientation, treatment engagement, empowerment, focused awareness of experience, and bodily sensations and thoughts, and it includes guided awareness exercises and homework practice. Phase 2 consists of an educational workshop about schizophrenia care, practicing coping skills to confront difficulties regarding symptoms, and problem solving. Phase 3 includes behavioral rehearsals of relapse prevention strategies, community support resources, and future plans. [The main content of the MBPP and its seven components are outlined in an appendix available online as a data supplement to this report.]

The MBPP also adopted several strategies to address traditional Chinese cultural tenets. For instance, the first stage focuses on understanding strong interdependence and inviting more practical assistance among group members. In the second and third stages, participants are encouraged to cultivate an open and accepting mode of responses to problems and stimuli and to develop a “decentered” perspective (psychologically letting go of unpleasant events) on their thoughts and feelings (8). They are also assisted in reducing their self-consciousness and need to “save face” (to preserve one’s dignity and avoid any disgrace), reconstruction of their self-image, and improving their insights into schizophrenia.

The usual care group (and MBPP participants) received routine psychiatric outpatient services. These services consisted of monthly medical consultation and treatment by a psychiatrist, nursing advice on medication and community services, and brief education sessions on mental illness and its treatment by nurses or social workers.

One trained research assistant who was blind to the group assignment administered the pretest and two posttests. Symptom severity, functioning, social support, and insight into illness were rated, respectively, with the Brief Psychiatric Rating Scale (12), Specific Level of Functioning Scale (13), six-item Social Support Questionnaire (14), and Insight and Treatment Attitudes Questionnaire (4). The Chinese versions of these instruments were validated, indicating satisfactory reliability and validity (7,15). Patients’ average number and length of rehospitalizations in the previous six months were calculated. Multivariate analysis of variance (MANOVA) was performed for the outcome variables to determine the treatment effects over time, followed by post hoc Tukey’s honestly significant difference analysis. Data were analyzed on an intention-to-treat basis that maintained the advantages of random assignment and included all participants’ outcome scores in data analysis (10).

Results

Forty-five (94%) MBPP participants completed the program; only three (6%) in both the MBPP and control groups dropped out at the posttests. The 96 participants had a mean±SD age of 25.8±8.5 years (range 19–41), with an average 3.1±2.1 years of illness at recruitment (range from three months to five years). Fifty-three of them were male (55%), 84 (88%) had completed secondary school or above, and 88 (92%) were living with up to three family members. Thirty-three (34%) and 27 (28%) were taking second-generation (risperidone, for example) and blended modes of neuroleptics, respectively. No significant differences in sociodemographic characteristics were found between the study groups and the 241 nonparticipants. [These characteristics and the results of between-groups comparisons are summarized in a table in the online data supplement.] There were also no significant differences in the baseline outcome measure scores between the two study groups, according to Student’s t test.

Results of the repeated-measures MANOVA test indicated that there was an overall statistically significant between-groups difference on the six dependent (outcome) variables over the 18-month follow-up (F=5.87, df=5 and 94, p=.001; Wilks’ λ=.98, partial η²=.28). The results of the MANOVA test (Table 1) indicated that there were statistically significant differences between the two groups regarding patients’ insight into illness, symptom severity, functioning, and number and length of rehospitalizations at the posttests. The post hoc comparisons indicated that the MBPP participants’ symptom severity, illness insight, and length of rehospitalizations had improved significantly at the two posttests but that their functioning and number of rehospitalizations improved significantly only at the 18-month follow-up.

Discussion

The findings provide preliminary support for the efficacy of the MBPP in a Chinese population to improve patients’ functioning and illness relapse in schizophrenia care. With only a few clinical trials, these findings suggest that mindfulness-based education can be effective not only for recurrently depressed patients (8) but also for schizophrenia sufferers, as suggested by Chadwick and colleagues (9). This program, which addresses the specific cultural needs of schizophrenia patients (such as enhancing self-awareness, interdependence, and positive thoughts), can improve these patients’ psychosocial health and reduce the number and length of rehospitalizations over an 18-month follow-up period. This is one of the few clinical trials that have demonstrated significant longer-term effects of mindfulness-based training on schizophrenia patients’ mental and psychosocial functioning (9). It is noteworthy that these improvements might be a combined effect of mindfulness training, psychoeducation, and problem solving, all of which were considered therapeutic factors in previous psychosocial interventions (4,5,15). Future research may use a larger sample to explore the relationships among the perceived benefits, therapeutic components, mechanisms of change, and intervention techniques that are applied in a mindfulness-based program.

Developing a cognitive mediation model for psychotic symptoms, particularly hallucinations and delusions, is less straightforward than effects of antipsychotic medication on symptomatic beliefs. The findings from this study suggest that this mindfulness program can provide persons suffering from schizophrenia with more insight into and acceptance of the illness and its symptoms. MBPP participants will be less disturbed by and better able to manage their psychotic symptoms and enhance their psychosocial functioning. Further research is recommended on distress and related behaviors caused by psychotic symptoms and on the mediational role of cognition in driving or combating such distress. It is also noteworthy that the confounding effects of covariates, such as medication adherence and other psychotherapeutic interventions, were not examined in this study and thus provide important issues for future research. The participants were not blind to the intervention undertaken; as such, a Hawthorne effect could not be excluded.

Conclusions

This mindfulness-based education program conducted in three outpatient clinics for Chinese patients with schizophrenia was found to be more effective than usual psychiatric care. It is important to validate the longer-term effects of the MBPP and investigate its cost-effectiveness in comparison with other psychosocial interventions and in larger samples with diverse sociocultural backgrounds and with different comorbidities, such as substance misuse and mood disorder.