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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.
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Mrs Glaucia Barbosa,
PACFA Reg. Provisional 25212
MCouns, MQCA(Clinical)
ABN: 19 476 932 954
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