In the present pilot study, we administered brief multifamily psychoeducation consisting of four sessions over six weeks to relatives of patients with depressive disorder. Families participating in this program reported significant improvements in their mental health, care burden and expressed emotion.
The K6 score on the degree of mental health fell significantly after the intervention and this suggests that the mental health of relatives significantly improved during the short intervention period of six weeks. K6 is the standard that was developed to screen for anxiety and mood disorder, and it was reported that if the K6 score is more than nine points, the probability of having an anxiety or a mood disorder is 50% [32
]. Sixteen relatives (50%) had a K6 score of more than nine points before the intervention, but only three (9.3%) did so after the intervention. This suggests that providing brief multifamily psychoeducation for relatives of patients with depressive disorder helps reduce the probability of a mental illness in the relatives themselves.
Furthermore, the care burden of relatives living with the patient, evaluated by the J-ZBI_8 and DFL, significantly improved after the intervention. This suggests that brief multifamily psychoeducation alleviates family care burden and the difficulty of family life at least in the eyes of the relatives.
The reduction in the FAS score indicates that the EE of relatives decreased through brief multifamily psychoeducation. Studies on EE have primarily been conducted on the families of patients with schizophrenia. The family's EE is a good predictor of whether a patient relapses, and an association between a high EE level and high rate of recurrence has been demonstrated [42
]. On the other hand, with regard to depressive disorder, there have been fewer studies on the relationship between the family's EE and the course of the illness. Although Hayhurst et al. [43
] reported that there was no clear association between the EE of a spouse and recurrence of depression in the patient, three studies reported that high EE predicted bad consequence [44
Because brief multifamily psychoeducation reduced the FAS score on the degree of EE, it is thought that it would have a good influence not only on their families but also on the patients. Fabbri et al. [22
] reported that the relapse rate was lower in the group who received family intervention than in the control group. In a future study, it is worth investigating whether brief multifamily psychoeducation to relatives of patients improves depressive symptoms and the QOL of patients.
In this study, the multifamily psychoeducation remarkably reduced the FAS score in women, but not in men. The baseline score of the FAS among women was significantly higher than that among men (55.1 ± 17.1 for women, 36.0 ± 16.0 for men). This may be due to the difference in gender-related expectations between men and women in Japanese society. Wittmund et al. [9
] reported that female spouses seem to have a burden-related increased risk of depression, independent of the partner's type of illness. The reason why only the women's FAS score remarkably decreased in this study cannot be definitively determined, but it may be because women respond better to increased social support obtained through telling her experience to other participants and getting advice from the other participants in family psychoeducation. For male relatives, we must further refine methods of psychoeducation.
The change in the mean FAS score of the participants whose relatives were inpatients was 13.9, and that of participants whose relatives were outpatients was 9.2. Moreover, the change in the mean J-ZBI_8 score of the participants whose relatives were inpatients was 5.4, and that of participants whose relatives were outpatients was 3.1. Although the FAS and J-ZBI_8 scores at baseline did not show significant differences between relatives of inpatients and relatives of outpatients (FAS, 55.6 ± 13.3 in relatives of inpatients, 45.2 ± 21.3 in relatives of outpatients; J-ZBI_8, 12.2 ± 6.1 in relatives of inpatients, 10.1 ± 7.2 in relatives of outpatients), the relatives' burdens were numerically heavier for inpatients than for outpatients and were more responsive to our interventions.
This study has a number of obvious limitations due to its preliminary nature. The sample size was small and there was no control group. In addition, the present study evaluated the relatives only after the intervention, and the long-term consequences of this brief multifamily psychoeducation were unclear. The duration and severity of MDD in the patients varied. However, the results of this study are noteworthy, because the mental health, care burden and EE of relatives of patients with depressive disorder significantly decreased after our short intervention. This suggests that brief multifamily psychoeducation is a useful intervention to reduce the psychosocial burden of relatives of patients with MDD. It may even ameliorate the course of the illness in the patients themselves.