Schizophrenia Research 96 (2007) 232 245

www.elsevier.com/locate/schres

Effectiveness of psychoeducation for relapse, symptoms,

knowledge, adherence and functioning in psychotic disorders:
A meta-analysis
T.M. Lincoln , K. Wilhelm, Y. Nestoriuc
Faculty of Psychology, Philipps-Universitt Marburg, Germany
Received 6 May 2007; received in revised form 21 July 2007; accepted 23 July 2007
Available online 7 September 2007

Abstract
Psychoeducation (PE) for schizophrenia and other psychotic disorders is widely adopted but insufficiently evaluated. So
far, meta-analytic data has demonstrated efficacy for PE when interventions include family members. Whether PE directed
solely at patients is also effective remains unclear. The current meta-analysis evaluates short- and long-term efficacy of PE
with and without inclusion of families with regard to relapse, symptom-reduction, knowledge, medication adherence, and
functioning.
Randomized controlled trials comparing PE to standard care or non-specific interventions were included. A literature search in
the Cochrane Library, PsycINFO and Medline retrieved 199 studies for closer examination, of which 18 studies, reporting on 19
comparisons, met the inclusion criteria. These studies were coded with regard to methodology, participants, interventions and
validity. Effect sizes were integrated using the fixed effects model for homogeneous effects and the random effects model for
heterogeneous effects.
Independent of treatment modality, PE produced a medium effect at post-treatment for relapse and a small effect size for
knowledge. PE had no effect on symptoms, functioning and medication adherence. Effect sizes for relapse and rehospitalization
remained significant for 12 months after treatment but failed significance for longer follow-up periods. Interventions that included
families were more effective in reducing symptoms by the end of treatment and preventing relapse at 712 month follow-up.
Effects achieved for PE directed at patients alone were not significant.
It is concluded that the additional effort of integrating families in PE is worthwhile, while patient-focused interventions alone
need further improvement and research.
2007 Elsevier B.V. All rights reserved.
Keywords: Psychoeducation; Schizophrenia; Psychotic disorders; Effectiveness

Corresponding author. Section for Clinical Psychology and Psychotherapy, Faculty of Psychology, Philipps-Universitt Marburg, Gutenbergstr.
18, 35032 Marburg, Germany. Tel.: +49 6421 2823647; fax: +49 6421 2828904.
E-mail address: lincoln@staff.uni-marburg.de (T.M. Lincoln).
0920-9964/$ - see front matter 2007 Elsevier B.V. All rights reserved.
doi:10.1016/j.schres.2007.07.022

T.M. Lincoln et al. / Schizophrenia Research 96 (2007) 232245

1. Background
Psychoeducation (PE) is a frequently applied intervention for psychotic disorders in German speaking
European countries. PE has been defined as systematic
didactic-psychotherapeutic intervention, designed to
inform patients and their relatives about the disorder
and promote coping (Wiedemann et al., 2003). In a
recent survey of all psychiatric institutions in Germany,
Austria and Switzerland 72% of the responding institutions reported that they had offered PE for schizophrenia
in the year 2003, mostly directed at patients during
inpatient stay (Rummel-Kluge et al., 2006).
1.1. State of research on PE, limitations and open
questions
Several meta-analyses have demonstrated the efficacy of family interventions which include PE as one
component among others, such as communication,
social skill training or problem solving skill training
(Barbato and D`Avanzo, 2000; Mari and Streiner, 1994;
Pfammatter et al., 2006; Pharoa et al., 2006; Pilling et al.,
2002a,b; Wunderlich et al., 1996). However, the
combination of PE with additional interventions makes
it hard to specify its contribution to outcome and failure
to evaluate treatment components on their own increases
the risk of using sparse funding on a mixture of
efficacious and useless treatment ingredients (Merinder,
2000). Moreover, some of the additional components
included in PE-packages, such as social skill training
(Pfammatter et al., 2006) or relapse prevention (Mueser
et al., 2002) have been shown to be effective on their
own, while the effectiveness of the educational element
of conveying knowledge on the etiology and symptoms
of the disorder is less clear.
Two meta-analyses focussed more directly on PE: A
cochrane review (Pekkala and Merinder, 2004) analyzed
10 randomized controlled studies on PE compared to
standard care, of which nine included the patients'
relatives. PE significantly reduced relapse or readmission
rates at nine to 18 month follow-up. The results also
indicated that PE could have a positive impact on
knowledge gain, adherence to medication and global
level of functioning, but these analyses were based on
very small numbers of studies using measures that the
authors found difficult to interpret. Pitschel-Walz et al.
(2001) meta-analytically evaluated the effects of 25
studies on the effect of PE family interventions in
reducing relapse. They found a small significant effect
for the interventions compared to standard care. However,
even in these analyses the authors did not specify quality

233

or quantity of PE according to the definition above in their

inclusion criteria. As a consequence, Pekkala and
Merinder included interventions that consisted purely of
medication counseling (e.g. Goulet et al., 1993; Razali
and Yahya, 1995) while Pitschel-Walz included a row of
studies in which PE was only a minor part of the
intervention (Hogarty et al., 1997; Randolph et al., 1994;
Vaughan et al., 1992). Mueser and colleagues (2002)
reviewed four randomized controlled trials on psychoeducation-programs and found three of them to increase
participants' knowledge but only one to have a positive
effect on medication adherence.
Another limitation of the present state of research is
that meta-analyses and reviews have generally focused
on family PE rather than patient directed PE or have not
separated studies by focus of intervention. The two
exceptions to this have yielded inconclusive results:
Pitschel-Walz et al. (2001) analyzed six studies that
compared family intervention with patient interventions.
They found the integration of effect sizes to reveal no
significant differences at post-assessment and the results
for follow up assessments to be inconclusive. The
authors point out that conclusions are difficult to draw
due to the low number and the heterogeneity of studies.
Merinder (2000) reviewed seven randomized controlled
studies on the efficacy of patient education. While most
of these studies reported a significant effect of PE on
knowledge, positive effects were scarce for compliance,
relapse and symptoms, but here too interpretation was
complicated by methodological limitations and insufficient reporting.
Thus, there is still no meta-analytically proven
efficacy for PE that is directed at patients only. This
does not correspond well with clinical practice in which
the more readily conducted patient-directed approaches
clearly dominate. For example, of the responding institutions in the investigation carried out by Rummel-Kluge
et al. (2006) 33% offered PE for patients and relatives,
1% offered PE for relatives only and 66% offered PE for
patients only. In order to provide clear guidelines for
clinical practice it is important to establish more
definitely whether PE offered to patients alone is an
effective treatment compared to standard care and how
much can be gained by the additional effort of involving
the family.
Finally, most studies evaluating PE have focused on
knowledge and adherence, symptom reduction and relapse prevention. Hence, these outcome variables are
reflected in prior meta-analyses. Increasing patients'
knowledge about the disorder and its treatment can be
expected to lead to better collaboration with professionals, promote adherence and self-management of

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T.M. Lincoln et al. / Schizophrenia Research 96 (2007) 232245

(2) Investigated patients were required to have the

following diagnoses: schizophrenia, schizoaffective disorder, delusional disorder, short psychotic
disorder or schizotype disorder according to a
diagnostic classification scheme.
(3) The comparison group was required to be either
non-active such as waiting-list (WL) or treatmentas-usual (TAU), or a non-specific intervention
(NSI) without proven effectiveness (e.g. problemsolving; supportive treatment, leisure time
groups). Studies with active control-groups (e.g.
CBT or other forms of PE) were excluded.
(4) Studies were required to describe a treatment
protocol in which PE was the core element of
treatment (conducted in more than 50% of the
total treatment time). PE was defined according to
the definition by the Arbeitsgruppe Psychoedukation (Wiedemann et al., 2003), with a focus on
conveying relevant information about the disorder
and its treatment while promoting better coping.
Specifically, conveying of information had to be a
major component which could, but need not be
supplemented by behavioral interventions (e.g.
enhancing coping strategies and early symptom
monitoring) and had to take place in a direct
therapistpatient interaction. Studies using solely
internet programs or written material were
excluded.
(5) Treatment outcome had to be reported for relapse or
rehospitalization, symptoms, functioning, knowledge about the disorder or treatment adherence.
(6) Studies were required to provide statistical data
that allow to estimate effect sizes: means and
standard deviations, t- or F-values, change scores,
frequencies or probability levels.
(7) Studies had to report in English, German or French.

symptoms and thus reduce symptom severity and

susceptibility to relapses (Mueser et al., 2002). While
these outcomes thus remain important, there is growing
agreement that relevant changes in clinical performance
should also be having an impact on functional outcome
(Mari and Streiner, 1994) as such improvement allows
patients to spend less time with symptoms and more time
pursuing their goals (Mueser et al., 2002).
The present meta-analysis aims at evaluating the
efficacy of interventions for schizophrenia and other
psychotic disorders in which PE is the primary element,
with and without integration of family members, on
knowledge about the disorder, adherence, relapse and
rehospitalization, symptoms and functioning.
2. Method
2.1. Search procedure
Relevant studies were identified by an electronic
literature search in the databases PsycINFO, Cochrane
Library and Medline for articles published from the
first available year to March 2006. We used the search
terms psychoeducation, or (patient/family)education
or education combined with either schizophrenia,
schizophren, or psychosis in the complete text of the
article. This procedure was adopted to ensure that
interventions with broader labels than psychoeducation
(e.g. illness management or psychosocial rehabilitation) would not be missed if they included educational
elements. Additional studies were identified by a manual search in Schizophrenia Research and Schizophrenia Bulletin from 1995 to March 2006 and in reference
lists of reviews and meta-analyses on PE for psychotic
disorders. A priori decision was made to search only
for published work and to control for publication bias
via posteriori analysis. Together, these searches
generated 2952 studies. Of these, 2752 publications
could be excluded after screening the title. In these
cases the title made clear without doubt that the article
was not relevant to the research question, e.g. by referring to a different population (e.g. obese children).
Two independent investigators (first and second
author) screened the abstracts (k = 129) or the complete
article (k = 70) of the remaining 199 publications for
relevance to the defined topic and fulfillment of inclusion criteria.
2.2. Inclusion criteria
(1) Studies were required to apply a randomized
controlled design.

A total of 18 studies met these criteria and were

included in the meta-analysis. Details of the selection
process are shown in Fig. 1.
2.3. Data abstraction and validity assessment
Each study was coded including information on
extrinsic properties of studies, methodology, participants, treatment and methodological quality by two
independent raters using a structured coding scheme
(see Appendix A).1 Interrater-reliability was estimated
using Cohen's Kappa for categorical variables and the
1

The full versions of the coding scheme can be requested from the
authors.

T.M. Lincoln et al. / Schizophrenia Research 96 (2007) 232245

235

Fig. 1. Flow of trials through the selection process.

intra class correlation coefficients for continuous

variables. Mean Kappas for the methodology, participants and treatment characteristics were 0.98 and 0.92
for the coding of the validity. Interrater-reliabilities for
single items varied between .65 and 1.00 with 96% of
the items reaching a coding reliability above .75. Coding
discrepancies were discussed and resolved.

the treatment effect for studies that reported means and

standard deviations for intervention and control group.
Hedges' g refers to the mean difference between the
intervention (IG) and control group (CG) divided by the
pooled standard deviation:
P

X IG  X CG
g p
:
2
2 =n n
nIG  1SIG nCG  1SCG
IG
CG  2

2.4. Effect size calculation

Effect sizes were calculated separately for each
outcome variable, treatment group and time-point. We
used Hedges' g (Hedges and Olkin, 1985) to estimate

For studies that did not report means and standard

deviations on the continuous variables of interest we
computed equivalent effect sizes from t and F statistics
and exact probability levels (Rosenthal, 1994). For

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T.M. Lincoln et al. / Schizophrenia Research 96 (2007) 232245

categorical outcome data (rehospitalization, relapse,

medication adherence) the logarithmized Odds Ratio
(OR) was calculated and transformed
into Hedges' g
p
(Rustenbach, 2003): g p3 lnORc0:55lnOR. In
the case of zero in cells, we calculated the OR by raising
the frequency in each cell by 0.5 (Fleiss, 1994; Haddock
et al., 1998).
A correction for small sample bias was applied to the
effect sizes (Hedges and Olkin, 1985).
2.5. Integration of effect sizes
2.5.1. Integration of dependent effect sizes
We categorized the outcome variables into four
categories according to the time of assessment (post;
16-month follow-up; 712-month follow-up; N12month follow-up) and areas (rehospitalization and
relapse; symptoms; functional outcome; knowledge;
adherence). This resulted in 20 combinations, for which
effect sizes were integrated. In cases, in which
dependent effects remained within a category, these
were combined to a total effect using the arithmetic
mean (Hedges and Olkin, 1985; Matt and Cook, 1994).
The inter-correlations between the outcome variables
were derived from published literature or estimated.
Dependent effect sizes also resulted from a study that
compared two different types of PE interventions with a
control group (Hornung et al., 1999a,b, 1995). In this
case the mean effect size was calculated and the
variances were adjusted post-hoc.
2.5.2. Integration of independent effect sizes
We weighted the effect sizes by the inverse of their
sampling variances (Hedges and Olkin, 1985) and
calculated mean effect sizes by averaging the weighted
effects within the different types of outcome categories
and time-points.
The homogeneity statistic Q (Shadish and Haddock,
1994) was calculated to determine whether each set of
effect sizes shared a common population effect size. In
the cases of homogeneity a fixed effects model (FEM)
was used. In cases of heterogeneity we used a random
effects model (REM).

test for a moderating effect of active control intervention

versus treatment as usual, as the latter is likely to
produce higher effect sizes.
To identify whether patient status at baseline (inpatients versus outpatients) had an impact on relapse
rates, a weighted least squares multiple regression of the
individual effect sizes for relapse was conducted, controlling for treatment duration in weeks and ethnic background (European or American/Canadian versus Asian).
Ethnic background was considered to be a potential
moderator due to differences in health care systems and
attitudes, while treatment duration was considered
relevant because outpatients were receiving slightly
longer treatments. The individual effect-sizes for relapse
refer to those obtained in the longest follow-up period.
Finally, a moderating effect of methodological
quality of the studies was tested by correlating the
weighted mean effect size per study (based on all effects
achieved at different assessment times) with the score of
the validity rating.
2.7. Sensitivity analyses
A potential publication bias was examined by
calculating the fail-safe N criterion (Rosenthal, 1979),
which estimates how many unpublished studies with
insignificant effects (dfs, defined here as 0) are needed in
order to reduce the found effects to a critical effect (dcrit,
defined here as 0.1), using the formula:
P

kfs

k d  dcrit
P :
dcrit  d fs

To analyze the impact of the method, we contrasted

the results obtained by a fixed and a random effects
model.
3. Results
3.1. Characteristics of included studies
A descriptive overview of all integrated studies is
presented in Table 1.

2.6. Moderator analyses

In order to compare intervention formats with and
without participation of family members, we used a
categorical integration model. The presence of a
moderating effect is indicated by heterogeneity between
classes (significant Qb) and homogeneity within classes
(non-significant Qw). The same procedure was used to

3.1.1. Extrinsic characteristics

All studies were published between 1982 and 2005.
Five studies were published before 1995 and five studies
were published after 2000. Studies were conducted in
Great Britain (k = 5); China (k = 4), Germany and
Switzerland (k = 3), Greece (k = 1) Scandinavia (k = 2),
USA and Canada (k = 3).

Table 1
Treatment Characteristics, Number of Participants (N), Effect sizes and Confidence Intervals for Relapse, Symptoms, Functioning, Knowledge and Adherence at Post (PO)- and Follow-Up (FU)
Assessments
Study/place

Treatment

Sample characteristics

FU

Effect sizes and confidence intervals

Relapse

PE-P and
PS vs. WL;
20 wks

Buml et al.
(1996) Germany

PE-P-F vs.
TAU;
20 wks,
8 sessions
PE-P and
SST vs. SR
16 wks
PE-F vs.
TAU
24 wks

Predominantly white
UK-outpatients,
schizophrenia
(excluding long-stay patients)
Inpatients, schizophrenia

Functioning

Knowledge

Adherence

146 P0
FU1

.00 (.32.32)
.43 (.10.76)

163 FU1 .45 (.14.76)

FU2

.18 ( .13.49)
.58 (.27.89)

Outpatients, schizophrenia,
29 P0
non-acute, chronic
(mean duration of disorder 8.9 yrs)
Outpatients, schizophrenia,
61 P0
Chien et al.
(2004, 2005) China
non-chronic (mean duration of
61 FU2
disorder 2 yrs), medium
education level
Fries et al. (2003)
PE-P and
Inpatients, schizophrenia or
40 P0
Switzerland
CS vs. ST
schizoaffective disorder, chronic
21 FU2 .65 a (.001.30)
(2 previous admissions), non-acute
Herz et al. (2000)
PE-P-F vs.
Outpatients, schizophrenia or
82 P0 .48 (.14.81)
USA
TAU 18 months schizoaffective disorder, chronic
(2 previous admissions),
high level of education (50% college)
61 FU2 .22 ( .73.29)
Hornung et al. (1999a,b, PE-P + LTG vs. Chronic outpatients
1995) Germany
LTG; 32 wks,
(2 previous admissions), non-acute
59 FU3 .13 ( .39.65)
10 sessions.
(4 wks since previous acute episode)
Hornung et al.
PE-P-F + LTG
Chronic outpatients
61 FU2 .12 ( .63.39)
(1999a,b, 1995)
vs. LTG 32 wks, (2 previous admissions), non-acute
57 FU3 .24 ( .29.77)
Germany
10 sessions
(4 wks since previous
acute episode)
Leavy et al. (2004)
PE-F vs. TAU
In-and outpatients, 42.5% first
106 FU1 .00 ( .38.38)
England
7 sessions
episode psychotic disorder;
106 FU2 .69 (.301.08)
white UK-residents
Leff et al. (1982)
PE-F vs. TAU
High risk for relapse outpatients,
24 FU2 1.27 (.392.15)
England
schizophrenia, high EE relatives,
medium education
Browne et al.
(1996) Ireland

.04 (.62.55)

.11 (.41.63)
.31 ( .37.99)

.36 (.99.28) .88 a ( 1.54.23) .03 ( .65.59)

.14 (1.02.74) .32 ( 1.20.56) .43 (.1.32.46)

.46 (.02.90)

.76 ( 1.20.32)

.16 b ( .60.27)
.53 b (.09.97)

1.16 c (.711.62)
.41 c ( .01.84)

237

(continued on next page)

T.M. Lincoln et al. / Schizophrenia Research 96 (2007) 232245

Atkinson et al.
(1996) Scotland

Symptoms

Study/place

Treatment

Sample characteristics

FU

Effect sizes and confidence intervals

Relapse

Li and Arthur (2005)

China
Merinder et al. (1999)
Denmark
Posner et al. (1992)
Canada

Rund et al. (1994)

Norway

Shin and Lukens

(2002) USA

Tarrier et al. (1988)

England

Tomaras et al. (2000)

Greece

Xiong et al. (1994)

China

Inpatients, schizophrenia, non-acute,

89 P0
ca. two thirds experiencing first
admission, medium education
PE-P-F vs.
Inpatients, psychotic disorders, chronic 46 P0
TAU 8 wks
(mean duration of disorder: 8.2 yrs)
46 FU2
55 P0
PE-F vs. WL
Young (40) outpatients,
schizophrenia; chronic
55 FU1
(2 previous admissions),
medium to high education
(mean: 12 yrs)
PE-F vs. NI
Recent-onset and chronic patients,
223 P0
36 wks
schizophrenia, living in
the community in rural China,
low education (17% illiterate)
24 P0
PE-F vs. TAU
Early onset of psychotic disorder
104 wks
(1318 yrs). Treatment continues
from acute, inpatient to remitted,
outpatient phase
PE-P vs. ST
KoreanAmerican outpatients,
48 P0
10 wks
chronic schizophrenia,
schizoaffective or
schizophreniform disorder,
high education (35% college)
PE-P-F vs. TAU First episode (30%) and chronic
44 FU2
2 sessions
acute schizophrenia inpatients
(mean duration of disorder 6.3 yrs),
low to medium education
PE-P-F and
Non-acute outpatients with
34 P0
IPST vs. IPST; schizophrenia or schizoaffective
26 FU2
52 wks,
disorder, chronic
26 FU3
13 sessions
(mean duration of disorder 8.0 yrs)
PE-P-F vs. TAU Urban Chinese inpatients,
63 FU1
acute schizophrenia at enrollment,
61 FU2
main treatment in outpatient status,
60 FU3
medium education (mean 9 yrs)

Symptoms

Functioning

.49 (.15.83)

.64 (.201.08)

1.04 (.601.48)

.26 ( .15.68)

.36 ( .16.88)

.22 (.37.81)
.19 (.40.78)

.68 (.131.23)
.48 e (.151.12)

1.15 (.871.43)

.40 ( .411.21)

.89 (0.051.73)

1.11 (.501.91)

.12 ( .47.71)

.06 ( .61.50)
.44 (.22.09)

.17 ( .48.82)

.60 (.161.03)
.69 (.251.12)
.28 (.16.72)

Knowledge
d

Adherence

Note. PO = post-assessment, FU-1 = follow-up at 16-months; FU-2 = follow-up at 712-months; FU-3 = follow-up N 12-months; PE-P = psychoeducation for patients; SST = Social Skills Training;
SR = supportive rehabilitation; PE-P-F = psychoeducation for patients and family; TAU = treatment as usual; PS = problem solving; WL = waiting list; CS = coping strategies; ST = supportive therapy;
LTG = Leisure Time Group; PE-F = psychoeducation for family; NI = no intervention; IPST = individual psychosocial treatment.
a
n = 40 for this analysis.
b
n = 89.
c
n = 92.
d
n = 101.
e
n = 39.

T.M. Lincoln et al. / Schizophrenia Research 96 (2007) 232245

Ran et al. (2003)

China

PE-P-F vs.
TAU 26 wks

238

Table 1 (continued)

T.M. Lincoln et al. / Schizophrenia Research 96 (2007) 232245

3.1.2. Treatment characteristics

Five studies investigated patient directed PE, six
studies investigated family-directed PE and seven
studies investigated patient and family-directed PE. In
two studies the intervention was applied in an individual
format (Leavy et al., 2004; Li and Arthur, 2005), in
twelve studies PE was conducted in groups and in four
studies the format was not defined.
Control interventions were TAU in ten studies, WL in
two studies and NSI (e.g. supportive rehabilitation,
leisure groups) in six studies.
Treatment was conducted in an inpatient setting in
two studies, an outpatient setting in eleven studies and in
a combination of both in five studies. Nine studies
provided information on the duration of treatment in the
patient intervention groups, with a mean2 of 27.8 weeks
(SD = 18.5). Seven studies provided information on the
duration of family intervention, averaging 36.8 weeks
(SD = 18.4) with a mean of 11.8 sessions (SD = 14.4).
The majority of studies provided prepost-treatment
data (k = = 14), eight of these additionally provided
follow-up-data. Four studies provided only follow-updata.
Only five studies explicitly provided data for dropout
during treatment, with a mean rate of 2.6% (SD = 3.6) in
the intervention groups and 3.8% (SD = 6.9) in the control
groups. The rates of missing data could be reconstructed
from the data provided by a further nine studies. Based on
these 14 studies, the mean loss from pre to post
assessment was 6.2% (SD = 15.2) in the intervention
groups and 6.9% (SD = 15.6) in the control groups.
3.1.3. Patient characteristics
A total of 1534 participants were investigated (mean
per study = 83.7; SD = 60.1). All studies investigated
patients with psychotic disorders according to the
Diagnostic and Statistical Manual for Mental Disorders,
the International Classification of Diseases or the
Chinese Classification of Mental Disorders. Only three
studies reported the use of a structured or standardized
interview procedure. Two studies additionally included
patients with delusional disorder, seven studies included
schizoaffective disorder and four studies included other
psychotic disorders. In all other cases, there were no
details on diagnostic in-or exclusion criteria other than
schizophrenia or psychosis. The mean age of the
participants was 30.5 (SD = 4.9, k = 7). The majority

239

were men (59.3%, SD = 11.2; k = 13). The mean duration

of disorder was 75.8 months (SD = 43.2; k = 5).
3.1.4. Outcome measures
We categorized the outcome data into five groups,
which provided the basis for the integration of effects:
(1) relapse and rehospitalization data was provided by
14 studies; (2) symptoms of schizophrenia were assessed
in six studies using the Brief Psychiatric Rating Scale
(Chien and Chan, 2004; Fries et al., 2003; Li and Arthur,
2005; Merinder et al., 1999; Shin and Lukens, 2002), the
Scale for Assessment of Positive Syndromes and the Scale
for Assessment of Negative Syndromes (Browne et al.,
1996; Fries et al., 2003); (3) functioning was assessed in
four studies by the Global Assessment Scale (Fries
et al., 2003; Hornung et al., 1995; Rund et al., 1994)
and the Social Functioning Scale (Atkinson et al.,
1996); (4) patients' knowledge of disorder was assessed
in four studies using the Early Signs Questionnaire
(Herz et al., 2000), a self-devised measure to assess
knowledge of schizophrenia (Merinder et al., 1999) and
the Knowledge about Schizophrenia Interview (Li and
Arthur, 2005). In the study by Fries et al. (2003) the
instrument was not specified; (5) medication adherence
was assessed in four studies by dichotomizing the
continuity of medication intake.
3.1.5. Validity
The maximum possible score from the rating of
validity according to the coding plan (see Appendix A)
was 18, indicating maximum validity and zero indicating minimum validity. Values for the included studies
ranged from 15 (Herz et al., 2000; Ran et al., 2003) to 6
(Atkinson et al., 1996). The mean score across studies
was 11.0 (SD = 2.5), which speaks for a medium
validity of the included studies. Specifically, 16 studies
made use of multiple measurement methods, 15 studies
used reliable instruments, 12 studies provided information that allowed to conclude that the intervention
groups were comparable with regard to socio-demographic properties or clinical variables, six studies
provided information on inter-rater reliability of the
measures, six studies used blinded raters, five studies
used trained raters to do the assessments, five studies
varied the treatment setting and four studies used multiple recruiting methods.
3.2. Efficacy of PE for different types of outcome
variables and time-points

2
Means of patient and study characteristics were calculated by
sample-size-weighted averaging of means or numbers reported in the
primary studies.

The effect size calculation for the five outcome areas

and four follow-up time points resulted in a total of 49

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T.M. Lincoln et al. / Schizophrenia Research 96 (2007) 232245

Table 2
Mean weighted effect sizes from controlled comparisons as a function
of outcome category and follow-up period

3.3. Impact of treatment format, patient status and

validity

Outcome category

In an additional analysis we calculated mean effect

sizes separately for interventions directed at family
members and patients versus interventions directed
solely at patients. Comparisons were restricted to
outcome measures and time points that were reported
in at least two studies within each format. This was the
case for symptoms at post-treatment and relapse/
rehospitalization at 712 month follow-up. Table 3
depicts the results of these analyses. With regard to
symptom change, the average effect sizes for both
treatment modalities were small and insignificant.
However, there were significant differences between
the modalities as indicated by the between group
homogeneity statistic (Qb = 10.6, p = .00, power = .90),
while the effect sizes were homogeneous within the
groups (non-significant Qw). Small effects were also
achieved for relapse/rehospitalization at 712 month
follow-up, but only the effect for the family included
intervention was significant. Here too, the differences
between the modalities were significant (Qb = 11.4,
p = .00, power = .92) while the effect sizes were homogeneous within the groups. In sum, although family PE
was superior, neither format had a significant effect on
symptom change. However, only family focused interventions were able to significantly reduce the rates of
relapse and rehospitalization.
We tested for a moderating effect of control-group by
comparing the effect sizes for rehospitalization and
relapse achieved for interventions that were compared
to TAU (not including wait-list-conditions) with those
achieved for interventions that were compared to NSI.

Post-assessment
Relapse/
Rehospitalization a
Symptoms a
Functional outcome a
Knowledge a
Medication adherence a
Follow-up 6 months
Relapse/
Rehospitalization
Follow-up 712 months
Relapse/
Rehospitalization a
Symptoms
Functional outcome a
Follow-upN12 months
Relapse/
Rehospitalization

k N
5 452
6
3
4
2

95% CI
0.53

0.120.95 0.01 3.45

313 0.29 0.130.70

210 0.03 0.840.78
278 0.48 0.120.83
171 0.25 1.250.75

0.08
0.97
0.00
0.31

5.38
2.82
3.31
1.00

4 387

0.35

0.140.55 0.00 4.60

7 362

0.48

0.150.82 0.00 5.93

3 128
2 112

0.19 0.160.55 0.14 0.75

0.19 0.590.97 0.32 1.00

3 144

0.21 0.070.49 0.07 0.15

Note. k = number of integrated studies; N = number of investigated

patients, d = weighted mean effect size; CI = confidence interval for d;
p = level of significance for d; Q = homogeneity statistic for d.
a
Integrations carried out in random effects model.

effect sizes as presented in Table 1. These effect sizes

ranged from .88 (functioning, Fries et al., 2003) to
1.27 (relapse, Leff et al., 1982).
Due to the small number of studies and the fact that
most studies did not provide data for all outcome areas
and time-points an integration of effect sizes was not
possible for each combination of outcome area and time
point.
As shown in Table 2, the weighted effect sizes for
relapse and rehospitalization ranged from medium (posttreatment) to small (follow-up 6 months and 7
12 months) and were no longer significant at follow-up
N12 months. Confidence intervals were generally large.
General efficacy of PE for symptom reduction could be
calculated for post-treatment and follow-up 712 months.
Both effect sizes were small and failed significance.
Effect sizes for functional outcome could be
calculated for post-treatment and the follow-up period
712 months. Both effect sizes were not significant.
An integrated effect size for a gain in knowledge
about the disorder could only be calculated for postassessment. This effect size was small, but in the range
of small to large effect sizes.
Finally, an integrated effect size for the effect of PE
on medication adherence could only be calculated for
post-assessment. This effect size was small, negative
and insignificant.

Table 3
Analysis of variance in effect sizes as a function of treatment format
Treatment modality

k N

Random effects model

d

Symptoms at
post-assessment
PE without family
PE with family
Relapse/
Rehospitalizations at
712 month-follow-up
PE without family
PE with family

95% CI

Qwi (p)

3 117 0.24 .39.86 .23 3.86 (.15)

3 196 0.33 .26.93 .14 0.58 (.75)

2 101 0.18 .47.82 .30 1.72 (.19)

6 322 0.48
.10.85 .00 4.78 (.44)

Note. k = number of integrated studies; N = number of investigated

patients, d weighted mean effect size; CI = confidence interval for d; p =
level of significance for d; Qwi = homogeneity statistic within each
group.

T.M. Lincoln et al. / Schizophrenia Research 96 (2007) 232245

241

Sufficient numbers of studies were available for comparisons at post and follow-up-2. At post, studies with a
NSI control condition (k = 2) produced a significantly
higher effect for relapse and rehospitalization than
studies with a TAU control condition (k = 3) (dNSI =
0.64, dTAU = 0.46, Qb = 17.1, p = .00, power = .99)
while the effect sizes were homogeneous within the
groups (QwNSI = 3.8, n.s.; QwTAU = 0.0, n.s.). At followup studies with a NSI control condition (k = 3) produced a
significantly smaller effect for relapse and rehospitalization than studies with a TAU control condition (k = 4)
( d N S I = 0.24, d TA U = 0.33, Q b = 13.6, p = .00,
power = .96) while the effect sizes were homogeneous
within the groups (QwNSI = 2.0, n.s.; QwTAU = 1.6, n.s.).
Taken together, there was no clear trend for higher effects
of NSI compared to TAU control conditions.
Patient status was not a significant predictor of
relapse after controlling for duration and ethnic background in the regression model (F = 2.58, p = .12).
However there was a tendency for outpatients to profit
more ( = .44, p = .14).
The methodological quality of the studies as assessed
by the validity rating was not significantly correlated
with the weighted mean effect size per study (r = .27,
p = .28, k = 18).

various outcome domains, using clearly defined inclusion criteria with regard to the PE-intervention. Due to
this criterion, a large number of studies encountered in
the literature search and included in other analyses were
excluded. For example, of the 25 studies in the analysis
by Pitschel-Walz (Pitschel-Walz et al., 2001) only three
studies fulfilled our criteria, the most frequent reasons
for exclusion being that the interventions did not fulfill
our criteria for PE or diagnosis.
Overall, PE was shown to have a short term medium
effect on relapse, which grew slightly smaller with time
and was no longer significant after one year. PE had a
small, but significant effect on knowledge by the end of
the intervention. The effects of PE on symptom
reduction, functioning and medication adherence were
insignificant. The format comparisons favored PE
directed at patients and their family over a mere patient
intervention. Furthermore, PE proved significant with
regard to relapse when the family was included while all
effect sizes for PE directed at patients only were
insignificant. The differences between PE compared
with treatment-as-usual and PE compared to nonspecific control interventions were inconsistent.

3.4. Results of the sensitivity analyses

Due to the heterogeneity of studies and the low

numbers for each outcome category, confidence intervals were generally large. As a consequence, the effect
sizes can not reliably be categorized as small or
medium according to the classification by Cohen
(1977). The fact that methodologically weaker studies
did not produce significantly differing effects underlines the validity of our findings. However, the numbers
of fail safe studies needed to reduce some of the effect
sizes to insignificance were low. It is possible that there
are a row of unpublished studies with zero effects and
that the overall effect sizes might be overestimated in
this analysis.
Although the ES size-differences between nonspecific-control-group comparisons and TAU or WL
conditions were not consistently in favor of inactive
control-interventions, it must be noted that the majority
of patient directed interventions (80%) and only a minority of family directed interventions (14%) employed
an active control-condition and that this might have
contributed to effect size-differences between the
intervention formats.
The fact that the included studies were conducted in a
variety of different countries and cultures can be
considered as a strength of the current meta-analysis
with regard to the generalizability of the findings.

3.4.1. Publication bias

We calculated the fail safe N separately for each
category of integrated effect sizes that produced
significant effect sizes. The fail-safe numbers were as
follows: 22 (relapse at posttreatment), 15 (knowledge at
post-treatment), 10 (relapse at follow-up-1) and 27
(relapse at follow-up-2).
3.4.2. Comparison of integration methods
Three out of ten integrations produced homogeneous
effects and were carried out using the fixed effects
model. In order to test whether the results are independent of the selected integration method, we compared
the results of these analyses to results we would have
obtained using a random effects model. In all the integrations the effect sizes were independent of the model
used.
4. Discussion
4.1. Summary of results
The aim of this analysis was to establish the efficacy
of PE with and without family inclusion with regard to

4.2. Generalizability

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T.M. Lincoln et al. / Schizophrenia Research 96 (2007) 232245

4.3. Discussion of findings

The finding that there is a small effect on relapse and
rehospitalization for PE directed at patients and family
members is in line with the other meta-analyses on PE
(Pekkala and Merinder, 2004; Pitschel-Walz et al.,
2001). The size of the effect is comparable with overall
effect sizes found for other forms of effective interventions in schizophrenia, such as CBT (Jones et al., 2004;
Pilling et al., 2002a,b), antipsychotic medication
(Leucht et al., 1999) or case-management (Ziguras and
Stuart, 2000) which are generally small, presumably due
to multifaceted etiology and maintenance factors and the
large heterogeneity of symptoms in schizophrenia.
The finding that PE was ineffective in improving
adherence is in line with the systematic review by
Zygmunt et al. (2002) who also found interventions and
family programs relying on PE to improve medication
adherence to be ineffective. Divergence to results from
older reviews and analyses might be explained by the
diversity of methods to assess adherence. Future studies
could profit from following the suggestions for assessing adherence put forward by Velligan et al. (2006).
The most interesting finding is that PE offered solely
to patients was ineffective. Although PE directed at
patients during inpatient stay is frequently employed and
has practical advantages (Rummel-Kluge et al., 2006),
there are also some relevant concerns with it which might
account for the insignificance. First, many patients with
schizophrenia have little insight into the presence of a
mental disorder or do not attribute symptoms to it
(Gharabawi et al., 2006; Sevy et al., 2004). Many of these
patients do not readily accept the alternative illness
interpretation put forward in PE. Reluctance is often
particularly pronounced if patients feel that their
individual and often psychosocial explanations are not
being taken seriously (Hofer et al., 2001). Second, due to
the large diversity of symptoms in schizophrenia, many
patients find it hard to detect their own experiences in the
standardized program descriptions of symptoms and may
conclude that the diagnosis does not apply to them. Third,
although PE programs have become more interactive
there is still a lot of directive lecturing involved, which is
problematic for patients suffering from poor concentration and memory and might explain why more interactive
presentation of information as well as more behavioral
components have been found to produce higher effects
(Buttner, 1996; Dixon and Lehman, 1995; Mullen et al.,
1985; Zygmunt et al., 2002). Finally, the programs do not
require to accompany patients after the group has
terminated and support them in integrating the knowledge into their daily life (e.g. monitoring medication,

stress and early signs of relapse). For an intervention to

have an impact, the basic messages have to be understood
and accepted by the patient, related to his or her own
problems as well as remembered and integrated into everyday life. PE offered to patients alone during inpatient stay
seems vulnerable with regard to any of these steps. Some
of the listed problems might be reduced by delivering PE
to patients in an individual format, however none of the
patient interventions investigated in this analysis has taken
this approach. Also, as the moderator analysis revealed a
tendency for outpatients to improve more from PE with
regard to relapse, this could also prove to be a more
promising approach that warrants further research.
We assume that the inclusion of the family might
automatically resolve some of the difficulties listed
above as family members are involved in integrating the
knowledge into reality and supporting patients in the
monitoring of symptoms and stress level and that this
might explain why it is more effective. In addition,
family directed PE might reduce negative communication by promoting understanding (Szmukler et al., 1996)
and thus contribute to relapse prevention, even without
explicit communication training.
The relevance of family inclusion for effective PE
might also explain why it was effective for relapse,
while symptoms remained stable. Possibly the main
effect of PE is that family members learn to cope better
with schizophrenia, resulting in less rehospitalization, in
spite of unchanged symptoms.
While PE patient groups are frequently employed, the
inclusion of relatives is still not an integral part of
treatment for schizophrenia, despite its proven effectiveness in reducing medical costs (Mino et al., 2007). A more
detailed analysis resulting from the investigation by
Rummel-Kluge et al. (2006) showed that only 2% of the
family members had taken part in PE in the investigated
year. Dixon (1999) found that only 8% of all questioned
patients reported that their relatives had ever taken part in
supportive or PE interventions. Comparable percentages
have been found for Italy (Magliano et al., 2006). Barriers
to the implementation of family PE are mainly seen to
come from organizational factors (Dixon, 1999). In
particular, the caseloads of many clinicians in psychiatric
institutions often do not leave time for the additional effort
of contacting and motivating relatives to participate.
4.4. Conclusions
Although common in clinical practice, PE groups
directed solely at patients are under-researched and
remain to be proven effective. The additional effort of
integrating relatives into treatment is definitely worth-

T.M. Lincoln et al. / Schizophrenia Research 96 (2007) 232245

while and should be encouraged where possible. As

family inclusion is not always feasible it could be helpful
to further investigate the barriers to effectiveness of
patient directed PE, which might improve if it is offered
to patients who are out of the acute stage and if patients
are supported individually in transferring their knowledge into everyday life.
Role of Funding Source
There was no specific funding for this study. Costs for literature
were covered by the Department of Clinical Psychology at the
Philipps-University Marburg.
Contributors
The authors designed the study, analyzed the data and wrote the
manuscript.
Conflict of Interest
All authors declare that they have no conflict of interest.
Acknowledgement
We would like to thank Christiane Suttner for coding part of the
studies and Prof. H-H. Schulze for methodological advice.

Appendix A
Coding scheme for study characteristics
(1) Identification (authors, year of publication, place
of study); (2) methodology (recruitment methods, type
of outcome variables [symptoms, relapse, functional
outcome, adherence and knowledge about disorder],
measurement points, diagnostic procedure and classification system, protocol and control of medication); (3)
participants (number, diagnosis, status [chronic, acute],
duration of disorder, age, gender); (4) treatment (setting,
number of sessions for each type of intervention, kind of
additional interventions, intervention in control group,
focus [patients, relatives or combination], method
[interactive versus directive], format [group, single,
combined], duration of intervention in weeks, therapists
[psychologists, doctors, nurses] and dropout-rate).
Coding scheme for validity rating
(1) Validity of the statistical conclusion (comparability
of intervention groups with regard to socio-demographic
or clinical variables, reliability of measures); (2) internal
validity (blindness of investigators, assessment of interrater-reliability, training of raters); (3) construct validity
(multiple outcome measures, one intervention: PE) and
(4) external validity (multiple recruitment methods,
multiple settings, heterogeneous patients within each
group). Studies were coded 2 if the criterion was fulfilled,
1 if partially fulfilled and 0 if not fulfilled or not reported.
The maximum possible score was 18.

243

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