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International Journal of Mental Health Nursing (2018) 27, 61–71 doi: 10.1111/inm.12294

Randomized, controlled trial of a brief family-
centred care programme for hospitalized patients
with bipolar disorder and their family caregivers
Hsiu-Ju Lee,1 Esther Ching-Lan Lin,2 Mei-Bih Chen,1 Tung-Ping Su3 and Li-Chi Chiang4
Department of Nursing, Taipei Veterans General Hospital, Taipei, 2Department of Nursing, National Cheng Kung
University and Hospital, Tainan, 3School of Medicine, National Yang-Ming University, Taipei, and 4School of
Nursing, National Defense Medical Center and China Medical University, Taipei and Taichung, Taiwan

ABSTRACT: Family interventions have been emphasized in the treatment of bipolar disorder
(BPD) due to the bidirectional and entangled relationships between patients and the family system,
and have benefits for patients’ symptoms and health; however, the effects of family interventions on
family function and caregivers’ health-related outcomes have not been well investigated. This
randomized, controlled trial with 47 hospitalized patients with BPD/family caregiver dyads at a
medical centre in northern Taiwan compared the effects of a brief family-centred care (BFCC)
programme with treatment as usual (TAU). All of the family caregivers in two groups were invited
to attend a routine 60-min family discussion group about violence and suicide prevention. The TAU
group without specific family interview for patient and family caregiver dyad. In the BFCC group,
four 90-min BFCC programme sessions were additionally provided twice a week for each
hospitalized family dyad. We hypothesized that, first, family caregivers in the BFCC group could
increase their family function, and second, improve perceived health status and reduce caregiver’s
burdens compared to the TAU. The results showed that family caregivers in the BFCC group
significant interaction effects in overall family function (P = 0.03) and subscale conflict (P = 0.04),
communication (P = 0.01), and problem-solving (P = 0.04), but there were no significant
interaction effects on the caregivers’ perceived health status and caregivers’ burdens. Our findings
support both the feasibility of using the BFCC programme for inpatients and its specific benefits
for family function. An intensive family intervention during hospitalization has been suggested in
psychiatric practice to support patients with BPD and family caregivers.
KEY WORDS: bipolar disorder, family function, family-centred care.

mixed episodes, which are characterized by several

mood dysregulations, impulsivity, risky behaviour, and
Bipolar disorder (BPD) is a severe and long-term psy- €
interpersonal problems (Keck et al. 2001; Osby et al.
chiatric illness with recurrent depressive, manic, and 2001). According to the World Health Organization,
BPD is the seventh leading cause of disability-adjusted
life-years for people aged 15–44 years (World Health
Correspondence: Li-Chi Chiang, School of Nursing, National
Defense Medical Center and China Medical University, 161, Sec- Organization 2004). Patients with BPD have life-long
tion 6, Mingchuan East Road, Neihu, Taipei 114, Taiwan. Email: impaired interpersonal relationships and disturbed edu- cational and occupational performance caused by the
Hsiu-Ju Lee, MS, RN.
Esther Ching-Lan Lin, PhD, RN. early onset and recurrence of BPD (Mitchell & Malhi
Mei-Bih Chen, MS, RN. 2004). They also utilize more mental health services
Tung-Ping Su, PhD, MD.
Li-Chi Chiang, PhD, RN. (Frye et al. 2005) and have higher suicide rates than
Accepted September 18 2016. others in that age group (Mitchell & Malhi 2004).

© 2016 Australian College of Mental Health Nurses Inc.

62 H.-J. LEE ET AL.

Family caregivers often express positive (compas- and family caregivers’ health-risk behaviours, and
sionate) or negative (harsh) reactions, or both, when reductions in their depressive symptoms and subjective
confronted with a patient’s emotional instability (Mas- burdens. A poorly-functioning family has been associ-
kill et al. 2010). Interpersonal relationship conflicts ated with severe psychopathology and low psychosocial
between family caregivers and patients with BPD not functioning in patients with BPD (Ferreira et al. 2013;
only affect patients’ symptom fluctuations, but also Sullivan et al. 2012). Although previous psychoeduca-
bidirectionally affect caregivers’ physical and psycholog- tional interventions might alleviate patients’ and family
ical health. Evidence shows that caregivers have heavy caregivers’ symptomatic severity and the caregivers’
care burdens, in addition to health and emotional prob- burdens, the extent of the benefits of family-focussed
lems (Beentjes et al. 2012; van Der Voort et al. 2009). interventions for family function remains unclear
One review (Steele et al. 2009) of the psychiatric symp- (Reinares et al. 2016).
toms of caregivers for patients with BPD found that Several family nursing models have been developed
46% of caregivers claimed to be depressed, and that for family nursing practice (Bomar, 2004). Simpson
32.4% reported that they had to use mental health ser- et al. (2006) demonstrated that the Calgary Family
vices for their depression. Other studies indicated that Intervention Model (CFIM) is a good family system
family caregivers are overwhelmed by providing infor- nursing approach for psychiatric nurses caring for
mal care during the transitional discharge period (Ger- Chinese individuals with a mental illness and their
son & Rose 2012; Lee et al. 2013; Pompili et al. 2014), families. By providing a meta-perspective, the CFIM
and that different caregiving phases require different (Wright & Leahey 1994, 2013) emphasizes that each
coping mechanisms (van Der Voort et al. 2009). family is unique and has the potential to change the
Because Taiwan is strongly influenced by traditional presenting problem. This model focusses on improv-
Confucian culture, in which family is an essential bond- ing and sustaining family functioning in the cognitive,
ing relation of social structure, the value of familial affective, and behavioural domains. Based on the
interdependence is particularly emphasized (Chen CFIM, family interventions include highlighting the
2001). Moreover, family caregivers usually escort strengths of patients and family members, providing
patients to clinic visits and sleep on a hospital-provided information and education, validating and normalizing
cot in the same room during admission (Huang et al. emotions, encouraging family support and sharing the
2009). Family caregivers also take the burden of burden of care, managing respite or relief from care,
responsibility when caring for patients with BPD after maintaining family rituals, and staying flexible and
they are discharged (Yen et al. 2010). However, family responsive to unique family needs. Health profession-
caregivers might undergo complex conflicts because als use therapeutic conversations and the therapeutic
they feel trapped, helpless, and distressed. They also relationship with the family to encourage them to
feel stigmatized by others because the family member think about their health problems, discover the
they care for has a mental illness (Huang et al. 2009). strengths of the patient–family collaboration, and
Therefore, it is essential to provide family caregivers develop effective strategies (Arango 2011; Leahey &
appropriate knowledge about the illness and to teach Harper-Jaques 2010). Lee et al. (2013) conducted a
them constructive coping strategies. qualitative study to explore the experiences of eight
Several family-focussed psychosocial treatments have family caregivers of BPD patients during the hospital-
reported benefits for patients with BPD and their care- ization transitional period based on family-centred
givers (Justo et al. 2007; Miziou et al. 2015; Reinares care. The nurse-initiated family interviews could
et al. 2016). Miklowitz et al. (2000) found that a 9- mobilize family recourses to help families’ healing by
month, manual-based programme of family-focussed identifying family strengths and resources, looking for
psychoeducational treatment could delay and reduce solutions to problems, transforming effective commu-
the number of relapses and depressive symptoms in nicating style, and making their decisions (Lee et al.
patients followed up for 1 year. Reinares et al. (2010) 2013).
also reported that caregivers who had undergone family The brief family-centred care (BFCC) programme
psychoeducation had fewer recurrent mood episodes based on the CFIM was developed to systematically
and longer relapse-free intervals. Perlick et al. (2010) assess families, and provide specific intensive interven-
reported that, after 12–15 sessions of psychoeduca- tions for each family in an acute psychiatric setting. In
tional and cognitive-behavioural intervention, there the present study, our primary hypothesis was that the
were significant improvements in patients’ symptoms BFCC programme for the family dyads for hospitalized

© 2016 Australian College of Mental Health Nurses Inc.


patients with BPD would improve their family function,

and our secondary hypothesis was that it would benefi-
cially affect the caregivers’ health status and burdens. Patients were enrolled if they met the Diagnostic and
Statistical Manual of Mental Disorders (DSM), 4th edi-
tion (American Psychiatric Association 1994) criteria for
bipolar-I or bipolar-II disorder, were able to be inter-
The study design was a randomized, controlled trial to viewed, and had a Hamilton Depression Rating Scale
repeatedly measure the primary outcomes of family (HDRS) score <17 and a Young Mania Rating Scale
function and secondary outcomes of perceived health (YMRS) score <38 (Keck 2004) to prevent adverse
status and family caregiver burden. Family caregivers of effects caused by patients’ mood instability. Patients
BPD patients were eligible and agreed to participate in who had lived alone or lived with their family for
the present study, and were recruited while they were in <6 months, had been concurrently diagnosed with an
a psychiatric acute ward at a 3032-bed medical centre in intellectual disability (DSM-V) (American Psychiatric
northern Taiwan with their family member who had a Association 2013), had been newly diagnosed with BPD
mental illness. During the allocation process, patients at this admission, or could not speak Chinese, were
and family caregivers were randomly assigned to either excluded. Family caregivers who: (i) were significant in
the BFCC group or treatment-as-usual (TAU) group by the patient’s life; (ii) were at least 18 years old; (iii) lived
a computer-generated process using simple randomiza- with the patient for at least 6 months; (iv) were able to
tion by the corresponding author (principal investiga- speak and understand Chinese or Taiwanese; and
tor). Participants were not informed of their group (v) were able to answer questionnaires written in
allocation status during this process by using sealed, Chinese were included. Caregivers diagnosed with a seri-
opaque envelopes. Following baseline measurements, ous mental illness or intellectual disabilities were excluded.
neither study staff nor participants were blinded to par- Systematic reviews of family interventions indicated
ticipants’ allocation. After the families were allocated the small effect size on the patients’ symptoms and fam-
into the BFCC group or TAU group with the permission ily relationship (Justo et al. 2007; Reinares et al. 2016).
of the researcher (the first author), each family was Because of limited family intervention studies and the
invited to participate in a routine 60-min family discus- lack of previous studies about family function among
sion group about violence and suicide prevention. The patients with BPD, we selected a small effect size of 0.2
families in the BFCC group had four 90-min family based on conservative considerations and balancing the
interviews with the patient–family caregiver dyad during resources available for conducting this innovative inter-
the hospitalization period. All outcome measures were vention study (Cohen 1988). We calculated the sample
self-reported by the family caregivers and returned in a size for two groups and repeated measures twice by a
sealed envelope to a location separate from personnel G*Power analysis (Faul et al. 2007) with two-tailed tests
who were involved in the intervention. (a = 0.05 and b = 0.80), and determined that we would
The human rights protection protocols and all ethi- require a total of 28 patients, with 14 per group to
cal considerations were approved by the institutional detect the effects in repeated measures by a within-
review board of the research setting before the recruit- between interaction (Fig. 1).
ing of participants. Family caregivers were given a let-
ter explaining the details of the study and informing
patients that they had the right to withdraw from the
study at any time, and for any reason, in accordance TAU
with the Declaration of Helsinki. Signed, written per- All patients were given the standard hospital-provided
mission was obtained prior to data collection and ran- services: psychiatric nursing care, occupational therapy,
domization. The principal investigator endeavoured to and pharmacotherapy. All of the family caregivers were
keep the participants in the study after enrolment. In only to attend a routine 60-min family discussion group
order to control the fidelity of the trial, we followed about violence and suicide prevention without any
the original protocol approved by the institutional specific patient–family dyad interview.
review board of the research setting during the trial,
and did not make any amendments. A copy of the full BFCC programme
trial protocol is available from the corresponding The BFCC programme was developed based on the
author upon request. CFIM, and adapted for hospitalized patients with

© 2016 Australian College of Mental Health Nurses Inc.

64 H.-J. LEE ET AL.

Hospitalization Assessed for eligibility of bipolar

disorder (n = 134)

Within 3 days
of admission Excluded criteria (n = 74)
♦ Do not meet inclusion criteria (n = 35)
Enrolment ♦ Declined to participate (n = 39)

Randomized (n = 60)

Within 10–12
days of


Experimental group (n = 30) Comparison group (n = 30)

♦ Received the brief family-centered ♦ Received treatment as usual
care programme (n = 20) (n = 27)
♦ Did not receive allocated ♦ Did not receive allocated intervention
intervention (n = 10) (n = 3)
- Family refused to participate (n = 6) - Patient refused to participate (n = 3)
- Patient refused to participate (n = 4)
Within 19–21
days of
admission Discontinued intervention (n = 4) Lost to follow-up (n = 7)

-Reasons: patients’ or family’s -Reasons: patients’ worsening

Follow up unwilling to participate or symptoms, failing to keep their
failing to keep their appointments, unexpected
appointments discharge
Analysed (n = 16) Analysed (n = 20)

FIG. 1: Consort flow diagram.

BPD and their family caregivers. Lee & Chiang had nursing, provided the BFCC programme twice a week
discussions with Dr. Lorraine Wright who created the for each dyad in the experimental group. The core
CFIM and inspire us to develop a new family nursing principles treated family as a single unit and provided
care model in our psychiatric unit and design the individually-tailored interventions to improve family
interview guidelines for the patient–family caregiver function through psychoeducation and social and
dyad. The family caregivers were also invited to attend emotional support, while actively raising questions to
a routine 60-min family discussion group, the TAU facilitate constructive awareness and changes. Four
group. The BFCC protocol is outlined as four treat- 90-min, in-depth sessions for each dyad were initially
ment sessions, specific goals, and example questions held in a quiet interview room to assess family func-
(Table 1). The therapist (LHJ), an experienced psychi- tion; provide information about BPD; to support and
atric nurse with a Master degree in psychiatric empower the dyads to change communication styles

© 2016 Australian College of Mental Health Nurses Inc.


TABLE 1: Protocol of the brief family-centred care programme

Session Goals Example questions

1. Assessment
• To assess each family’s composition, developmental stage, interaction • Describe your family
and communication styles, and family function • What is the effect of bipolar disorder on your family?
• To understand the effect of disease on the family, and explore their • What has been your experience of arguing?
subjective narrative illness experiences and coping strategies • How have the patient’s disease-related behaviours and
responses affected the family?
2. Social–emotional support and psychoeducation
• To explore the family’s strengths and resources • What obstacles do you face in caring for your family
• To offer appreciation, validation, empowerment, and member with a mental illness at home?
normalization of their emotional reactions • Who do you call for help, and what do they do?
• To analyse family dynamics, as well as facilitate constructive • One of your strengths is your awareness of. . ..?
beliefs and communication styles • Under what circumstances might you experience negative
• To encourage mutual support and strengthen the exterior emotions towards others?
support system • When do you and your family feel negatively towards
• To provide necessary illness-related knowledge and each other?
treatment information to patients and families • How could you do better?
• Who else can help?
3. Challenge to change
• To define the family’s problems • Try to explain why your feelings change
• To help family members understand the emotions • How do you wish your family could help you?
behind their conflicts • When you see the patient struggling, you feel. . .?
• To guide their brainstorming and cooperative discussions • How will you change the situation now?
about facilitating solutions instead of perpetuating existing
constraining ones
• To formulate problem-solving plans and coach them in
communication and emotional self-regulation
4. Termination
• To individually appreciate each family member’s effort • Share your findings from these past sessions
during treatment • What tasks have you achieved and not yet achieved
• To develop discharge plans during treatment?
• To summarize the therapist’s observations about the illness • How do you hope your family will help you?
adaptation and management of the whole family and • Under which circumstances would you be willing to
achieved tasks in the previous sessions be rehospitalized?
• To provide a prospective future and impart hope • What do you think about the patient’s living
arrangements after discharge?

and resolve conflicts; and to sustain or improve family provided observations about family communication,
function in the cognitive, affective, and behavioural encouraged them to change communication styles,
domains. In the 90-min, in-depth session for the cog- taught them self-regulatory behaviour, and enabled
nitive domain, the therapist assessed the strength, new behaviours to resolve family conflicts. At the end
potential energy, external resources, and obvious and of each session, the therapist (LHJ) reviewed the fam-
hidden family problems of the family function of each ilies’ interactions, responses about their subjective
family, and the family’s subjective narrative and cop- experiences, beliefs, and values to clarify their prob-
ing strategies for illness, which were cooperatively lems, and then told the families what she had con-
brainstormed. The therapist discussed how to avoid cluded in her review.
problems, and provided specific psychoeducation. In
the session for the affective domain, the therapist
encouraged the family to express feelings and talk
about the meaning of the emotions behind the con- Baseline assessments of sociodemographic data and
flict; and discussed appreciation, validation, empower- clinical symptoms were compiled. The sociodemo-
ment, and normalization of their emotions. In the graphic data of the patient and family caregiver
session for the behavioural domain, the therapist included sex, age, education, marital status, and

© 2016 Australian College of Mental Health Nurses Inc.

66 H.-J. LEE ET AL.

employment. Family caregivers were asked to report independence, and family responsibilities. Each item is
their kinship, history of BPD, and frequency of hospi- rated on a 0–4 Likert scale, and 11 negative items are
talization. Patients’ clinical data about mood states, reverse-scored. Higher scores indicate better family
how long they had had psychiatrist-diagnosed BPD, function. The FFS has been well tested (internal con-
and how many times they had been hospitalized sistency: 0.75, retest reliability: 0.72) and has good
were obtained from medical records by our research criteria-related validity with Beck’s Depression Inven-
assistants. tory (Wang & Ko 2001).
Their clinical symptoms were assessed using the
YMRS and the HDRS by independent raters. The 11- Chinese health questionnaire-12
item YMRS was used to evaluate manic symptoms (to- The Chinese Health Questionnaire (CHQ)-12 was
tal score range: 0–60), with good reliability and validity used for the family caregivers’ self-reported assess-
(Hwu 1999; Young et al. 1978). Four items were rated ments of the severity of their own mental problems in
on a 0–8 Likert scale (irritability, speech, thought con- the previous 2 weeks. The CHQ-12 was derived from
tent, and disruptive/aggressive behaviour), and the the General Health Questionnaire (GHQ) and con-
remaining seven items were rated on a 0–4 Likert scale tains 12 items in four dimensions: physiological and
(Young et al. 1978). The 17-item HDRS is the most somatic, anxiety and worry, depression and poor rela-
widely used depression-assessment scale, with good tionships, and sleep problems. Each item is rated on
reliability and validity (Hamilton 1960; Hwu 1999). It a 0–3 Likert scale. Total scores <3 indicate normal
includes nine items rated on a 0–4 Likert scale and psychological health, and total scores >3 indicate
eight items on a 0–2 Likert scale (total score range: worsening symptoms and that a patient is at risk of
0–54). mental illness. Higher scores indicate worsening con-
Post-treatment assessments for the BFCC group ditions. The CHQ-12 was developed and has been
were done after the intervention had been completed, well tested among community groups for screening
and for the TAU group, it was done 19–21 days after psychiatric problems, and shows acceptable reliability
the patients had been hospitalized. and validity (Cheng & Williams 1986). Reliability was
The primary outcome indicator was family function, tested by internal consistency, with Cronbach’s alpha
and secondary outcomes were caregivers’ perceived of 0.83–0.84. Validity was examined at the optimal
health status and caregivers’ burden. All were assessed cut-off point of 3/4. Sensitivity was 77.8%, specificity
using self-reported questionnaires in Chinese at base- was 76.9%, the positive predictive value was 68.9%,
line and post-treatment. In the present study, ‘family the negative predictive value was 90%, the overall
function’ was defined as family cohesion, conflict, emo- misclassification rate was 17.6%, and the estimated
tional involvement, emotional expression, communica- area under the relative operating characteristic (ROC)
tion, problem-solving, independence, and family curve was 0.81.
responsibilities; ‘caregivers’ perceived health status’ was
defined as the caregiver’s perceived physiological and Caregiver burden inventory
somatic health status, anxiety and worry, depression, The Chinese version of the Caregiver Burden Inven-
poor relationships, and sleep problems; ‘caregiver bur- tory (CBI) (Novak & Guest 1989) was translated and
den’ was defined as five kinds of physiological, social, validated by Chou et al. (2002). They supported its
emotional, and chronological family burdens, and the good internal consistency and adequate construct valid-
development of family burdens. ity with moderate intercorrelations between subscales
and high factor loadings from a factor analysis of the
Family function scale Taiwanese population. The CBI contains 24 items in
The Chinese version of the Family Function Scale five dimensions: physiological, social, emotional,
(FFS) (Wang & Ko 2001) was developed from qualita- chronological, and developmental. Each item is rated
tive interviews on Taiwanese culture; it used the Fam- on a 0–4 Likert scale (total score range: 0–96). Higher
ily Adaptability and Cohesion Evaluation Scale-III scores indicate greater caregiver burdens.
(Olson 1986) and the Family Assessment Device
(Epstein et al. 1983) as its theoretical basis. The
Adverse event
44-item, Chinese version of the FFS includes eight
dimensions: cohesion, conflict, emotional involvement, While conducting the study, an adverse event was
emotional expression, communication, problem-solving, observed. Some family dyads seemed to need more

© 2016 Australian College of Mental Health Nurses Inc.


professional assistance during hospitalization, because least a 4-year college degree. Although the family care-
the BFCC programme facilitated the communication givers in the TAU group were younger than those in
and interaction of the whole family. the BFCC group (P = 0.053), there were no significant
demographic or clinical differences between the two
groups (Table 2).
Statistical analysis
Differences in demographic and baseline clinical vari-
Effect on family function, caregivers’ perceived
ables between the BFCC and TAU groups were evalu-
health status, and caregivers’ burden
ated using v2-tests. Differences in changes between
baseline and post-treatment CHQ-12, CBI, and FFS At baseline, there were no significant differences in the
scores were evaluated using generalized linear mixed- three outcome indicators between the two groups. For
model regression analyses (Hedeker & Gibbons 2006). the primary hypothesis related to family function, there
For each model, the baseline and post-treatment scores were significant group 9 time interactions for the total
were the repeated dependent variables, and the group FFS scores and subscales of conflict, communication,
was the independent variable. The ‘time effect’ is a test and problem-solving. It indicated that patients in the
of whether both groups improved between baseline BFCC group made greater improvements on overall
and post-treatment assessments. The group 9 time FFS scores and these three subscales than those in the
interaction is a test of whether patients in the BFCC TAU group. For the secondary hypothesis, there were
group differed significantly over time from those in the significant time effects for the subscales of depression
TAU group, and thus was the primary effect of inter- and poor relationships in both groups, and a marginal
est. SPSS 17.0 for Windows (SPSS, Chicago, IL, USA) effect for the CHQ total score (P = 0.05; Table 3).
was used for all analyses. Significance was set at However, there were no significant time effects or
P < 0.05. group differences for the CBI total score or the sub-
scales in either group. Furthermore, there were no sig-
nificant differences of rehospitalization after 1-year
follow up (25% (4/16) in the BFCC group and 50%
(10/20) in the TAU group (P = 0.502)).
Patient characteristics
Of the 134 patients screened for enrolment in the pre-
sent study, 35 did not meet the inclusion criteria and
39 declined to participate. Sixty patients were randomly We found that the BFCC programme intervention
assigned to either the BFCC group or the TAU group. improved the family function, but did not affect family
Ten patient/caregiver dyads in BFCC group and three caregivers’ self-perceived health status and caregivers’
in the TAU group refused to participate. Seven dyads burden. These brief family interventions taught care-
in the TAU group were lost to post-intervention assess- givers to communicate with patients, and patients and
ment because the patients’ symptoms worsened, the caregivers to deal with conflicts and to solve their prob-
patients failed to keep their appointments, or the lems by providing emotional support and information
patients were unexpectedly discharged. Four dyads in about BPD-related dysfunctional behaviours. It also
the BFCC group discontinued the intervention because assisted the dyads to develop new problem-solving
the patient, caregiver, or both were unwilling to partici- skills. All of this new knowledge eventually reached the
pate or failed to keep their appointments. Finally, 17 rest of the family and contributed to improving family
dyads in the BFCC group and 20 dyads in the TAU function. Evidence shows that family function has a
group were analysed. critical effect on the efficacy of family-focussed treat-
Half of the patients were male, aged 21–40 years ments (Sullivan et al. 2012), and on the symptomatic
old, were married, and unemployed or in school and functional recovery of patients with BPD (Ferreira
(Table 2). Most had a 4-year or 2-year college degree, et al. 2013; McCann et al. 2012; Reinares et al. 2016).
had been diagnosed with BPD more than 5 years However, most studies on family intervention have
before the commencement of the study, and had been examined the effects on patients’ symptomatology and
hospitalized more than once. Most of the family care- social functioning and on relatives’ depression, bur-
givers were the patients’ parents or spouses; they care- dens, or health-related behaviours. Few studies have
givers were married, aged 41–65 years old, and had at assessed family function as an outcome indicator. Our

© 2016 Australian College of Mental Health Nurses Inc.

68 H.-J. LEE ET AL.

TABLE 2: Participants’ characteristics

Patients with bipolar disorder Family caregivers

BFCC group (n = 16) TAU group (n = 20) BFCC (n = 16) TAU (n = 20)
n (%) n (%) v2 P-value n (%) n (%) v2 P-value

Male 8 (50.0%) 9 (45.0%) 0.765 0.380 6 (37.5%) 14 (70.0%) 0.051 0.380
Marital status
Single 9 (56.2%) 12 (60.0%) 0.764 0.401 4 (25.1%) 6 (30.0%) 0.181 0.538
Married 7 (43.8%) 8 (40.0%) 12 (75.0%) 14 (70.0%)
Age (years)
21–40 10 (62.5%) 10 (50.0%) 0.577 0.194 2 (12.5%) 7 (35.0%) 0.229 0.053
41–65 6 (37.5%) 10 (50.0%) 13 (81.1%) 9 (45.0%)
≥66 0 1 (5%) 1 (6.3%) 4 (20.0%)
High school or less 4 (25.0%) 6 (30.0%) 0.598 0.432 3 (18.8%) 5 (25.0%) 0.569 0.756
College degree 9 (56.3%) 8 (40.0%) 2 (12.5%) 7 (35.0%)
Master or higher 3 (18.8%) 6 (30.0%) 11 (68.7%) 8 (40.0%)
Yes 8 (50.0%) 9 (45.0%) 0.402 0.107 7 (43.8%) 4 (20.0%) 0.165 0.064
No 8 (50.0%) 11 (55.0) 9 (56.2%) 16 (80.0%)
Illness duration (years)
≤5 2 (12.5%) 6 (30.0%) 0.486 0.351 – – – –
6–10 7 (43.8%) 1 (5%)
11–15 1 (6.3%) 3 (15.0%)
≥16 6 (36.5%) 10 (50.0%)
≤5 11 (68.7%) 10 (50.0%) 0.981 0.354 – – – –
6–10 2 (12.5%) 2 (10.0%)
≥11 3 (18.8%) 8 (40.0%)

BFCC, brief family-centred care; TAU, treatment as usual.

findings support both the feasibility of using the BFCC the value of familial interdependence is emphasized
programme for inpatients, and using its specific bene- in Chinese society (Chen 2001), the BFCC assisted
fits for family function. the whole family to do the tasks required for them
A brief family intervention during hospitalization has to take care of their own family when they encounter
been suggested in psychiatric practice to support complex conflicts and distressed feelings, and to fulfil
patients with BPD and family caregivers. Miklowitz their moral responsibility (Huang et al. 2009). For
et al. (2013) found a greater treatment effect after a 4- this specific cultural context in Taiwan, family inter-
month family-focussed therapy session among adoles- vention that is individually tailored to patients’ char-
cents at high risk in families that are highly emotional acteristics and the family’s needs is particularly
versus emotionally-subdued families. Sullivan et al. valuable.
(2012) reported greater reductions in conflict over time The effects of the BFCC on caregivers’ health status
in high-conflict families of an adolescent with BPD and burden were not consistent with the benefits found
participating in family intervention, and a significant in similar studies (Fiorillo et al. 2015; Reinares et al.
improvement of the patient’s mania symptoms in low- 2010). Possibly, the short hospital stay (mean: 3 weeks)
conflict families. They suggested that family cohesion, in our study and the brevity of our interventions did
adaptability, and conflict could be useful predictors of not offer sufficient support or respite to the caregivers.
the course of adolescents’ mood symptoms, and that Reinares et al. (2010) and Fiorillo et al. (2015) sup-
family conflict might be an important target for family ported the benefits of the 12–18 90-min sessions of
intervention in early-onset BPD. It might, therefore, be psychoeducational family interventions for 6–15 months
crucial to provide a family intervention during transi- on patients’ symptoms and the family caregivers’ bur-
tion from hospital to home for continually improving den. Two recent reviews (Miziou et al. 2015; Reinares
family function and family caregivers’ health status, as et al. 2016) concluded that family interventions amelio-
well as reducing their care burden. Moreover, because rated caregivers’ health risk behaviours, depression,

© 2016 Australian College of Mental Health Nurses Inc.


TABLE 3: Comparison of family function and caregivers’ perceived health status and burden

BFCC group (n = 16) TAU group (n = 20) Time effect Time 9 group effect
Baseline test Post-test Baseline test Post-test
Mean (SD) Mean (SD) Mean (SD) Mean (SD) F (P-value) F (P-value)

FFS total scores 140.88 (22.82) 150.19 (23.12) 146.35 (18.08) 134.42 (20.05) 0.09 (0.77) 5.23 (0.03)*
Cohesion 26.00 (6.24) 25.63 (5.66) 24.35 (5.53) 23.26 (6.85) 0.87 (0.36) 0.27 (0.61)
Conflict 12.38 (4.29) 15.06 (4.68) 15.00 (2.79) 14.40 (2.85) 1.91 (0.18) 4.75 (0.04)*
Emotional involvement 9.25 (2.89) 10.63 (3.70) 11.20 (3.72) 10.45 (2.72) 0.23 (0.64) 2.66 (0.11)
Emotional expression 18.94 (3.62) 19.81 (2.86) 18.10 (4.44) 18.20 (4.15) 0.55 (0.47) 0.35 (0.56)
Communication 18.75 (6.01) 22.81 (5.41) 21.55 (5.36) 16.70 (5.93) 0.06 (0.81) 7.67 (0.01)*
Problem-solving 17.00 (6.47) 19.06 (4.12) 19.15 (4.44) 15.50 (5.61) 0.35 (0.55) 4.71 (0.04)*
Independence 22.19 (5.26) 21.44 (4.86) 22.10 (3.97) 21.50 (3.32) 0.74 (0.40) 0.01 (0.93)
Family responsibilities 16.38 (3.63) 15.75 (3.28) 14.90 (2.99) 14.45 (2.69) 1.06 (0.31) 0.03 (0.87)
CHQ total score 5.12 (2.47) 4.44 (2.07) 5.70 (3.47) 4.20 (3.11) 4.43 (0.05)* 0.59 (0.45)
Physiological and somatic aspects 0.88 (0.96) 0.56 (0.89) 1.10 (1.48) 0.90 (1.33) 1.35 (0.25) 0.65 (0.80)
Anxiety and worry 1.13 (1.09) 1.31 (1.14) 1.55 (1.32) 0.90 (1.12) 1.22 (0.28) 4.00 (0.05)
Depression and poor relationships 2.56 (0.89) 2.19 (0.91) 2.55 (0.89) 2.10 (0.64) 6.29 (0.02)* 0.05 (0.82)
Sleep problems 0.56 (0.51) 0.38 (0.50) 0.50 (0.51) 0.30 (0.47) 3.90 (0.06) 0.00 (0.95)
CBI total score 48.38 (11.37) 50.26 (14.74) 50.40 (21.75) 46.35 (20.06) 0.16 (0.69) 0.97 (0.33)
Physiological burden 10.94 (2.98) 9.94 (3.04) 10.00 (5.06) 8.80 (4.53) 3.20 (0.08) 0.03 (0.87)
Social burden 6.88 (3.28) 8.44 (4.08) 7.50 (4.73) 7.15 (3.63) 0.55 (0.46) 1.37 (0.25)
Emotional burden 8.10 (3.95) 9.44 (6.03) 8.80 (6.05) 9.15 (5.11) 0.09 (0.76) 0.98 (0.33)
Time burden 11.81 (4.28) 9.69 (3.89) 13.05 (5.11) 12.05 (5.18) 3.29 (0.08) 0.43 (0.52)
Development burden 10.56 (4.93) 12.56 (4.52) 11.05 (5.78) 10.20 (4.61) 0.47 (0.50) 2.89 (0.70)

BFCC, brief family-centred care; CBI, Caregiver Burden Inventory; CHQ, Chinese Health Questionnaire; FFS, Family Functioning Scale;
TAU, treatment as usual group. *P < 0.05.

and burden. In most studies, the intervention lasted for Our findings have some practical implications. First,
at least 6 months with 12–18 treatment sessions. The clinical nurses 24 hours stay with their patients and
relatively short duration of the acute care setting understand the relationships between patients and their
required an abbreviated and adapted family interven- family caregivers. We could provide family intervention
tion. Pragmatically, the short-form family-centred care in acute care settings to encourage family members
programme in the present study targeted the specific communication with each other. Therefore, psychiatric
transitional needs of the family while their family mem- nurses need adequate family interviewing training (Gou-
ber with BPD was hospitalized. Because there were, in dreau et al. 2006). For example, nurses must be aware
our pilot study (Lee et al. 2013), families with little of the value and conflicts of familial interdependence in
motivation to participate in family intervention after Chinese culture while conducting the BFCC pro-
their family member with BPD had been discharged gramme. Second, developing cultural-specific family-
from hospital, we implemented the BFCC by provid- centred interventions based on the CFIM for other
ing individually-tailored and task-oriented interven- mental illnesses, such as schizophrenia, depression,
tions to the identified urgent problems between organic disorders, and dementia, might benefit family
patients and family. As expected, the caregivers’ and caregivers in Chinese society and improve family func-
patients’ participation rates in the BFCC programme tion and the quality of care.
were high, which supported its feasibility for use The present study has some limitations. First, the
with patients awaiting discharge and their caregivers. sample size was modest, which limited the study’s statis-
Lee et al. (2013) also reported that the hospitaliza- tical power and might have contributed to undetectable
tion period is an accessible stage for igniting the significant effects of the BFCC programme on improve-
desire of patients and their caregivers to obtain pro- ments in caregivers’ health status and burdens. Second,
fessional help. Brief and focused family intervention the BFCC programme was provided when the patient
could met patients’ and caregivers’ specific needs and with BPD was hospitalized, and family dyads had to
strengthened family function during transition from agree to work together, which led to a selection bias:
hospital to home. There are ten family caregivers discontinued in the

© 2016 Australian College of Mental Health Nurses Inc.

70 H.-J. LEE ET AL.

BFCC intervention, it was supposed that the BFCC Bomar, P. J. (2004). Promoting Health in Families: Applying
might be increase their family conflict and less the inten- Family Research and Theory to Nursing Practice, 3rd
tion to attend in this trial. Therefore, our findings might edn. Philadelphia, PA: Saunders.
Chen, D. S. (2001). Taiwan’s social change in the patterns of
not be generalizable to uncooperative patients and fam-
social solidarity in the 20th century. The China Quarterly,
ily caregivers who have a multitude of family conflicts 165, 61–82.
and family problems. Third, we had no follow-up assess- Cheng, T. A. & Williams, P. (1986). The design and
ment and did not evaluate whether any of the BFCC development of a screening questionnaire (CHQ) for use
programme effects were lasting. With the positive results in community studies of mental disorders in Taiwan.
of the present study, and considering the high rate and Psychological Medicine, 16, 415–422.
cost of hospitalization for patients with BPD, longer- Chou, K. R., Lin, J. C. & Chu, H. (2002). The reliability and
validity of the Chinese version of the caregiver burden
term follow-up evaluation of the BFCC programme is
inventory. Nursing Research, 51, 324–331.
needed for future research. Fourth, the BFCC pro- Cohen, J. (1988). Statistical Power Analysis for the
gramme was compared with TAU, and did not control Behavioral Sciences, 2nd edn. Hillsdale, N. J.: Lawrence
for the non-specific factors related to the intervention Erlbaum.
(e.g. clinician time and attention). Fifth, participants van Der Voort, T. Y., Goossens, P. J. & Van Der Bijl, J. J.
were not blinded to their intervention groups in this (2009). Alone together: A grounded theory study of
study, which might have biased their responses to sub- experienced burden, coping, and support needs of spouses
jective outcome measures. of persons with a bipolar disorder. International Journal of
Mental Health Nursing, 18, 434–443.
Epstein, N. B., Baldwin, L. M. & Bishop, D. S. (1983). The
CONCLUSIONS McMaster family assessment device. Journal of Marital
and Family Therapy, 9, 171–180.
Our findings supported the feasibility of using the Faul, F., Erdfelder, E., Lang, A. G. & Buchner, A. (2007).
BFCC programme for patients with BPD and their G*Power 3: A flexible statistical power analysis program
caregivers during hospitalization in an acute care inpa- for the social, behavioral, and biomedical sciences.
tient setting. It also supported the positive effect on Behavior Research Methods, 39, 175–191.
Ferreira, G. S., Moreira, C. R., Kleinman, A. et al. (2013).
family function, but it did not decrease family care-
Dysfunctional family environment in affected versus
givers’ perceived health problems or burdens. For unaffected offspring of parents with bipolar disorder.
future research, we suggest larger samples, longer fol- Australian and New Zealand Journal of Psychiatry, 47,
low-up periods (e.g. 6 months or more), and assess- 1051–1057.
ments of patients’ symptoms and family function. Fiorillo, A., Del Vecchio, V., Luciano, M. et al. (2015).
Efficacy of psychoeducational family intervention for
bipolar I disorder: A controlled, multicentric, real-world
ACKNOWLEDGEMENTS study. Journal of Affective Disorders, 172, 291–299.
Frye, M. A., Calabrese, J. R., Reed, M. L. et al. (2005).
The authors wish to thank all of the patients with bipo- Use of health care services among persons who screen
lar disorder and their family caregivers who partici- positive for bipolar disorder. Psychiatric Services, 56,
pated in this preliminary study. 1529–1533.
Gerson, L. D. & Rose, L. E. (2012). Needs of persons with
serious mental illness following discharge from inpatient
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