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

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 Su 3 and Li-Chi Chiang 4

1 Department of Nursing, Taipei Veterans General Hospital, Taipei, 2 Department of Nursing, National Cheng Kung University and Hospital, Tainan, 3 School of Medicine, National Yang-Ming University, Taipei, and 4 School 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.


Bipolar disorder (BPD) is a severe and long-term psy- chiatric illness with recurrent depressive, manic, and

Correspondence: Li-Chi Chiang, School of Nursing, National Defense Medical Center and China Medical University, 161, Sec- tion 6, Mingchuan East Road, Neihu, Taipei 114, Taiwan. Email:

lichichiang@gmail.com Hsiu-Ju Lee, MS, RN. Esther Ching-Lan Lin, PhD, RN. Mei-Bih Chen, MS, RN. Tung-Ping Su, PhD, MD. Li-Chi Chiang, PhD, RN. Accepted September 18 2016.

© 2016 Australian College of Mental Health Nurses Inc.

mixed episodes, which are characterized by several

mood dysregulations, impulsivity, risky behaviour, and

interpersonal problems (Keck et al. 2001; Osby et al. 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 Organization 2004). Patients with BPD have life-long impaired interpersonal relationships and disturbed edu-

cational and occupational performance caused by the early onset and recurrence of BPD (Mitchell & Malhi 2004). They also utilize more mental health services (Frye et al. 2005) and have higher suicide rates than others in that age group (Mitchell & Malhi 2004).


Family caregivers often express positive (compas- sionate) or negative (harsh) reactions, or both, when confronted with a patient’s emotional instability (Mas- kill et al. 2010). Interpersonal relationship conflicts between family caregivers and patients with BPD not only affect patients’ symptom fluctuations, but also bidirectionally affect caregivers’ physical and psycholog- ical health. Evidence shows that caregivers have heavy care burdens, in addition to health and emotional prob- lems (Beentjes et al. 2012; van Der Voort et al. 2009). One review (Steele et al. 2009) of the psychiatric symp- toms of caregivers for patients with BPD found that 46% of caregivers claimed to be depressed, and that 32.4% reported that they had to use mental health ser- vices for their depression. Other studies indicated that family caregivers are overwhelmed by providing infor- mal care during the transitional discharge period (Ger- son & Rose 2012; Lee et al. 2013; Pompili et al. 2014), and that different caregiving phases require different coping mechanisms (van Der Voort et al. 2009). Because Taiwan is strongly influenced by traditional Confucian culture, in which family is an essential bond-

ing relation of social structure, the value of familial interdependence is particularly emphasized (Chen 2001). Moreover, family caregivers usually escort patients to clinic visits and sleep on a hospital-provided cot in the same room during admission (Huang et al. 2009). Family caregivers also take the burden of responsibility when caring for patients with BPD after they are discharged (Yen et al. 2010). However, family caregivers might undergo complex conflicts because they feel trapped, helpless, and distressed. They also feel stigmatized by others because the family member they care for has a mental illness (Huang et al. 2009). Therefore, it is essential to provide family caregivers appropriate knowledge about the illness and to teach them constructive coping strategies. Several family-focussed psychosocial treatments have reported benefits for patients with BPD and their care- givers (Justo et al. 2007; Miziou et al. 2015; Reinares

et al. 2016).

month, manual-based programme of family-focussed psychoeducational treatment could delay and reduce the number of relapses and depressive symptoms in patients followed up for 1 year. Reinares et al. (2010) also reported that caregivers who had undergone family psychoeducation had fewer recurrent mood episodes and longer relapse-free intervals. Perlick et al. (2010) reported that, after 12 15 sessions of psychoeduca- tional and cognitive-behavioural intervention, there were significant improvements in patients’ symptoms

Miklowitz et al. (2000) found that a 9-


and family caregivers’ health-risk behaviours, and reductions in their depressive symptoms and subjective burdens. A poorly-functioning family has been associ- ated with severe psychopathology and low psychosocial functioning in patients with BPD (Ferreira et al. 2013; Sullivan et al. 2012). Although previous psychoeduca- tional interventions might alleviate patients’ and family caregivers’ symptomatic severity and the caregivers’ burdens, the extent of the benefits of family-focussed interventions for family function remains unclear (Reinares et al. 2016). Several family nursing models have been developed for family nursing practice (Bomar, 2004). Simpson et al. (2006) demonstrated that the Calgary Family Intervention Model (CFIM) is a good family system nursing approach for psychiatric nurses caring for Chinese individuals with a mental illness and their families. By providing a meta-perspective, the CFIM (Wright & Leahey 1994, 2013) emphasizes that each family is unique and has the potential to change the presenting problem. This model focusses on improv- ing and sustaining family functioning in the cognitive, affective, and behavioural domains. Based on the CFIM, family interventions include highlighting the strengths of patients and family members, providing information and education, validating and normalizing emotions, encouraging family support and sharing the burden of care, managing respite or relief from care, maintaining family rituals, and staying flexible and responsive to unique family needs. Health profession- als use therapeutic conversations and the therapeutic relationship with the family to encourage them to think about their health problems, discover the strengths of the patient family collaboration, and develop effective strategies (Arango 2011; Leahey & Harper-Jaques 2010). Lee et al . (2013) conducted a qualitative study to explore the experiences of eight family caregivers of BPD patients during the hospital- ization transitional period based on family-centred care. The nurse-initiated family interviews could mobilize family recourses to help families’ healing by identifying family strengths and resources, looking for solutions to problems, transforming effective commu- nicating style, and making their decisions (Lee et al.


The brief family-centred care (BFCC) programme based on the CFIM was developed to systematically assess families, and provide specific intensive interven- tions for each family in an acute psychiatric setting. In the present study, our primary hypothesis was that the 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.


The study design was a randomized, controlled trial to repeatedly measure the primary outcomes of family function and secondary outcomes of perceived health status and family caregiver burden. Family caregivers of

BPD patients were eligible and agreed to participate in the present study, and were recruited while they were in

a psychiatric acute ward at a 3032-bed medical centre in

northern Taiwan with their family member who had a mental illness. During the allocation process, patients

and family caregivers were randomly assigned to either the BFCC group or treatment-as-usual (TAU) group by

a computer-generated process using simple randomiza-

tion by the corresponding author (principal investiga- tor). Participants were not informed of their group allocation status during this process by using sealed, opaque envelopes. Following baseline measurements, neither study staff nor participants were blinded to par- ticipants’ allocation. After the families were allocated into the BFCC group or TAU group with the permission of the researcher (the first author), each family was invited to participate in a routine 60-min family discus- sion group about violence and suicide prevention. The families in the BFCC group had four 90-min family interviews with the patient family caregiver dyad during the hospitalization period. All outcome measures were self-reported by the family caregivers and returned in a sealed envelope to a location separate from personnel who were involved in the intervention. The human rights protection protocols and all ethi- cal considerations were approved by the institutional review board of the research setting before the recruit- 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 with the Declaration of Helsinki. Signed, written per- mission was obtained prior to data collection and ran- domization. The principal investigator endeavoured to keep the participants in the study after enrolment. In order to control the fidelity of the trial, we followed the original protocol approved by the institutional review board of the research setting during the trial, and did not make any amendments. A copy of the full trial protocol is available from the corresponding author upon request.

© 2016 Australian College of Mental Health Nurses Inc.



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- viewed, and had a Hamilton Depression Rating Scale (HDRS) score < 17 and a Young Mania Rating Scale (YMRS) score < 38 (Keck 2004) to prevent adverse effects caused by patients’ mood instability. Patients who had lived alone or lived with their family for < 6 months, had been concurrently diagnosed with an intellectual disability (DSM-V) (American Psychiatric Association 2013), had been newly diagnosed with BPD at this admission, or could not speak Chinese, were excluded. Family caregivers who: (i) were significant in the patient’s life; (ii) were at least 18 years old; (iii) lived with the patient for at least 6 months; (iv) were able to speak and understand Chinese or Taiwanese; and (v) were able to answer questionnaires written in Chinese were included. Caregivers diagnosed with a seri- ous mental illness or intellectual disabilities were excluded. Systematic reviews of family interventions indicated the small effect size on the patients’ symptoms and fam- ily relationship (Justo et al. 2007; Reinares et al. 2016). Because of limited family intervention studies and the lack of previous studies about family function among patients with BPD, we selected a small effect size of 0.2 based on conservative considerations and balancing the resources available for conducting this innovative inter- vention study (Cohen 1988). We calculated the sample size for two groups and repeated measures twice by a G * Power analysis (Faul et al. 2007) with two-tailed tests ( a = 0.05 and b = 0.80), and determined that we would require a total of 28 patients, with 14 per group to detect the effects in repeated measures by a within- between interaction (Fig. 1).



All patients were given the standard hospital-provided services: psychiatric nursing care, occupational therapy, and pharmacotherapy. All of the family caregivers were only to attend a routine 60-min family discussion group about violence and suicide prevention without any specific patient family dyad interview.

BFCC programme

The BFCC programme was developed based on the CFIM, and adapted for hospitalized patients with

64 H.-J. LEE ET AL. Hospitalization Assessed for eligibility of bipolar disorder (n = 134)
Assessed for eligibility of bipolar
disorder (n = 134)
Within 3 days
of admission
Excluded criteria (n = 74)
♦ Do not meet inclusion criteria (n = 35)
♦ Declined to participate (n = 39)
Randomized (n = 60)
Within 10–12
days of
Experimental group (n = 30)
♦ Received the brief family-centered
care programme (n = 20)
♦ Did not receive allocated
intervention (n = 10)
Comparison group (n = 30)
♦ Received treatment as usual
= 27)
♦ Did not receive allocated intervention
= 3)
- Family refused to participate (n = 6)
- Patient refused to participate (n = 3)
- Patient refused to participate (n = 4)
Within 19–21
days of
Discontinued intervention (n = 4)
Lost to follow-up (n = 7)
Follow up
-Reasons: patients’ or family’s
unwilling to participate or
failing to keep their
-Reasons: patients’ worsening
symptoms, failing to keep their
appointments, unexpected
Analysed (n = 16)
Analysed (n = 20)

FIG. 1: Consort flow diagram.

BPD and their family caregivers. Lee & Chiang had discussions with Dr. Lorraine Wright who created the CFIM and inspire us to develop a new family nursing care model in our psychiatric unit and design the interview guidelines for the patient family caregiver dyad. The family caregivers were also invited to attend a routine 60-min family discussion group, the TAU group. The BFCC protocol is outlined as four treat- ment sessions, specific goals, and example questions (Table 1). The therapist (LHJ), an experienced psychi- atric nurse with a Master degree in psychiatric

nursing, provided the BFCC programme twice a week for each dyad in the experimental group. The core principles treated family as a single unit and provided individually-tailored interventions to improve family function through psychoeducation and social and emotional support, while actively raising questions to facilitate constructive awareness and changes. Four 90-min, in-depth sessions for each dyad were initially held in a quiet interview room to assess family func- tion; provide information about BPD; to support and 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




Example questions



To assess each family’s composition, developmental stage, interaction and communication styles, and family function

Describe your family

What is the effect of bipolar disorder on your family?

To understand the effect of disease on the family, and explore their subjective narrative illness experiences and coping strategies

What has been your experience of arguing?

How have the patient’s disease-related behaviours and responses affected the family?


Socialemotional support and psychoeducation

To explore the family’s strengths and resources

What obstacles do you face in caring for your family member with a mental illness at home?

Who do you call for help, and what do they do?

To offer appreciation, validation, empowerment, and normalization of their emotional reactions


One of your strengths is your awareness of .?


To analyse family dynamics, as well as facilitate constructive beliefs and communication styles

To encourage mutual support and strengthen the exterior support system

To provide necessary illness-related knowledge and treatment information to patients and families

Under what circumstances might you experience negative emotions towards others?

When do you and your family feel negatively towards each other?

How could you do better?


Who else can help?


Challenge to change

To define the family’s problems

Try to explain why your feelings change

To help family members understand the emotions behind their conflicts

How do you wish your family could help you?

When you see the patient struggling, you feel ?

To guide their brainstorming and cooperative discussions about facilitating solutions instead of perpetuating existing constraining ones

How will you change the situation now?

To formulate problem-solving plans and coach them in communication and emotional self-regulation



To individually appreciate each family member’s effort during treatment

To develop discharge plans

To summarize the therapist’s observations about the illness adaptation and management of the whole family and achieved tasks in the previous sessions

To provide a prospective future and impart hope

Share your findings from these past sessions

What tasks have you achieved and not yet achieved during treatment?

How do you hope your family will help you?

Under which circumstances would you be willing to be rehospitalized?

What do you think about the patient’s living arrangements after discharge?

and resolve conflicts; and to sustain or improve family function in the cognitive, affective, and behavioural domains. In the 90-min, in-depth session for the cog- nitive domain, the therapist assessed the strength, potential energy, external resources, and obvious and hidden family problems of the family function of each family, and the family’s subjective narrative and cop- ing strategies for illness, which were cooperatively brainstormed. The therapist discussed how to avoid 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- flict; and discussed appreciation, validation, empower- ment, and normalization of their emotions. In the session for the behavioural domain, the therapist

© 2016 Australian College of Mental Health Nurses Inc.

provided observations about family communication, encouraged them to change communication styles, taught them self-regulatory behaviour, and enabled new behaviours to resolve family conflicts. At the end of each session, the therapist (LHJ) reviewed the fam- ilies’ interactions, responses about their subjective experiences, beliefs, and values to clarify their prob- lems, and then told the families what she had con- cluded in her review.


Baseline assessments of sociodemographic data and clinical symptoms were compiled. The sociodemo- graphic data of the patient and family caregiver included sex, age, education, marital status, and


employment. Family caregivers were asked to report their kinship, history of BPD, and frequency of hospi- talization. Patients’ clinical data about mood states, how long they had had psychiatrist-diagnosed BPD, and how many times they had been hospitalized were obtained from medical records by our research assistants. Their clinical symptoms were assessed using the YMRS and the HDRS by independent raters. The 11- item YMRS was used to evaluate manic symptoms (to- tal score range: 0 60), with good reliability and validity (Hwu 1999; Young et al. 1978). Four items were rated on a 0 8 Likert scale (irritability, speech, thought con- tent, and disruptive/aggressive behaviour), and the remaining seven items were rated on a 0 4 Likert scale (Young et al. 1978). The 17-item HDRS is the most widely used depression-assessment scale, with good reliability and validity (Hamilton 1960; Hwu 1999). It includes nine items rated on a 0 4 Likert scale and eight items on a 0 2 Likert scale (total score range:

0 54). Post-treatment assessments for the BFCC group were done after the intervention had been completed, and for the TAU group, it was done 19 21 days after the patients had been hospitalized. The primary outcome indicator was family function, and secondary outcomes were caregivers’ perceived health status and caregivers’ burden. All were assessed using self-reported questionnaires in Chinese at base- line and post-treatment. In the present study, ‘family function’ was defined as family cohesion, conflict, emo- tional involvement, emotional expression, communica- tion, problem-solving, independence, and family responsibilities; ‘caregivers’ perceived health status’ was defined as the caregiver’s perceived physiological and somatic health status, anxiety and worry, depression, poor relationships, and sleep problems; ‘caregiver bur- den’ was defined as five kinds of physiological, social, emotional, and chronological family burdens, and the development of family burdens.

Family function scale

The Chinese version of the Family Function Scale (FFS) (Wang & Ko 2001) was developed from qualita- tive interviews on Taiwanese culture; it used the Fam- ily Adaptability and Cohesion Evaluation Scale-III (Olson 1986) and the Family Assessment Device (Epstein et al. 1983) as its theoretical basis. The 44-item, Chinese version of the FFS includes eight dimensions: cohesion, conflict, emotional involvement, emotional expression, communication, problem-solving,


independence, and family responsibilities. Each item is rated on a 0 4 Likert scale, and 11 negative items are reverse-scored. Higher scores indicate better family function. The FFS has been well tested (internal con- sistency: 0.75, retest reliability: 0.72) and has good criteria-related validity with Beck’s Depression Inven- tory (Wang & Ko 2001).

Chinese health questionnaire-12

The Chinese Health Questionnaire (CHQ)-12 was used for the family caregivers’ self-reported assess- ments of the severity of their own mental problems in the previous 2 weeks. The CHQ-12 was derived from the General Health Questionnaire (GHQ) and con- tains 12 items in four dimensions: physiological and somatic, anxiety and worry, depression and poor rela- tionships, and sleep problems. Each item is rated on a 0 3 Likert scale. Total scores < 3 indicate normal psychological health, and total scores > 3 indicate worsening symptoms and that a patient is at risk of mental illness. Higher scores indicate worsening con- ditions. The CHQ-12 was developed and has been well tested among community groups for screening psychiatric problems, and shows acceptable reliability and validity (Cheng & Williams 1986). Reliability was tested by internal consistency, with Cronbach’s alpha of 0.83 0.84. Validity was examined at the optimal cut-off point of 3/4. Sensitivity was 77.8%, specificity was 76.9%, the positive predictive value was 68.9%, the negative predictive value was 90%, the overall misclassification rate was 17.6%, and the estimated area under the relative operating characteristic (ROC) curve was 0.81.

Caregiver burden inventory

The Chinese version of the Caregiver Burden Inven- tory (CBI) (Novak & Guest 1989) was translated and validated by Chou et al. (2002). They supported its good internal consistency and adequate construct valid- ity with moderate intercorrelations between subscales and high factor loadings from a factor analysis of the Taiwanese population. The CBI contains 24 items in five dimensions: physiological, social, emotional, chronological, and developmental. Each item is rated on a 0 4 Likert scale (total score range: 0 96). Higher scores indicate greater caregiver burdens.

Adverse event

While conducting the study, an adverse event was observed. Some family dyads seemed to need more

© 2016 Australian College of Mental Health Nurses Inc.


professional assistance during hospitalization, because the BFCC programme facilitated the communication and interaction of the whole family.

Statistical analysis

Differences in demographic and baseline clinical vari- ables between the BFCC and TAU groups were evalu- ated using v 2 -tests. Differences in changes between baseline and post-treatment CHQ-12, CBI, and FFS scores were evaluated using generalized linear mixed- model regression analyses (Hedeker & Gibbons 2006). For each model, the baseline and post-treatment scores were the repeated dependent variables, and the group was the independent variable. The ‘time effect’ is a test of whether both groups improved between baseline and post-treatment assessments. The group 9 time interaction is a test of whether patients in the BFCC group differed significantly over time from those in the TAU group, and thus was the primary effect of inter- est. SPSS 17.0 for Windows (SPSS, Chicago, IL, USA) was used for all analyses. Significance was set at P < 0.05.


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 assigned to either the BFCC group or the TAU group. Ten patient/caregiver dyads in BFCC group and three in the TAU group refused to participate. Seven dyads in the TAU group were lost to post-intervention assess- ment because the patients’ symptoms worsened, the patients failed to keep their appointments, or the patients were unexpectedly discharged. Four dyads in the BFCC group discontinued the intervention because the patient, caregiver, or both were unwilling to partici- pate or failed to keep their appointments. Finally, 17 dyads in the BFCC group and 20 dyads in the TAU group were analysed. Half of the patients were male, aged 21 40 years old, were married, and unemployed or in school (Table 2). Most had a 4-year or 2-year college degree, had been diagnosed with BPD more than 5 years before the commencement of the study, and had been hospitalized more than once. Most of the family care- givers were the patients’ parents or spouses; they care- givers were married, aged 41 65 years old, and had at

© 2016 Australian College of Mental Health Nurses Inc.


least a 4-year college degree. Although the family care- givers in the TAU group were younger than those in the BFCC group ( P = 0.053), there were no significant demographic or clinical differences between the two groups (Table 2).

Effect on family function, caregivers’ perceived health status, and caregivers’ burden

At baseline, there were no significant differences in the three outcome indicators between the two groups. For the primary hypothesis related to family function, there were significant group 9 time interactions for the total FFS scores and subscales of conflict, communication, and problem-solving. It indicated that patients in the BFCC group made greater improvements on overall FFS scores and these three subscales than those in the TAU group. For the secondary hypothesis, there were significant time effects for the subscales of depression and poor relationships in both groups, and a marginal effect for the CHQ total score ( P = 0.05; Table 3). However, there were no significant time effects or 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)).


We found that the BFCC programme intervention improved the family function, but did not affect family caregivers’ self-perceived health status and caregivers’ burden. These brief family interventions taught care- givers to communicate with patients, and patients and caregivers to deal with conflicts and to solve their prob- lems by providing emotional support and information about BPD-related dysfunctional behaviours. It also assisted the dyads to develop new problem-solving skills. All of this new knowledge eventually reached the rest of the family and contributed to improving family function. Evidence shows that family function has a critical effect on the efficacy of family-focussed treat- ments (Sullivan et al. 2012), and on the symptomatic and functional recovery of patients with BPD (Ferreira et al. 2013; McCann et al. 2012; Reinares et al. 2016). However, most studies on family intervention have examined the effects on patients’ symptomatology and social functioning and on relatives’ depression, bur- dens, or health-related behaviours. Few studies have assessed family function as an outcome indicator. Our


TABLE 2: Participants’ characteristics


Patients with bipolar disorder

Family caregivers

BFCC group ( n = 16) n (%)

TAU group (n = 20) n (%)

BFCC (n = 16)

TAU ( n = 20)





n (%)

n (%)

v 2




8 (50.0%)

9 (45.0%)



6 (37.5%)

14 (70.0%)



Marital status


9 (56.2%)

12 (60.0%)



4 (25.1%)

6 (30.0%)




7 (43.8%)

8 (40.0%)

12 (75.0%)

14 (70.0%)

Age (years)


10 (62.5%)

10 (50.0%)



2 (12.5%)

7 (35.0%)




6 (37.5%)

10 (50.0%)

13 (81.1%)

9 (45.0%)


Education High school or less College degree Master or higher Employed Yes No Illness duration (years)


1 (5%)

1 (6.3%)

4 (20.0%)

4 (25.0%)

6 (30.0%)



3 (18.8%)

5 (25.0%)



9 (56.3%)

8 (40.0%)

2 (12.5%)

7 (35.0%)

3 (18.8%)

6 (30.0%)

11 (68.7%)

8 (40.0%)

8 (50.0%)

9 (45.0%)



7 (43.8%)

4 (20.0%)



8 (50.0%)

11 (55.0)

9 (56.2%)

16 (80.0%)


2 (12.5%)

6 (30.0%)





7 (43.8%)

1 (5%)


1 (6.3%)

3 (15.0%)


6 (36.5%)

10 (50.0%)



11 (68.7%)

10 (50.0%)





2 (12.5%)

2 (10.0%)


3 (18.8%)

8 (40.0%)

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

findings support both the feasibility of using the BFCC programme for inpatients, and using its specific bene- fits for family function. A brief family intervention during hospitalization has been suggested in psychiatric practice to support patients with BPD and family caregivers. Miklowitz et al. (2013) found a greater treatment effect after a 4- month family-focussed therapy session among adoles- cents at high risk in families that are highly emotional versus emotionally-subdued families. Sullivan et al. (2012) reported greater reductions in conflict over time in high-conflict families of an adolescent with BPD participating in family intervention, and a significant improvement of the patient’s mania symptoms in low- conflict families. They suggested that family cohesion, adaptability, and conflict could be useful predictors of the course of adolescents’ mood symptoms, and that family conflict might be an important target for family intervention in early-onset BPD. It might, therefore, be crucial to provide a family intervention during transi- tion from hospital to home for continually improving family function and family caregivers’ health status, as well as reducing their care burden. Moreover, because

the value of familial interdependence is emphasized in Chinese society (Chen 2001), the BFCC assisted the whole family to do the tasks required for them to take care of their own family when they encounter complex conflicts and distressed feelings, and to fulfil their moral responsibility (Huang et al. 2009). For this specific cultural context in Taiwan, family inter- vention that is individually tailored to patients’ char- acteristics and the family’s needs is particularly valuable. The effects of the BFCC on caregivers’ health status and burden were not consistent with the benefits found in similar studies (Fiorillo et al. 2015; Reinares et al. 2010). Possibly, the short hospital stay (mean: 3 weeks) in our study and the brevity of our interventions did not offer sufficient support or respite to the caregivers. Reinares et al. (2010) and Fiorillo et al. (2015) sup- ported the benefits of the 12 18 90-min sessions of psychoeducational family interventions for 6 15 months on patients’ symptoms and the family caregivers’ bur- den. Two recent reviews (Miziou et al. 2015; Reinares et al. 2016) concluded that family interventions amelio- 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


Baseline test


Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

F ( P-value)

F ( P-value)

FFS total scores Cohesion Conflict Emotional involvement Emotional expression Communication Problem-solving Independence Family responsibilities CHQ total score Physiological and somatic aspects Anxiety and worry Depression and poor relationships Sleep problems CBI total score Physiological burden Social burden Emotional burden Time burden Development burden

140.88 (22.82) 150.19 (23.12) 146.35 (18.08) 134.42 (20.05) 0.09 (0.77)

5.23 (0.03)*

26.00 (6.24)

25.63 (5.66)

24.35 (5.53)

23.26 (6.85)

0.87 (0.36)

0.27 (0.61)

12.38 (4.29)

15.06 (4.68)

15.00 (2.79)

14.40 (2.85)

1.91 (0.18)

4.75 (0.04)*

9.25 (2.89)

10.63 (3.70)

11.20 (3.72)

10.45 (2.72)

0.23 (0.64)

2.66 (0.11)

18.94 (3.62)

19.81 (2.86)

18.10 (4.44)

18.20 (4.15)

0.55 (0.47)

0.35 (0.56)

18.75 (6.01)

22.81 (5.41)

21.55 (5.36)

16.70 (5.93)

0.06 (0.81)

7.67 (0.01)*

17.00 (6.47)

19.06 (4.12)

19.15 (4.44)

15.50 (5.61)

0.35 (0.55)

4.71 (0.04)*

22.19 (5.26)

21.44 (4.86)

22.10 (3.97)

21.50 (3.32)

0.74 (0.40)

0.01 (0.93)

16.38 (3.63)

15.75 (3.28)

14.90 (2.99)

14.45 (2.69)

1.06 (0.31)

0.03 (0.87)

5.12 (2.47)

4.44 (2.07)

5.70 (3.47)

4.20 (3.11)

4.43 (0.05)*

0.59 (0.45)

0.88 (0.96)

0.56 (0.89)

1.10 (1.48)

0.90 (1.33)

1.35 (0.25)

0.65 (0.80)

1.13 (1.09)

1.31 (1.14)

1.55 (1.32)

0.90 (1.12)

1.22 (0.28)

4.00 (0.05)

2.56 (0.89)

2.19 (0.91)

2.55 (0.89)

2.10 (0.64)

6.29 (0.02)*

0.05 (0.82)

0.56 (0.51)

0.38 (0.50)

0.50 (0.51)

0.30 (0.47)

3.90 (0.06)

0.00 (0.95)

48.38 (11.37)

50.26 (14.74)

50.40 (21.75)

46.35 (20.06) 0.16 (0.69)

0.97 (0.33)

10.94 (2.98)

9.94 (3.04)

10.00 (5.06)

8.80 (4.53)

3.20 (0.08)

0.03 (0.87)

6.88 (3.28)

8.44 (4.08)

7.50 (4.73)

7.15 (3.63)

0.55 (0.46)

1.37 (0.25)

8.10 (3.95)

9.44 (6.03)

8.80 (6.05)

9.15 (5.11)

0.09 (0.76)

0.98 (0.33)

11.81 (4.28)

9.69 (3.89)

13.05 (5.11)

12.05 (5.18)

3.29 (0.08)

0.43 (0.52)

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 at least 6 months with 12 18 treatment sessions. The relatively short duration of the acute care setting required an abbreviated and adapted family interven- tion. Pragmatically, the short-form family-centred care programme in the present study targeted the specific transitional needs of the family while their family mem- ber with BPD was hospitalized. Because there were, in our pilot study (Lee et al. 2013), families with little motivation to participate in family intervention after their family member with BPD had been discharged from hospital, we implemented the BFCC by provid- ing individually-tailored and task-oriented interven- tions to the identified urgent problems between patients and family. As expected, the caregivers’ and patients’ participation rates in the BFCC programme were high, which supported its feasibility for use with patients awaiting discharge and their caregivers. Lee et al. (2013) also reported that the hospitaliza- tion period is an accessible stage for igniting the desire of patients and their caregivers to obtain pro- fessional help. Brief and focused family intervention could met patients’ and caregivers’ specific needs and strengthened family function during transition from hospital to home.

© 2016 Australian College of Mental Health Nurses Inc.

Our findings have some practical implications. First, clinical nurses 24 hours stay with their patients and understand the relationships between patients and their family caregivers. We could provide family intervention in acute care settings to encourage family members communication with each other. Therefore, psychiatric nurses need adequate family interviewing training (Gou- dreau et al. 2006). For example, nurses must be aware of the value and conflicts of familial interdependence in Chinese culture while conducting the BFCC pro- gramme. Second, developing cultural-specific family- centred interventions based on the CFIM for other mental illnesses, such as schizophrenia, depression, organic disorders, and dementia, might benefit family caregivers in Chinese society and improve family func- tion and the quality of care. The present study has some limitations. First, the sample size was modest, which limited the study’s statis- tical power and might have contributed to undetectable significant effects of the BFCC programme on improve- ments in caregivers’ health status and burdens. Second, the BFCC programme was provided when the patient with BPD was hospitalized, and family dyads had to agree to work together, which led to a selection bias:

There are ten family caregivers discontinued in the


BFCC intervention, it was supposed that the BFCC might be increase their family conflict and less the inten- tion to attend in this trial. Therefore, our findings might not be generalizable to uncooperative patients and fam- ily caregivers who have a multitude of family conflicts and family problems. Third, we had no follow-up assess- ment and did not evaluate whether any of the BFCC programme effects were lasting. With the positive results of the present study, and considering the high rate and cost of hospitalization for patients with BPD, longer- term follow-up evaluation of the BFCC programme is needed for future research. Fourth, the BFCC pro- gramme was compared with TAU, and did not control for the non-specific factors related to the intervention (e.g. clinician time and attention). Fifth, participants were not blinded to their intervention groups in this study, which might have biased their responses to sub- jective outcome measures.


Our findings supported the feasibility of using the BFCC programme for patients with BPD and their caregivers during hospitalization in an acute care inpa- tient setting. It also supported the positive effect on family function, but it did not decrease family care- givers’ perceived health problems or burdens. For future research, we suggest larger samples, longer fol- low-up periods (e.g. 6 months or more), and assess- ments of patients’ symptoms and family function.


The authors wish to thank all of the patients with bipo- lar disorder and their family caregivers who partici- pated in this preliminary study.


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