Wednesday, 7 December 2016

Psycho-education as an effective intervention for clients presenting with anxiety: A Systematic Review


Psycho-education as an effective intervention for clients presenting with anxiety:
A Systematic Review

1. Implementation

               A systematic review was conducted aiming to examine the effectiveness of psychoeducation as an intervention for clients presenting with anxiety. Several modifications needed to be made from the previous project proposal. The initial intention of undertaking a qualitative review was changed into a quantitative review, primarily because all studies selected for meeting the inclusion criteria used a quantitative method. This modification was advantageous as it reduced the time needed to analyze the studies because quantitative research is more structured than qualitative research and provides very objective and precise statistic results which are easier to be analyzed (Hopkin, 2008) without having the researcher’s personal perceptions (Hopkin, 2008). Due to time constrains to complete the review the search was narrowed and only studies with adult participants were searched for, instead of studies in which participants were children, adolescents and adults as was previously planned. Although the main reason for excluding studies with children and adolescents was based on staying within the time frame for this review, it could be a positive change in regards to the reliability of the studies chosen. Punch (2002) argues that there are many implications influencing the results of research with children as they have less vocabulary to understand instructions and express themselves. Furthermore, they may not be accurate when answering a question because of fear or desire to please the adult instructor due to power imbalance between the child and the adult (Punch, 2002). They also may mix their normal developmental child fantasy with the reality, which leads to unreliable results (Punch, 2002). In addition, because of the necessity of completing the review before the due date for this review, the search was also narrowed regarding the type of publication. Thesis, conference papers and dissertations were excluded and only government publications and scientific journal articles were considered. This modification could have had a negative impact in this systematic review as reducing the number of sources limited the amount of possible data and increased the chances of publication bias (Garg, Hackam, & Tonelly, 2008). However, in order to reduce this risk, a quality assessment criteria table was created to include only high standard papers that met the inclusion criteria (Garg, Hackam, & Tonelly, 2008). Another modification from the project proposal is that it was planned to included articles written in English and Portuguese. However, no study published in Portuguese that met the inclusion criteria was found. This might also have caused another negative impact in this review, as utilizing only papers written in English increased the chances of not including relevant information (Garg, Hackam, & Tonelly, 2008). Moreover, in the project proposal, it was not defined if the studies included would be those evaluating effectiveness of psychoeducation for treatment of anxiety as a primary, or secondary symptoms or both. The final decision made was to accept anxiety as both, a primary and secondary symptom for two reasons: first, because both were present in the most relevant papers selected for this review. Secondly, due to the significance given by the literature that anxiety symptoms are present not only as a primary symptom in several psychological disorders and in 30% of all disabilities (Rummel-Kluge, Pitschel-Walz & Kissling, 2009), but it is also as one of the primary basic human adaptive reactions to an internal or external threat (Bender, Reinholdt-Dunne, Esbjørn, & Pons, 2012). Furthermore, a quality assessment criteria table was created in order to determine the relevance of the papers to be selected, which was another aspect that was not clear in the project proposal. 
2. Results

                The search for this review started on October 10, when Medline (via EBSCO), CINAHL, Scopus, PsychINFO and Chocrane Library databases were assessed through the University of Queensland library website. The key words searched were: psychoeducation combined with anxiety and effectiveness. From 10/10/16 to 28/10/16, a total of 230 articles were initially identified in the above databases (see appendix: 1- Table 1: PRISMA Flow Chart for the Search Strategy Process). A total of 8 papers were duplicates. Twenty-nine studies were excluded after screened abstracts. Only 10 papers were assessed and 2 were excluded for not meeting the inclusion criteria (see appendix 2- Table 2: Quality Assessment Criteria) resulting in a final number of 8 papers included in this review (see appendix 3- Table 3: Data Extraction).

2.1 Search details: 

             The search was based in full text linked articles from 2006 to 2016, browsed by the subject “psychology” and utilizing advanced search section. Titles of the papers were read first, then the abstract of articles selected were read. 
2.2. Study characteristics: 
                From the 230 articles initially identified, 8 papers were included and their characteristics are described in Table 3: Data Extraction (see appendix 3).

2.3. Quality analysis:

               A table of quality assessment criteria (see appendix 2- Table 2: Quality Assessment Criteria) was created in order to establish if the selected studies were only quantitative studies of a high stander. This contains 18 questions assessing date and type of publication, clear description of the study, aims, theoretical framework and literature review, recruitment process and type of participants, intervention process and methods, outcomes, ethical process and risk of bias, as well as validity of data and generalisability. All 8 papers included utilized validated measures and results describing the statistical significance of psychoeducation in decreasing anxiety levels (Chiang et al., 2016; Tellez et al., 2015; Oflaz et al., 2008; Wong et al., 2016; Vidal et al., 2013; Ztrk et al., 2015; Rajiah et al., 2014; Shahmansouri et al., 2014). From the 10 papers assessed only two papers were excluded for not meeting the inclusion criteria: “Bipolar disorder with comorbid anxiety disorders: impact of comorbidity on treatment outcome in cognitive behavioral therapy and psychoeducation” (Hawke et al., 2013), and “A multi-service practice research network study of large group psychoeducational cognitive behavioural therapy” (Delgadillo et al., 2016). The Hawke et al. (2013) study was excluded because it did not have a specific measure for anxiety, no control group to assess outcomes, the sample utilized was very small and the study was not generalizable. In addition, it did not measure psychoeducation as an effective intervention to decrease on anxiety levels, but measured the impact of commorbidity of Bipolar and anxiety disorders on treatment outcome in cognitive behavioral therapy and psychoeducation (Hawke et al., 2013). The Delgadillo et al. (2016) study was excluded because it did not measure effectiveness of psychoeducation on anxiety levels, but rather the outcomes of psychoeducation in different group sizes (Delgadillo et al., 2016). 
2.4. Review of studies:

               All 8 studies selected for this review included adult participants above 18 years of age, from different countries and utilized a defined inclusion/exclusion criteria process to recruit participants. No significant demographics difference were reported regarding participants in any of the studies. They applied psychoeducation as a primary or adjunctive intervention, individually or in different group sizes. The number of sessions varied from 1 to 12 lasting 60 to 90 minutes and performed follow-up. The study with the smallest sample was Vidal et al. (2013) with 32 participants, assessing anxiety levels of people with ADHD. The study with the biggest sample was Rajiah et al. (2014) with 225 participants, assessing anxiety levels of university students. Only two studies analyzed both primary and secondary outcomes (Vidal et al., 2013; Wong et al., 2016).
               Comparing the studies, only two utilized psychoeducation as the only intervention compared to a control group, both showing significant decrease in anxiety levels (Ztrk et al., 2015; Tellez et al., 2015). Six studies used psychoeducation combined with other interventions (Chiang et al., 2016; Oflaz et al., 2008; Wong et al., 2016; Vidal et al., 2013; Rajiah et al., 2014; Shahmansouri et al., 2014). Six studies showed similar positive outcomes in which psychoeducation was able to decrease anxiety levels (Tellez et al., 2015; Oflaz et al., 2008; Wong et al., 2016; Vidal et al., 2013; Ztrk et al., 2015; Rajiah et al., 2014). Six studies also demonstrated a reduction in other associated symptoms such as pain, fear, depression, worry, hyperactivity and impulsivity (Tellez et al., 2015; Oflaz et al., 2008; Wong et al., 2016; Vidal et al., 2013; Ztrk et al., 2015; Rajiah et al., 2014). Five studies showed other improvements such as: participants learning about the disorder (Chiang et al., 2016; Rajiah et al., 2014) and coping skills to manage symptoms (Chiang et al., 2016; Vidal et al., 2013), changed beliefs (Shahmansouri et al., 2014), improved attention deficit (Vidal et al., 2013), academic performance of students (Rajiah et al., 2014), client's motivation (Vidal et al., 2013; Rajiah et al., 2014) and improvement in treatment adherence (Vidal et al., 2013). Psychoeducation also helped the combined intervention to be more efficient (Vidal et al., 2013).
                Regarding differences, only one of the studies showed less reduction of anxiety in the treatment group than in the control group (Chiang et al., 2016). However, it was observed in this study that participants who had received psychoeducation have learned how to recognize their feelings so they were more able to report anxiety symptoms than the control group (Chiang et al., 2016). Additionally, results of only one study described that psychoeducation had a very small impact on anxiety levels (Shahmansouri et al., 2014).
               Overall, all the above studies' results described psychoeducation as an effective intervention for clients experiencing anxiety as a primary symptom regarding physical pain, fear of surgery and academic assessments (Ztrk et al., 2015; Shahmansouri et al., 2014; Rajiah et al., 2014), as well as generalized anxiety disorder (Wong et al., 2016). Outcomes were also positive regarding psychoeducation as an effective intervention to decrease anxiety as a secondary symptom in phobia (Tellez et al., 2015), PTSD (Oflaz et al., 2008) and ADHD disorders (Vidal et al., 2013).
3. Discussion

               It was shown by all studies, which incorporated a quantitative method with validated measures, included in this review that psychoeducation is an effective intervention to decrease anxiety levels as a primary and secondary symptom in adult clients. The studies also utilized different numbers and types of participants, in different settings, applying psychoeducation in different group sizes, and combined with different interventions, which indicates that psychoeducation can be effective in a variety of circumstances.
               All the studies presented limitations that could have affected reliability of results. Chiang et al. (2016) study with caregivers of patients in the intensive care unity reported limitations due to have a small sample size as it was difficult to recruit participants because of the high level of anxiety they were experiencing regarding their family member's state of health in the hospital (Chiang et al., 2016). Dental anxiety was investigated in Tellez et al. (2015). In this study, the application of the intervention was not uniform as it was not always applied by trained professional, and the follow up period was short (Tellez et al., 2015). In the Oflaz et al. (2008) study, participants were earthquake survivals experiencing PTSD (Oflaz et al., 2008). The limitations included a small sample size, and PTSD symptoms based in participants' self-reports (Oflaz et al., 2008). The Wong et al. (2016) study evaluated people with generalized anxiety disorder and found the following limitations: a small sample size, long term follow up was impossible due to ethical reasons, and primary and secondary outcome measures could have caused an error due to the multiple testing, differences in group adherence, and only one degree of anxiety level was measure making the study impossible to be generalized (Wong et al., 2016). Vidal et al. (2013) study who investigated anxiety levels in people with ADHD had a small sample size as the only limitation (Vidal et al., 2013). The limitations in Ztrk et al. (2015) study using participants with mastalgia were the small sample size and short follow up period (Ztrk et al., 2015). Shahmansouri et al.'s (2014) study regarding anxiety levels concerning surgery, the limitation was also the small sample size (Shahmansouri et al., 2014) and in Rajiah et al.'s (2014) study analyzing anxiety levels in first year Pharmacy students the limitation was collecting data from only private universities, which also makes the results difficult to generalized (Rajiah et al., 2014). 
              The primary limitation of this review was that the papers analised described a variety of different contexts and disorders in which the intervention was applied, as well the diverse type of inclusion/exclusion criteria, type of participants, combined interventions, methods, and outcome measures were used, making the results difficult to be compared.
                The strengths of this review were the utilization of reliable databases, narrowing the search to only adults to prevent a more complex analysis of the implications of research made with children and adolescents (Punch, 2002), and the creation of a quality appraisal table to assess the quality of papers. 
              On the other hand, the main weakness identified were the short time frame for completion leading thesis, conference papers and gray literature, as well as papers written in languages other than English to be excluded, which limited the number of evidence (Garg, Hackam, & Tonelly, 2008). Another weakness was that the majority of the studies had a very small sample size.
                Previous systematic reviews showed similar results indicating the usefulness of psychoeducation to treat anxiety symptoms in a variety of settings (Houghton & Saxon, 2007), with different types of participants (Chua & Pachana, 2016), either applied alone or with combined approaches for a variety of mental and physical illness (Dumbar, 2009). Results from these reviews also described how psychoeducation is relevant to practice. Findings demonstrated the necessity of psychoeducaional programs to reduce anxiety of caregivers of patients in ICU hospitals and how psychoeducation can be delivered by nurses (Chiang et al., 2016), not only in a hospital settings, but also for people with PTSD after a natural disaster (Oflaz et al., 2008). It can also be applied in dental offices to decrease anxiety and fear of dental procedures (Tellez et al., 2015), in counselling or psychology private rooms or agencies for clients with generalized anxiety disorder (Wong et al., 2016). In addition, the application of psychoeducation indicated great benefits to clients with ADHD who described not only a decrease in anxiety levels and symptoms of depression (Vidal et al., 2013) but also an improve in attention deficit, hyperactivity, impulsivity, self-esteem and quality of life (Vidal et al., 2013). In terms of physical symptoms, psychoeducation was shown to be able to reduced anxiety and pain in women with mastalgia (Ztrk et al., 2015) and anxiety about surgery (Shahmansouri et al., 2014). Finally, universities and schools might want to investigate the application of psychoeducation to manage psychological distress associated with assessments, which can also improve students' motivation and grades (Rajiah et al., 2014).
                A conclusion that can be drawn from this analysis is that psychoeducation has been extensively documented by the current literature (Houghton & Saxon, 2007) and demonstrated by a number of validated assessment measures used in the studies included in this review as an effective treatment for client presenting with anxiety (Wong et al., 2016).              
              As a result of the limitations reported in the studies, several gaps were identified. It was also highlighted that, as the needs of people are different, some may benefited more from combined therapies, including medication, than from psychoeducation alone (Wong et al., 2016). Further research is still needed with more homogeneous studies and larger samples to confirm these findings and fill the gaps. Moreover, long-term follow up is necessary to explore long term effectiveness of treatment approaches, as well as benefits of psychoeducation applied alone or in conjunction with other approaches. 
4. References

Bender, P. K., Reinholdt-Dunne, M. L., Esbjørn, B. H., & Pons, F. (2012). Emotion dysregulation and anxiety in children and adolescents: Gender differences. Personality and Individual Differences, 53(3), 284-288. doi:
Chiang, V. C. L., Chien, W. T., Wong, H. T., Lee, R. L. P., Ha, J., Leung, S. S. K., & Wong, D. F. K. (2016). A Brief Cognitive-Behavioral Psycho-Education (B-CBE) Program for Managing Stress and Anxiety of Main Family Caregivers of Patients in the Intensive Care Unit. International Journal of Environmental Research and Public Health, 13(10), 962. doi:10.3390/ijerph13100962
Chua, J., & Pachana, N. A. (2016). Use of a psychoeducational skill training DVD program to reduce stress in chinese australian and singaporean dementia caregivers: A pilot study. Clinical Gerontologist: The Journal of Aging and Mental Health, 39(1), 3-14. doi:10.1080/07317115.2015.1101634
Delgadillo, J., Kellett, S., Ali, S., Mcmillan, D., Barkham, M., Saxon, D., Donohoe, G., Stonebank, H., Mullaney, S., Eschoe, P., Thwaites, R., Lucock, M. (2016). A multi-service practice research network study of large group psychoeducational cognitive behavioural therapy. Behaviour Research and Therapy, Vol.87, pp.155-161 [Peer Reviewed Journal]. Doi:
Dunbar, S. B. (2009). Effect of a psychoeducational intervention on depression, anxiety, and health resource use in implantable cardioverter defibrillator patients. Pacing and Clinical Electrophysiology, 32(10), 1259; 1259-1271; 1271
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Hawke, L., Velyvis, V., & Parikh, S. (2013). Bipolar disorder with comorbid anxiety disorders: impact of comorbidity on treatment outcome in cognitive behavioral therapy and psychoeducation. International Journal of Bipolar Disorders, Vol.1(1), pp.1-6 [Peer Reviewed Journal]. Doi: 10.1186/2194-7511-1-15
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Oflaz, F., Hatipoğlu, S., & Aydin, H. (2008). Effectiveness of psychoeducation intervention on post-traumatic stress disorder and coping styles of earthquake survivors. Journal of Clinical Nursing, Vol.17(5), pp.677-687 [Peer Reviewed Journal]. doi: 10.1111/j.1365-2702.2007.02047.x
Punch, S. (2002). Research with children: the same or different from research with adults? Childhood: A Global Journal of Child Research, 2002, Vol.9(3), p.321-41 [Peer Reviewed Journal] doi: 10.1177/090756820200900300
Rajiah, K., M.Pharm., & Saravanan, C. (2014). The Effectiveness of Psychoeducation and Systematic Desensitization to Reduce Test Anxiety Among First-year Pharmacy Students. American Journal of Pharmaceutical Education, vol.15; 78(9): 163. doi: 10.5688/ajpe789163
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Shahmansouri, N., Janghorbani, M., Salehi O. A., Karimi, A. A., Noorbala, A. A., Arjmandi, A.,& Nikfam, S. (2014). Effects of a psychoeducation intervention on fear and anxiety about surgery: Randomized trial in patients undergoing coronary artery bypass grafting. Psychology, Health & Medicine, Vol.19(4), p.375-383 [Peer Reviewed Journal]. Doi:
Tellez, M., Potter, C M., Kinner, D G., Jensen, D., Waldron, E., Heimberg, R G., Myers Virtue, S., Zhao, H., Ismail, A. I.(2015). Computerized Tool to Manage Dental Anxiety. A Randomized Clinical Trial. Journal of dental research, Vol.94(9), pp.174S-80S [Peer Reviewed Journal]. doi: 10.1177/0022034515598134
Vidal, R., Bosch, R., Nogueira, M., Gómez-Barros, N., Valero, S., Palomar, G., Corrales, M., Richarte, V., Mena, B., Casas, M., Ramos-Q., & Josep A. (2013). Psychoeducation for Adults With Attention Deficit Hyperactivity Disorder vs. Cognitive Behavioral Group Therapy: A Randomized Controlled Pilot Study. The Journal of Nervous and Mental Disease, 2013, Vol.201(10), p.894-900. [Peer Reviewed Journal] doi:10.1097/NMD.0b013e3182a5c2c5
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Wong, S. Y. S., Yip, B. H. K., Mak, W. W. S., Mercer, S., Cheung, E. Y. L., Ling, C. Y. M., Lui, W. W. S., Tang, W. K., Lo, H. H. M., Wu, J. C. Y., Lee, T. M. C., Gao, T., Griffiths, S. M., Chan, P. H. S., & Ma, H. S. W. (2016). Mindfulness-based cognitive therapy v. group psychoeducation for people with generalised anxiety disorder: randomised controlled trial. The British journal of psychiatry : the journal of mental science,Vol.209(1), pp.68-75 [Peer Reviewed Journal]. DOI: 10.1192/bjp.bp.115.166124
Ztrk, A. B., Zenl, Y., Strike, S. B., Nel, S., Sker, G., & Seydaoglu, G.(2015). The effect of psychoeducation on anxiety and pain in patients with mastalgia. Nordic Journal of Psychiatry, Vol.69(5), p.380-385 [Peer Reviewed Journal]. Doi:

Mrs Glaucia Barbosa,
PACFA Reg. Provisional 25212 
MCouns, MQCA(Clinical)  

                                                               ABN: 19 476 932 954

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