The Influence of Family-Expressed Emotion on the Risk of Relapse in Patients with Schizophrenia: Outcomes from a Community Medicine Intervention

Schizophrenia is a syndrome characterized by fundamental deviations in thinking, perception, and affect. Expressed emotion (EE) is a crucial risk factor in influencing the occurrence of relapse. In Indonesia, there is still no community therapy activity related to the family EE against the risk of relapse of schizophrenia patients. This is the underlying need for community psychiatry activities against families of patients with schizophrenia and related parties. This cross-sectional study was conducted in Puri, Mojokerto, Indonesia. The method was divided into three stages: field introduction, community diagnosis, and community therapy. In 36 schizophrenia patients, it was found that the level of EE experienced by the patients was relatively low, and the risk of recurrence within one year was around 43.27%. Based on these findings, the families of schizophrenia patients in Puri District can express good positive emotions towards their patients, which is in line with the relatively low risk of relapse. The author did an EE assessment by sharing a questionnaire as a short-term evaluation of the occurrence of relapse.As a continuation of the program, long-term evaluation will be returned to the community health centre and carried out by the program holder. Community medicine benefits community health centers, communities, and students by increasing family and community awareness of schizophrenia and improving the quality of community health centers and public health. Students also learn how to educate families with schizophrenia.

INTRODUCTION

Schizophrenia is a chronic mental disorder characterized by cognitive impairment, delusions, hallucinations, abnormal thoughts, and irregular behavior. There are 24 million people worldwide suffering from Schizophrenia. Most symptoms of schizophrenia appear in their 20s and older adults, and are more common in men¹¹. Each region in Indonesia has different rates of schizophrenia incidence, one of which is in the Puri, Mojokerto, where 96 patients were diagnosed with Schizophrenia. Schizophrenic patients undoubtedly experience disability, which is often caused by negative symptoms (loss or deficit), cognitive impairment (disturbance in attention, memory), positive symptoms (suspicion, delusions, and hallucinations), and executive function disorders²².

A total of 81.9% of schizophrenic patients experience relapses within five years after the first episode appears. Relapses are the return or worsening of the disease after the remission period³³. There are several risk factors for schizophrenia relapses, including drug-taking compliance, interpersonal relationships, daily living ability, family communication, participation in therapy rehabilitation, and history of hospital admission in the past year. Among the factors that affect relapses, relationships with families become one of the crucial factors in determining prognosis compared to other factors⁴⁴.

Expressed Emotion (EE) is interpreted as emotions expressed in the family environment between caregivers and schizophrenic patients and other psychiatric disorders. it has been found that EE can be used in predicting relapse symptoms or relapse in various mental disorders⁵⁵. EE has five components: critical comments (CC), hostility, emotional over-involvement (EOI), positive remarks, and warmth. CCs are influenced by negative evaluation and tone of voice when conveying their feelings (anger, rejection, irritability, ignorance, blame, negligence, etc.). EOI includes the feelings or actions of overprotecting and self-sacrificing from the family to the patient⁶⁶. In Indonesia, there is still no community therapy activity related to the family EE against the risk of relapse of schizophrenia patients. This is the underlying need for community psychiatry activities against families of patients with schizophrenia and related parties.

Community Medicine activities held by the Faculty of Medicine, Universitas Airlangga, consist of three activities. The first is WWF (Work With Family), which aims to improve students’ ability to enhance their individual and family health care. Each student in a team gets a specific case and then performs a comprehensive examination, home visits, and solutions related to the problem.

The second is WWHT (Work With Health Teams). The students are trained to perform holistic health care management in primary health care. The third is WWC (Work With Community), where this activity aims to improve health in the scope of the community. WWC is done through 3 stages: field recognition, community diagnosis, and community therapy.

MATERIALS AND METHODS

The method can be divided into three stages: field recognition, community diagnosis, and community therapy, which are completed within three weeks.

1. Community anamnesis in the form of field recognition

Researchers conducted interviews with the Puri Community Health Center to get a general picture of the problems in the Puri Community Health Center's working area. After learning about the high number of schizophrenia cases, researchers conducted a direct survey with the families of schizophrenia patients to assess the emotions expressed by the family towards the patient using the Family Questionnaire (FQ) questionnaire and the risk of recurrence for schizophrenia patients using the SMART Card. The FQ is a questionnaire that describes emotions and emotional behavior, or expressed emotion, that consists of 20 questions with the answer options never, rarely, often, and very often. The SMART card is a measuring tool resulting from research on The Biopsychocultural-spiritual factors influencing relapse of schizophrenic patients by Margarita M. Maramis, M. Sofyan Almahdy, and Atika⁷⁷. This card contains 12 questions that help predict the risk, in percentage terms, of the likelihood of recurrence of adult schizophrenia within 1 year. Samples were taken by purposive sampling. The data obtained were analyzed univariately using SPSS-27.

2. Community Diagnosis

The workshop was held at the Mlaten, Puri, Mojokerto, Indonesia. Representatives from the Puri Community Health Center, Mental health cadres for villages spread across Puri District, village officials, psychiatry residents, and representatives from the patient's family attended. The results of the survey obtained at the field recognition stage were presented by representatives of young doctors, focusing on problems related to the expression of family emotions towards patients and the risk of recurrence of schizophrenia patients in Puri, Mojokerto, Indonesia.

Cross-sector participants were divided into five groups to discuss risk factors and solutions to community problems. The discussion session ended with each participant filling in suggested solutions for the two things that had been discussed previously. The proposed suggestions were presented, and solutions were determined using the Nominal Group Technique (NGT) Delbecq method, followed by all cross-sector participants present. NGT is a structured group-based technique used to create an agreement. Participants were asked to answer questions individually based on predetermined, structured questions written by the facilitator. Next, participants were asked to prioritize ideas and suggestions issued by group members collectively⁸⁸. There is one solution that is possible and agreed upon. This was followed by an oral and written Memorandum of Understanding (MoU) in the form of a commitment to consider the survey results that had been carried out through distributing questionnaire research instruments. The MoU results in a joint commitment to carry out community therapy to solve this problem. Community diagnosis is carried