|Year : 2019 | Volume
| Issue : 5 | Page : 413-419
Perspectives about Illness, Attitudes, and Caregiving Experiences among Siblings of Persons with Schizophrenia: A Qualitative Analysis
Anekal C Amaresha1, Ganesan Venkatasubramanian2, Daliboina Muralidhar3
1 Department of Sociology and Social Work, CHRIST (Deemed to be University), Hosur Road, Bengaluru, Karnataka, India
2 Department of Psychiatry, National Institute of Mental Health and Neurosciences, Hosur Road, Bengaluru, Karnataka, India
3 Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences, Hosur Road, Bengaluru, Karnataka, India
|Date of Submission||31-Jul-2019|
|Date of Acceptance||14-Aug-2019|
|Date of Web Publication||5-Sep-2019|
Dr. Anekal C Amaresha
Assistant Professor of Social Work, 9th Floor, Central Block, CHRIST (Deemed to be University), Hosur Road, Bengaluru - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Siblings of persons diagnosed with schizophrenia (SPS) are one among the major sources of support for persons with schizophrenia. There is a dearth of psychosocial literature on SPS in India. This qualitative study explored the perspectives about the illness, attitudes, and caregiving experiences of SPS. Materials and Methods: Qualitative audio-recorded interviews were conducted with 15 SPS, purposively selected from a tertiary mental health hospital of Southern India. A general inductive approach was adopted to analyze the qualitative data. Results: Four broad themes were identified from qualitative data analysis. (1) SPS described several explanatory models of mental illness in terms of causal attributions and treatment care. (2) They had expressed emotion toward their ill siblings, such as criticality, hostility, and emotional over-involvement. (3) They experienced objective and subjective burden while caring for their ill sibling. In spite of all these, (4) they were part of their ill siblings' care in terms of ensuring regular follow-ups and drug adherence and supported their livelihood. They coped up with adaptive as well as maladaptive strategies. Conclusion: SPS provide significant support to their affected siblings. However, they do have non-biomedical models of mental illness and negative attitudes toward patients and experience burden. Hence, psychosocial interventions may help SPS while caregiving for their affected siblings.
Keywords: Experiences, explanatory models, expressed emotion, siblings, Schizophrenia
Key messages: Siblings of persons with Schizophrenia (SPS) play an important role in the treatment and recovery of their ill siblings. This qualitative study revealed that SPS has non-biomedical models of mental illness and negative attitudes toward their ill siblings, and they experience burden. Personalized interventions are required to address the issues.
|How to cite this article:|
Amaresha AC, Venkatasubramanian G, Muralidhar D. Perspectives about Illness, Attitudes, and Caregiving Experiences among Siblings of Persons with Schizophrenia: A Qualitative Analysis. Indian J Psychol Med 2019;41:413-9
|How to cite this URL:|
Amaresha AC, Venkatasubramanian G, Muralidhar D. Perspectives about Illness, Attitudes, and Caregiving Experiences among Siblings of Persons with Schizophrenia: A Qualitative Analysis. Indian J Psychol Med [serial online] 2019 [cited 2019 Oct 24];41:413-9. Available from: http://www.ijpm.info/text.asp?2019/41/5/413/266107
The functional impairment caused by schizophrenia,, affects the whole family of persons with schizophrenia., More often, the patients in India live with their family members as compared with the patients of western countries.,, Hence, family members in India are highly involved in caregiving activities.,, Also, the family caregivers are more engaged in treatment-related decision making of their patients. These factors expose family members to several challenges from the onset of the illness until the patient's recovery.
Previous studies from India and western countries have reported that caregivers sometimes have supernatural beliefs about mental illness; they attribute illness to social causes and seek non-formal treatment from faith healers.,, Such illness perspectives with stigmatizing attitudes about mental illness among caregivers may result in a prolonged duration of untreated illness,,, which could cause a burden for the family caregivers. Also, they experience emotional problems and are reported to have unmet needs, which have a major impact on their well-being.,
The existing literature predominantly highlights the illness beliefs and experiences of parents,,, and spouses of patients diagnosed with schizophrenia.,,, There has been a growing interest in research with siblings of persons diagnosed with schizophrenia (SPS). Studies have found that they also experience psychosocial consequences of illness, such as poor mental health, poor relationships with their ill siblings, burden, maladaptive coping, and stigma.,, However, the available studies on SPS are from developed countries and have predominantly reported the outcomes of sisters of persons with schizophrenia. There is a paucity of studies from India and from the Asian subcontinent exploring the SPS' illness perspectives, attitudes, and caregiving experiences.
Persons diagnosed with schizophrenia need long-term family support in their recovery. However, India has a lack of government-supported aftercare homes for persons with mental illness. Worries may arise when the parents are aged and there are no other family members to look after the patients In view of this, understanding their issues will help us in designing and providing specific interventions to SPS. Hence, this study aimed to explore the SPS' perspectives about their affected sibling's illness and caregiving experiences.
| Materials and Methods|| |
The Human Ethics Committee of National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India, has approved the study related protocol. Written informed consents were obtained from all the participants prior to the interviews.
Setting and participants
The participants for this study were selected from the Schizophrenia Clinic and outpatient and in-patient departments of Psychiatry, NIMHANS, Bengaluru. The SPS were included in this study if they were a biological sibling of a person diagnosed with schizophrenia (DSM-IV); aged between 18 and 60 years; able to speak English, Kannada, or Telugu; not having any mental illness as per M.I.N.I-5.0 International Neuropsychiatric Interview, and found to be not suffering from any medical illness according to a qualified medical professional. In total, 37 subjects were screened for eligibility. Fifteen SPS (Male = 11; Female = 4) who met the inclusion criteria were included in this study. Out of the 15 SPS, 10 were elder siblings, and 5 were younger [Table 1].
Interviews and data collection
To explore the SPS' illness perspectives, attitudes, and caregiver experiences, a semistructured qualitative interview schedule was prepared. This included the sociodemographic profile of the SPS and their ill siblings and open-ended questions. This schedule was face- and content-validated by five mental health professionals who had experience in the field (one psychiatrist, three psychiatric social workers, and one anthropologist) and were not a part of this study. Some of the open-ended questions included were as follows:
Being a brother/sister of a patient, can you describe your experience?
-What is your understanding of your brother's/sister's illness?
How are you managing your sibling and taking care of yourself?
How are you involved in your brother's/sister's care?
With each question, circular questions were asked, and adequate probes were introduced when participants were not expressive to provide rich data. Each audio-recorded interview lasted for 30–45 min.
The qualitative interviews were transcribed and translated into English text. A general inductive approach to qualitative data analysis was adopted. The transcripts were read several times to familiarize with the interview content. The qualitative data were managed and analyzed in QDA Miner Lite Version. 1.4.2 (http://provalisresearch.com/products/qualitative-data-analysis-software/freeware/). During the initial reading of the transcripts, the small text segments featuring illness perspectives, attitudes, and caregiving experiences of SPS were carefully marked and highlighted, and codes were created. Initial coding was done for five interview transcripts, and the codes were further refined by removing redundant codes, renaming the existing codes, and adding new codes. The coding for the remaining transcripts was completed based on the framework developed from the initial five transcripts. At the analysis of the 14th interview transcript, the codes were saturated, but the coding was completed for all 15 participants. After the coding process, two peer research scholars independently verified the consistency of the codes with the transcripts. The disagreements between the peer research scholars on the codes were resolved with discussion, to reach a consensus. Later, the finalized codes were imported into Microsoft Excel spreadsheet for sorting and grouping. The codes with common features and meaning were grouped and assigned under the overarching themes.
| Results|| |
The analysis resulted in the identification of four major themes, such as explanatory models of mental illness, expressed emotion, caregiving experience, and ways of caregiver involvement and coping.
1. Explanatory models of mental illness
Nine out of 15 SPS recalled and described that before consulting mental health professionals, they used to call their affected sibling's illness terms such as “hucchu,” “loosu,” “paithya” [words for madness in the Kannada language], “thikkalu,” and “picchi” [words for madness in the Telugu language]. These terms are highly widespread and commonly discussed among caregivers in southern parts of India.
“He was behaving very unusually… He was talking to himself and smiling in a way that was totally irrelevant…We thought he has hucchu [madness]” (Participant 15, younger brother, 22 years).
“He was fine during the final year of his bachelor's degree. After the exams, he started reporting that he can hear voices… He started suspecting that people around him are stopping him doing well in exams… We thought he is stressed out due to exams and it will resolve after some time… But it did not… Then we realized it was picchi [madness]” (Participant nine, elder brother, 42 years).
Causal attributions about the illness are often influenced by close relatives and community people. Some of the important causal factors reported by SPS were black magic, God's curse, and “gaali” [word for possession of evil spirit in the Telugu language]. One SPS narrated that
“He was regularly going to work and earning money. Later he used to tell that he is not interested in work… He was complaining a lot about his co-workers. He used to fight with us for no reason… Then we thought that this is because of vamachara" [word for “black magic” in the Kannada language] (Participant 14, younger brother, 31 years).
Before consulting the mental health center, SPS made choices with their families on seeking treatment for their ill sibling based on the existing cultural beliefs in the community. It was a ritual for many SPS to visit “Swamis” [religious priests], religious places such as temples, and “Mantravaadis” [black magicians] at some point of the illness trajectory.
“We did not know where to go initially… Some people told us to take him to temples and perform poojas [religious rituals] and some have advised seeking help from black magicians…We visited a few temples…prayed to the God…and even approached Mantravaadis [black magicians]… But we lost so much money performing the rituals they suggested” (Participant 12, younger brother, 25 years).
2. Expressed emotion
Expressed emotion (EE) denotes the quality of family interactions or attitude of the family members toward their mentally ill patients that includes the existence of criticality, hostility, and emotional over-involvement. EE is considered to be important indicator of relapse of symptoms of schizophrenia. During the interviews, SPS did exhibit EE toward the patients in the form of criticality and over-involvement.
Owing to a lack of knowledge and increased responsibilities caused predominantly by the negative symptoms or socio-occupational dysfunction, many of the SPS were highly critical toward their patients. Six of them expressed criticality. Some of the SPS reported that
“Yes, he has an illness… But that doesn't mean that he cannot do anything. He always gives reasons for not doing an activity… It's frustrating sometimes” (Participant four, an elder brother, 34 years).
“He has improved a lot compared to the earlier times. But still he escapes from work… Being lazy will not help in any way…. There are no days in which we haven't argued on day-to-day issues” (Participant 13, elder brother, 45 years)
Five of the siblings were over-involved in the care, where they were overprotective toward their siblings. SPS were overcautious and anticipated mistakes. Hence, some of the SPS did not allow their ill siblings to perform their daily routines.
“We know he can manage household finances since he has done Masters in Commerce… But I don't want to take the risk… Though it is an extra responsibility, I would like to take charge of the finances myself.” (Participant seven, younger brother, 27 years)
3. Caregiving experience
Eleven of the SPS reported a negative impact of the illness in the form of burden. They experienced both objective as well as the subjective burden due to the severity of the illness and increased responsibilities.
The onset of the illness caused financial burden and increased responsibilities for the SPS, because the patients were having significant socio-occupational dysfunction and were unemployed as reported by the SPS.
“I'm the only earning member now… If he were not suffering from this illness, he would have joined some work… It would have helped to decrease our financial difficulties” (Participant seven, younger brother, 27 years).
“My responsibilities are increased now… He is not at all helping us in any-way. He even refuses to fetch water or shop for groceries” (Participant 12, younger brother, 25 years).
SPS reported that their relationship with the ill sibling has worsened due to the negative symptoms. They also reported that their marital relationship was affected because of their involvement in the caregiving. A few SPS reported that caregiving responsibilities such as follow-up visits and consultations significantly interfered with their daily work.
“He is not like earlier… He doesn't care about my words… His attitude towards us has definitely worsened” (Participant 4, elder brother, 34 years).
“My husband will not understand the difficulties that my sister is having. Sometimes he stops me from meeting my sister… If I ask for any help with regard to my sister, he won't talk to me for a few days” (Participant eight, elder sister, 36 years).
SPS reported the subjective burden in the form of grief and started avoiding people due to the embarrassment they faced at the initial stages of their siblings' illness [self-stigma].
“I never thought that my sister would get mental illness… But when we came to know about it, it was upsetting… We were disturbed”.
(Participant eight, elder sister, 36 years).
“He was doubting the people around him, thinking that they are plotting against him… He used to throw stones at people and pick up quarrels… Neighbours used to complain about him… It was embarrassing and uncomfortable talking to people about his condition… We were deliberately avoiding them [people]”.
(Participant four, elder brother, 34 years).
4. Ways of caregiving involvement and coping
Despite all these experiences, a majority of the SPS (12 out of 15) were helping their affected siblings in several ways. Most of them were involved in taking ill siblings for follow-up visits and consultations. In addition, they were the major source of support of their ill siblings' livelihood. Some of them reported that
“Though I'm busy with my work, I take my sister for follow-ups… Every time, I take the opportunity to talk to doctors about treatment-related issues of my sister” (Participant 11, elder brother, 28 years)
“Since my sister is separated from her husband and is currently not working, my older brother and I are taking care of her medical expenses as well as daily needs” (Participant six, younger brother, 29 years)
SPS were involved in other important caregiving activities such as supervising the medications and daily activities, guiding other caregivers in the family about managing the patient, motivating the patients to carry out their daily activities, and spending quality time with the patients. They said the following:
“I'm not staying with my sister, but my parents are there with her… I call once in two days, inquire about her condition, and ensure medication intake… Every weekend, I visit my village and spend some quality time with family… If any emergency comes up, I take leave and go there” (Participant 11, an elder brother, 28 years)
SPS reported about the ways of coping with their ill siblings. It included both adaptive and maladaptive coping strategies. They said that
“Keeping myself busy at work helps me to distract my mind from home until evening” (Participant six, younger brother, 29 years)
“I won't share my problems with anyone… I'm not comfortable sharing them.” (Participant 14, younger brother, 31 years)
| Discussion|| |
This qualitative study explored the SPS' perspectives about the illness, attitudes, and experiences from the onset of illness to the ongoing treatment. SPS had their own explanatory models about the patients' illness. During the interviews, most of the SPS expressed some negative attitudes toward their ill siblings. They experienced both objective and subjective caregiver burden. Despite all these psychosocial consequences, they were pro-actively engaged in the care of their ill sibling.
In lower-middle-income countries like India, there are several non-medical belief models about mental illness. At the initial stages of illness, SPS in this study had beliefs that mental illness is a result of previous deeds, black magic, or God's curse. Hence, they sought treatment from religious and faith healers. These findings are in tune with previous studies conducted in Southern India with caregivers of mental illness., Likewise, some studies have also found the high prevalence of non-medical beliefs among patients as well., Some studies had reported similar findings where the persons and their caregivers preferred to seek treatment through these pathways to care before consulting any mental health professionals, These kinds of non-psychiatric care may delay the access to early psychiatric care and worsen the symptoms of the illness and the functioning of the patients.,
There is a lack of studies exploring the expressed emotion in SPS. This study has found EE among several SPS. This could be because of the negative symptoms of the patients and the SPS' attributions or beliefs about the illness, which are associated with high EE. Specifically, the controllability attributions are linked with high EE., This suggests that if the family members attribute that the symptoms can be controlled by the patient, it will lead to high EE., Caregivers EE is one of the major indicators of relapse, and it needs to be addressed with the established interventions.
The results on caregiving experience among SPS are similar to those of previous studies, where SPS experience an objective burden in terms of financial burden; an impact on the relationships with the affected sibling; increased responsibilities and impact on school, work, and recreational activities., In addition, studies had reported similar results with regard to subjective caregiving burdens, such as grief, stigma, anxiety, and distress., Burden among SPS is associated with factors such as the severity of the symptoms or the illness, disturbances on household routine, and medication non-adherence., Further, SPS who attribute that the illness is controllable, feel more burdened than those who feel that their affected siblings cannot control the illness.
Like other caregivers of schizophrenia patients, SPS do involve in and perform many caregiving activities regardless of the negative effects of the illness. There are differences with regard to the caregiving activities provided by SPS in this study and the western studies. Some of the previous studies from western countries have shown that SPS predominantly provide emotional support to the affected siblings,, that is, in contrast with our study findings, where SPS were found to be actively involved in patient care. They were providing treatment-related support in terms of accompanying the patients to follow-up consultations and support the patient's livelihood. Additionally, they were providing instrumental support, such as supervising medications and patients' daily activities. This is important in long-term care because the SPS outlive the parents. Also, they can share and reduce the burden experienced by other caregivers in the family.
SPS reported their coping strategies. They used both adaptive and maladaptive strategies such as distraction from the affected siblings by involving in or carrying out their regular work and internalizing their feelings. Similar results were found in previous studies., Additionally, previous studies have reported other coping strategies such as getting understanding about the illness by seeking information from professionals, active participation in caregiving, normalizing the situation, maintaining distance, avoidance, grieving, and isolation.,
This is the first qualitative study exploring the SPS' perspectives of the illness and caregiving experiences in India. SPS are known to be a high-risk group for mental illness. Hence, understanding their perspectives about the illness and the caregiver experiences, such as psychological distress, grief, burden, self-stigma, coping, feelings of guilt, fear of the future of their patients, etc., will help in designing specific interventions for SPS. This, in turn, would encourage SPS to be more active in the treatment process and provide long-term social support to their affected sibling.
The findings of the study should be interpreted cautiously, because it has several limitations such as small sample size and the participants being predominantly brothers and from urban backgrounds. Further, similar studies could be conducted with a large sample size with adequate representation of brothers and sisters. It would be interesting to see the comparison of the results with other caregivers of patients with schizophrenia from different social strata.
In conclusion, SPS do have some non-biomedical perspectives of mental illness. Such perspectives may restrict SPS engagement in the treatment process at least during the early course of the illness. Nevertheless, they provide instrumental support to their affected siblings. They do express some negative attitudes toward the patients and experience both objective and subjective burden. Hence, they may need special attention from the clinicians in terms of understanding their issues and providing need-based psychosocial interventions.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This work was supported by The Wellcome Trust/DBT India Alliance Senior Fellowship Grant (500236/Z/11/Z) to GV. ACA was supported by Wellcome Trust/DBT India Alliance.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bowie CR, Harvey PD. Cognitive deficits and functional outcome in schizophrenia. Neuropsychiatr Dis Treat 2006;2:531-6.
Green MF. What are the functional consequences of neurocognitive deficits in schizophrenia? Am J Psychiatry 1996;153:321-30.
Mueser KT, McGurk SR. Schizophrenia. Lancet 2004363:2063-72.
Awad AG, Voruganti LN. The burden of schizophrenia on caregivers. Pharmacoeconomics 2008;26:149-62.
Briggs A, Wild D, Lees M, Reaney M, Dursun S, Parry D, et al.
Impact of schizophrenia and schizophrenia treatment-related adverse events on quality of life: Direct utility elicitation. Health Qual Life Outcomes 2008;6:1-9.
Chadda RK. Caring for the family caregivers of persons with mental illness. Indian J Psychiatry 2014;56:221-7.
] [Full text]
Isaac M. Cross-cultural differences in caregiving: The relevance to community care in India. Indian J Soc Psychiatry 2016;32:25-7. [Full text]
Kulhara P, Wig NN. The chronicity of schizophrenia in North West India. Results of a follow-up study. Br J Psychiatry 1978;132:186-90.
Chatterjee S, Pillai A, Jain S, Cohen A, Patel V. Outcomes of people with psychotic disorders in a community-based rehabilitation programme in rural India. Br J Psychiatry 2009;195:433-9.
Magliano L, Fiorillo A, De Rosa C, Malangone C, Maj M. Beliefs about schizophrenia in Italy: A comparative nationwide survey of the general public, mental health professionals, and patients' relatives. Can J Psychiatry 2004;49:323-31.
Naik SK, Pattanayak S, Gupta CS, Pattanayak RD. Help-seeking behaviors among caregivers of schizophrenia and other psychotic patients: A hospital-based study in two geographically and culturally distinct indian cities. Indian J Psychol Med 2012;34:338-45.
] [Full text]
Phillips MR, Li Y, Stroup TS, Xin L. Causes of schizophrenia reported by patients' family members in China. Br J Psychiatry 2000;177:20-5.
Bergner E, Leiner AS, Carter T, Franz L, Thompson NJ, Compton MT. The period of untreated psychosis before treatment initiation: A qualitative study of family members' perspectives. Compr Psychiatry 2008;49:530-6.
Franz L, Carter T, Leiner AS, Bergner E, Thompson NJ, Compton MT. Stigma and treatment delay in first-episode psychosis: A grounded theory study. Early Interv Psychiatry 2010;4:47-56.
Tanskanen S, Morant N, Hinton M, Lloyd-Evans B, Crosby M, Killaspy H, et al.
Service user and carer experiences of seeking help for a first episode of psychosis: A UK qualitative study. BMC Psychiatry 2011;11:1-11.
Olwit C, Musisi S, Leshabari S, Sanyu I. Chronic sorrow: Lived experiences of caregivers of patients diagnosed with schizophrenia in Butabika Mental Hospital, Kampala, Uganda. Arch Psychiatr Nurs 2015;29:43-8.
Outram S, Harris G, Kelly B, Bylund CL, Cohen M, Landa Y, et al.
'We didn't have a clue': Family caregivers' experiences of the communication of a diagnosis of schizophrenia. Int J Soc Psychiatry 2015;61:10-6.
Young L, Murata L, McPherson C, Jacob JD, Vandyk AD. Exploring the experiences of parent caregivers of adult children with schizophrenia: A systematic review. Arch Psychiatr Nurs 2019;33:93-103.
Srinivasan TN, Thara R. Beliefs about causation of schizophrenia: Do Indian families believe in supernatural causes? Soc Psychiatry Psychiatr Epidemiol 2001;36:134-40.
Koschorke M, Padmavati R, Kumar S, Cohen A, Weiss HA, Chatterjee S, et al.
Experiences of stigma and discrimination faced by family caregivers of people with schizophrenia in India. Soc Sci Med 2017;178:66-77.
Singh S, Sinha D, Raut NB. Caregiving experience and marital adjustment in spouses of patients with schizophrenia. Indian J Soc Psychiatry 2019;35:125. [Full text]
Seeman MV. Spotlight on sibling involvement in schizophrenia treatment. Psychiatry 2013;76:311-22.
Sin J, Moone N, Harris P, Scully E, Wellman N. Understanding the experiences and service needs of siblings of individuals with first-episode psychosis: A phenomenological study. Early Interv Psychiatry 2012;6:53-9.
Stålberg G, Ekerwald H, Hultman CM. At issue: Siblings of patients with schizophrenia: Sibling bond, coping patterns, and fear of possible schizophrenia heredity. Schizophr Bull 2004;30:445-58.
Glick ID, Stekoll AH, Hays S. The role of the family and improvement in treatment maintenance, adherence, and outcome for schizophrenia. J Clin Psychopharmacol 2011;31:82-5.
Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al.
The Mini-International Neuropsychiatric Interview (M.I.N.I): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59(Suppl 20):22-33.
Thomas DR. A General inductive approach for analyzing qualitative evaluation data. Am J Eval 2006;27:237-46.
Charles H, Manoranjitham SD, Jacob KS. Stigma and explanatory models among people with schizophrenia and their relatives in Vellore, South India. Int J Soc Psychiatry 2007;53:325-32.
Saravanan B, Jacob KS, Johnson S, Prince M, Bhugra D, David AS. Belief models in first episode schizophrenia in South India. Soc Psychiatry Psychiatr Epidemiol 2007;42:446-51.
Kate N, Grover S, Kulhara P, Nehra R. Supernatural beliefs, aetiological models and help seeking behaviour in patients with schizophrenia. Ind Psychiatry J 2012;21:49-54.
] [Full text]
Saravanan B, Jacob KS, Deepak MG, Prince M, David AS, Bhugra D. Perceptions about psychosis and psychiatric services: A qualitative study from Vellore, India. Soc Psychiatry Psychiatr Epidemiol 2008;43:231-8.
Burns JK, Jhazbhay K, Emsley RA. Causal attributions, pathway to care and clinical features of first-episode psychosis: A South African perspective. Int J Soc Psychiatry 2011;57:538-45.
Temmingh HS, Oosthuizen PP. Pathways to care and treatment delays in first and multi episode psychosis. Findings from a developing country. Soc Psychiatry Psychiatr Epidemiol 2008;43:727-35.
Amaresha AC, Venkatasubramanian G. Expressed emotion in schizophrenia: An overview. Indian J Psychol Med 2012;34:12-20. [Full text]
Barrowclough C, Johnston M, Tarrier N. Attributions, expressed emotion, and patient relapse: An attributional model of relatives' response to schizophrenic illness. Behav Ther 1995;25:67-88.
Vasconcelos e Sa D, Wearden A, Barrowclough C. Expressed emotion, types of behavioural control and controllability attributions in relatives of people with recent-onset psychosis. Soc Psychiatry Psychiatr Epidemiol 2013;48:1377-88.
Kuipers E, Bebbington P, Dunn G, Fowler D, Freeman D, Watson P, et al.
Influence of carer expressed emotion and affect on relapse in non-affective psychosis. Br J Psychiatry 2006;188:173-9.
Lohrer PS, Lukens PE, Thorning H. Economic expenditures associated with instrumental caregiving roles of adult siblings of persons with severe mental illness. Community Ment Health J 2007;43:129-51.
Greenberg JS, Kim HW, Greenley JR. Factors associated with subjective burden in siblings of adults with severe mental illness. Am J Orthopsychiatry 1997;67:231-41.
Lively S, Friedrich RM, Rubenstein L. The effect of disturbing illness behaviors on siblings of persons with schizophrenia. J Am Psychiatr Nurs Assoc 2004;10:222-32.
Hatfield AB, Lefley HP. Future involvement of siblings in the lives of persons with mental illness. Community Ment Health J 2005;41:327-38.
Kinsella KB, Anderson RA, Anderson WT. Coping skills, strengths, and needs as perceived by adult offspring and siblings of people with mental illness: A retrospective study. Psychiatr Rehabil J 1996;20:24-32.
Friedrich RM, Lively S, Rubenstein LM. Siblings' coping strategies and mental health services: A national study of siblings of persons with schizophrenia. Psychiatr Serv 2008;59:261-7.
Bora E, Lin A, Wood SJ, Yung AR, McGorry PD, Pantelis C. Cognitive deficits in youth with familial and clinical high risk to psychosis: A systematic review and meta-analysis. Acta Psychiatr Scand 2014;130:1-15.