Intervention for Adolescents With Early Onset Psychosis and Their Families: A Randomized Controlled...

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Intervention for Adolescents With Early-OnsetPsychosis and Their Families: A Randomized

Controlled TrialAna Calvo, PhD, Miguel Moreno, MD, PhD, Ana Ruiz-Sancho, MD,

Marta Rapado-Castro, PhD, Carmen Moreno, MD, PhD, Teresa S�anchez-Guti�errez, MSc,Celso Arango, MD, PhD, Mar�ıa Mayoral, PhD

Objective: The present study aims to assess the efficacy of a structured psychoeducationalgroup intervention for adolescents with early-onset psychosis and their families. The interven-tion was implemented in parallel in 2 separate groups by focusing specifically on problem-solving strategies and structured psychosis-related information to manage daily life difficultiesassociatedwith the disease, tomitigate crises, and to prevent relapses. Method: Weperformeda 9-month, randomized, rater-blinded clinical trial involving 55 adolescent patients with early-onset psychosis and either or both of their parents. A psychoeducational problem-solvinggroup intervention (n ¼ 27) was compared with a nonstructured group intervention (n ¼ 28).The primary outcomes were number of hospitalizations, days of hospitalization, and visits to theemergency department. The secondary outcome measures were clinical variables and familyenvironment. Results: Assessments were performed before and after the intervention. At theend of the group intervention, 15% of patients in the psychoeducational group and 39% patientsin the nonstructured group had visited the emergency department (c2 ¼ 3.62, df ¼ 1, p ¼ .039).The improvement in negative symptoms was more pronounced in the psychoeducational group(12.84 [7.87]) than in the nonstructured group (15.81 [6.37]) (p ¼ .039). Conclusion: A parallelpsychoeducational group intervention providing written instructions in a structured mannercould help adolescents with early-onset psychosis and their parents to manage crises by imple-menting problem-solving strategies within the family, thus reducing the number of visits to theemergency department. Negative symptoms improved in adolescents in the psychoeducationalgroup. J. Am. Acad. Child Adolesc. Psychiatry, 2014;53(6):688–696. Key Words: psychosis,families, group therapy, psychoeducation

sychoeducational programs are amongthe most widely studied psychosocial in-
P terventions for psychotic disorders. These
programs are systematic and didactic, and consistof psychotherapeutic interventions aimed at pro-viding information about the disease in questionto patients and their relatives to foster copingskills and understanding.1

Studies in adult populations with schizophreniahave shown that psychoeducational interventionscan reduce the probability of relapse, number ofhospitalizations, and symptom severity.2,3 Theycan also improve social and occupational func-tioning and increase adherence to treatment.4,5

Additional benefits include reduced family bur-den, improved coping skills, and recognition andunderstanding of psychosis as a disease.2,6,7 In

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accordance with the stress-vulnerability model,environmental factors such as family interactionscan play an important role in the continuity ofthe disorder.8-10 Hence, family psychoeducationalprograms are aimed at influencing the environ-ment in which the patient lives11 by reducinganxiety and increasing family members’ self-confidence and ability to react constructively tobehavioral disturbances and the patient’s symp-toms. This result has been confirmed in recentstudies that show that the relapse rate can bereduced by approximately 20% if the parents ofpatients with schizophrenia are included in thetreatment.2 Strenuous efforts to engage familiesin the prevention of relapses are justified, because80% to 90% of patients are living with their par-ents when they are referred for treatment.12

AL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY

VOLUME 53 NUMBER 6 JUNE 2014

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INTERVENTION FOR ADOLESCENTS WITH EARLY-ONSET PSYCHOSIS AND THEIR FAMILIES

To our knowledge, only 1 study13 has assessedthe efficacy of a psychoeducational treatmentprogram in adolescents with psychosis, althoughit was not a randomized controlled trial. Fur-thermore, despite the fact that some programsoffer psychoeducational approaches for youngadults with a first episode of psychosis thatinclude parents as an important complement inthe program,14,15 none of them includes a specificage range for adolescents. Other studies evaluatethe efficacy of a family-focused psychoeduca-tional approach for adolescents with mooddisorders who frequently have accompanyingpsychotic features.16-19 Our study aimed to ex-amine the efficacy of a parallel, structured, andspecific psychoeducational group intervention(PE) for adolescent patients and their families bycomparing it with a nonstructured group inter-vention (NS).

To the best of our knowledge, this is the firstrandomized controlled trial to compare a PEintervention with an NS intervention in adoles-cents with early-onset psychosis. We hypothe-sized that patients in the PE group would havefewer hospitalizations, days in hospital, and visitsto the emergency department. We also hypothe-sized that these patients would have better

FIGURE 1 Study flow chart. Note: NS ¼ nonstructured gro

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clinical outcomes and more favorably perceivedfamily environments.

METHODStudy Design and ProcedureWe performed a randomized, rater-blinded, outpatienttrial. Participants were randomly allocated to PE or NSas an add-on intervention to treatment as usual, usinga computer-generated sequence.

The group treatment was conducted once every15 days at the outpatient clinic of the Child andAdolescent Psychiatry Department of Hospital GeneralUniversitario Gregorio Mara~n�on, Madrid, Spain. Aftercomplete explanation of the study, written informedconsent was obtained from all patients and their par-ents or legal guardians. The study was approved by theresearch and ethics committee of Hospital GeneralUniversitario Gregorio Mara~n�on.

Study ParticipantsThe program was offered to 90 participants (Figure 1).They were adolescent outpatients diagnosed with early-onset psychosis and accompanied by 1 or both parents.

The inclusion criterion for patients was the presenceof at least 1 positive psychotic symptom (delusions orhallucinations) before age 18 years and 1 of thefollowing diagnoses from the DSM-IV: schizophrenia,schizoaffective disorder, schizophreniform disorder,

up; PE ¼ psychoeducational group.

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CALVO et al.

bipolar disorder, major depressive disorder with psy-chotic features, brief psychotic disorder, or psychosisnot otherwise specified.

Patients were between 14 and 18 years of age andlived at home with either or both parents, caregivers, orlegal guardians.

The exclusion criteria were patient’s drug abuse ordependence at the time of the intervention (drug usewas not an exclusion criterion), the presence of anyneurological developmental disorder and inability toengage in conversation or read in Spanish that mightinterfere with the progress of group treatment.

Of the 55 patients enrolled in the program, 48 had afirst episode of psychosis (6 of them had never beenadmitted to hospital) and 7 had had previous episodes(1 hospitalization [n ¼ 1], 2 hospitalizations [n ¼ 3],and 3 hospitalizations [n ¼ 3]).

Assessment and Measurement InstrumentsAssessments were conducted blindly by psychiatristsexperienced in child and adolescent psychiatric disor-ders. Participants and their families were assessedbefore and after treatment. Baseline assessments weremade within a maximum of 1 month before the in-tervention, and post-treatment assessment within 1month after the intervention. In the case of patientswho discontinued treatment, the post-treatment as-sessments were made approximately 9 months after thebaseline assessment. Patient diagnoses were madeaccording to DSM-IV criteria following the Spanishversion of a semi-structured interview for children andparents, the Schedule for Affective Disorders andSchizophrenia for School-Age Children–Present andLifetime version (K-SADS PL).20,21

Clinical evaluations were performed by applyingthe Spanish version of the Positive and Negative Syn-drome Scale (PANSS).22,23 The level of functioning wasmeasured using the Children’s Global Assessment ofFunctioning Scale (C-GAS).24,25 Interrater reliability forthe scales was determined using the intraclass corre-lation coefficient, which was greater than 0.80. Adher-ence to treatment was appraised by analyzing levelsof antipsychotic medication in venous blood usinghigh-performance liquid chromatography.26 The over-all family psychological climate was assessed using theFamily Environment Scale (FES),27 both with patientsand with their relatives. This self-administered ques-tionnaire is a 90–item true/false inventory that evalu-ates various characteristics of the family environmentclustered in 10 different categories: cohesion, expres-siveness, conflict, independence, achievement orienta-tion, intellectual–cultural orientation, active-recreationalorientation, moral–religious emphasis, organization,and control.

Finally, our main outcome measures were obtainedthrough a specifically developed questionnaire to recordthe number of hospital admissions, the total number ofdays of psychiatric hospitalization, and the number of

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visits to the emergency department. The questionnairewas administered to both parents and adolescents. In-dependent corroboration of the data collected was car-ried out using medical records.

Programa de Intervenci�on en Psicosis Adolescente(PIENSA) ProgramOur program seeks to help patients and their familiesto create an environment that fulfills the particularneeds of patients with early-onset psychosis in order toimprove the disease course by modifying patient andfamily response to the usual stressors. Given the age ofthe participants and the fact that 1 of the develop-mental challenges that adolescents have to face as theymature is differentiation from their parents, we decidedto run 2 simultaneous and parallel groups: 1 group forparents and the other for adolescents in each of our2 proposed clinical interventions.28

Psychoeducational Intervention. The PE is an adapta-tion to our environment and population (adolescentsdiagnosed with early-onset psychosis and receivingtreatment in the Spanish National Health System) ofthe Psychoeducational Model and Multi-Family Treat-ment (MFT) fromMcFarlane et al.29 The adaptation wasdeveloped by 3 of the authors (A.R.-S., M.Moreno, andM.Mayoral). Our PE consisted of 2 consecutive phases:the initiation/alliance phase and the group phase(following the MFT format). The initiation phase con-sists of 3 individual sessions of 50 minutes each inwhich the group leaders interview families and ado-lescents separately. Once participants have completedthe initiation phase, they are invited to join 2 separategroups, one for patients and the other for parents. Thegroup phase consists of 12 sessions of 90 minutes each,once every 15 days. PE sessions are structured, and thepatients and their families receive written materialadapted for the adolescents in the PE modality. Thematerial is composed of 12 chapters, 3 of which addressmedication, side effects, and crisis management. Bothcontents and group structure were the same in theadolescents and parents’ version of the program.Groups specifically focused on problem-solving stra-tegies to manage daily life difficulties associated withthe disease to mitigate crises and to prevent relapses.After the session ended, both the adolescents and theparents were asked to put the psychoeducationalapproach into practice together (M. Mayoral, M. Mor-eno, O. Robles, R. Lozano, unpublished, 2012).

Nonstructured Intervention. The NS also has aninitiation phase (3 separate individual sessions forparents and adolescents) and 12 group sessions oc-curring every 15 days. Facilitators did not follow a pre-set model but used a supportive group approach thatconnected persons facing similar challenges, thusenabling members to share experiences and advice (forexample, on medication and side effects). No writtenmaterial was provided to parents or adolescents. Boththe PE and NS group interventions complemented





current individual psychiatric management and psy-chopharmacological treatment.

TherapistsTo control for therapist effects such as gender, personalcharacteristics, training, and experience, the same th-erapists delivered both group interventions, dependingon whether the groups were patient groups or parentgroups. Therefore, there were 2 therapists for the pa-tient groups (both of them delivered the PE and NSgroup interventions) and 2 different therapists for theparent groups. All group sessions were video recor-ded, and all therapists were then supervised in weeklyclinical review meetings by an experienced externalsupervisor (A.R.-S.) to assess their clinical competenceand their degree of adherence to the therapeutic model.Fidelity to treatment was assessed with an adherencequestionnaire with 22 items on a 5-point Likert-typescale (1–5). The highest score was 110; therapistsscored above 91, and the average was 102.9.28

Data AnalysisData were analyzed on an intention-to-treat basis, ac-cording to which all patients were analyzed in thetreatment groups to which they were randomly allo-cated, regardless of whether they had completely fol-lowed the scheduled design. The samples then includedboth treatment completers and treatment noncom-pleters. Statistical analysis was made using SPSS version20.0 for Windows. The baseline characteristics of thesample were compared using the Pearson c2 test forcategorical variables such as sex, ethnicity, and diag-nosis. Quantitative variables were analyzed using non-parametric tests (Mann–Whitney andWilcoxon) becauseour data did not fulfill the general linear model as-sumptions (normality and homoscedasticity).

TABLE 1 Sociodemographic, Diagnostic, and Clinical Data a

Characteristic n

Age, y, mean (SD) 16.4Male sex 16.0White ethnicity 25.0Diagnosis

Schizophrenia spectrum psychosis 9.0Affective psychosis 7.0Other psychosis 11.0

Neuroleptic dosage in CPZ equivalents, mean (SD) 1,107.6Risperidone 11.0Quetiapine 6.0Aripiprazole 5.0Olanzapine 2.0Clozapine 0.0No antipsychotic treatment 1.0

Note: Values are expressed as n (%) unless otherwise indicated. CPZ ¼ chlointervention.



Group differences were assessed using the Mann–Whitney test for the intergroup analysis and the Wil-coxon test for the intragroup analysis. The Pearson c2

test was used for categorical variables such as hospi-talization and visits to the emergency department. Ef-fect sizes were also calculated to quantify the effect ofthe intervention between groups.

RESULTSSociodemographic and Clinical VariablesWe found no statistically significant differencesbetween the PE and NS groups regarding socio-demographic, diagnostic, or clinical variables atbaseline (Table 1).

Group Intervention ComplianceNo statistically significant differences were ob-served between the 2 study groups with respectto the number of participants completing treat-ment (n ¼ 17 [63.3%], in the PE group versusn ¼ 11 [39.3%] in the NS group; c2 ¼ 3.08, df ¼ 1,p ¼ .079).

No significant differences were observed be-tween the 2 groups in the mean number of ther-apy sessions received by patients (7.37 [4.7] in thePE group versus 6.75 [4.94] in the NS group) orby parents (8.93 [4.07] in the PE group versus6.86 [4.82] in the NS group).

Adherence to Pharmacological TreatmentNo differences were observed between the groupsregarding antipsychotic medication measured inchlorpromazine (CPZ) equivalents30 at baseline(Table 1) or after treatment (PE, 234.28 [367.49];NS, 1805.24 [7538.59]; p ¼ .622).

t Baseline

PE NS

p Value% n %

1.34 16.5 1.45 .8859.3 18.0 64.3 .7092.6 24.0 85.7 .14

33.3 12.0 42.9 .4625.9 9.0 32.1 .5240.7 7.0 25.0 .21

7 4,007.11 345.28 506.16 .3940.7 11.0 39.322.2 5.0 17.918.5 5.0 17.97.4 5.0 17.91.0 3.63.7 1.0 3.6

rpromazine; NS ¼ nonstructured intervention; PE ¼ psychoeducational

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Intragroup analyses revealed a significant de-crease in the dosage of antipsychotics (CPZequivalents) during the treatment phase in the PEgroup (z ¼ –2.109, p ¼ .035). In the NS group, theantipsychotic dosage remained stable (z ¼ –1.067,p ¼ .286).

According to the results of high-performanceliquid chromatography, at baseline, 17 patientsin the PE adolescent group (63%) were takingtheir medication as prescribed and 9 (33.3%) werenot. One patient was not prescribed antipsychoticmedication. In the NS group, 14 patients (50%)were taking their medication as prescribed, and 6patients (21.4%) were not; in 7 cases (25%), thesample could not be extracted; and in 1 case(3.6%), the patient was not prescribed antipsy-chotic medication.

After the intervention, 14 of the 25 patientsin the PE group (51.9%) were taking their medi-cation as prescribed and 1 (3.7%) was not. Thesample was not processed in 7 cases (25.9%), and3 patients (11.1%) were not taking antipsychoticmedication. In the NS group, 12 of the 26 patients(42.9%) were taking their medication as pre-scribed, 1 (3.6%) was not, 11 case samples (39.3%)were not processed, and 2 patients (7.1%) werenot taking antipsychotic medication. No differ-ences were recorded between the 2 groups eitherat baseline or after the intervention.

Symptoms and Functional OutcomesWe observed statistically significant differencesbetween the 2 groups in the negative subscale of

TABLE 2 Symptoms and Functional Outcomes

Pretreatment Posttreatment

Mean SD Mean SD

PANSS PositivePE 14.77 8.22 10.72 14.33NS 16.92 9.10 11.77 3.93

PANSS NegativePE 16.55 7.27 12.84 7.87NS 17.03 7.42 15.81 6.37

PANSS TotalPE 61.85 23.37 50.29 19.28NS 69.00 27.71 55.35 17.39

GAFPE 64.37 18.79 73.92 14.33NS 58.46 19.02 66.31 15.23

Note: Boldface p values indicate significance. GAF ¼ Global Assessment oNegative Syndrome Scale; PE ¼ psychoeducational intervention.aWilcoxon test.bManneWhitney test.*p < .05; **p � .01; ***p � .001.

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the PANSS. The PE group showed a greater re-duction in negative symptoms after treatmentthan did the NS group (Table 2). A medium effectsize for improvement in negative symptoms wasobserved (r’ ¼ 0.41). There were no differencesbetween the groups in regard to the other PANSSscores (Table 2). The 2 groups improved in posi-tive symptoms and functioning after the inter-vention. However, only the PE group improvedin negative symptoms after the intervention.

Effects on RelapseNo differences were found between the groupsfor baseline data in terms of the number of hos-pitalizations, days of hospitalization, or number ofvisits to the emergency department. Patients inthe PE group had fewer visits to the emergencydepartment (c2 ¼ 3.62, df ¼ 1, p ¼ .039) in thepost-treatment assessment. A medium effect sizewas observed (r’ ¼ 0.42).

Similarly, a trend toward significance was ob-served regarding differences between the 2 studygroups in the number of post-treatment hospitaladmissions: 11% of patients were admitted in thePE group compared with 32% of the patients inthe support group (c2 ¼ 4.24, df ¼ 1, p ¼ .057).No differences were observed in the number ofdays of hospitalization between the 2 groups afterthe intervention (p ¼ .142) (Table 3).

Family EnvironmentThe patients’ ratings of their family environmentbefore and after the intervention are summarized

p Value Difference Between PE and NS (p Value)

.163b

.022a,*

.006a,*

.039b,*

.013a,*

.254a

.264b

.026a,*

.009a,*,***

.163b

.039a,*

.034a,*

f Functioning; NS ¼ nonstructured intervention; PANSS ¼ Positive and





in Table 4. We observed differences between the2 study groups in the FES subscale “active-rec-reational orientation,” which evaluates participa-tion in social activities. The recreational orientationscore for adolescents in the PE group increasedafter the PE.

No differences were observed between the2 study groups in parents’ ratings of their familyenvironment either at baseline or after theintervention.

DISCUSSIONThe present study shows that the short-termoutcome of early-onset psychosis was improvedby implementing a comprehensive psychoeduca-tional program early in the course of the disease.Our results shows that patients enrolled in the PEgroup had fewer visits to the emergency depart-ment, a reduction in the number and intensity ofnegative symptoms, and more active-recreationalinvolvement than patients in the NS group.

Relapse PreventionNaturalistic long-term follow-up studies haveshown that the early course of psychosis is char-acterized by relapses. Up to 80% of patients withfirst-episode psychosis experience a relapse within5 years of remission of the initial episode.31-34

Recurrent episodes are associated with highercosts in terms of personal and family suffering,resource consumption, and economics. Relapseswere related to poor prognosis35,36 and are likelyto interfere with the social and vocational devel-opment of young persons.3 Therefore, early in-tervention for first episode psychosis has a majoremphasis on reducing the number and severity ofrelapses.

TABLE 3 Outcome of Relapse

Relapse

Posttreatment

PE n ¼ 25 NS n ¼ 26 p Value

Patients hospitalized,n (%)

3 11.1 9 32.1 .057a

Days hospitalized,mean (SD)

4.08 13.03 7.42 13.64 .142b

Patients visited EDvisits, n (%)

4 14.8 11 39.3 .039a,*

Note: Boldface p value indicates significance. ED ¼ emergencydepartment; NS ¼ nonstructured intervention; PE ¼ psychoeduca-tional intervention.ac2 test.bManneWhitney test.*p � .05.



A recent meta-analysis on the efficacy of avail-able interventions for the prevention of relapsein young persons who experienced a first episodeof psychosis observed that specialized programsfor this condition were more effective in pre-venting relapse than was treatment as usual.37

Such programs usually take the form of asser-tive outreach programs (cognitive behaviortherapy, medication, family support) that includea combination of interventions in which familypsychoeducational groups are a fundamentalcomponent.15,38 It is precisely the combination ofspecific elements that makes them more effective(higher intensity of treatment than 1 interventionalone). However, when studies compared the ef-ficacy of 2 isolated modalities of intervention(without being integrated into a broader treatmentpackage) in relapse prevention, no differenceswere found,39,40 although, overall, psychologicalinterventions are more effective than treatment asusual.

In our study, patients who participated in thePE group had fewer visits to the emergencydepartment than patients in the NS group; thisobservation is relevant in terms of relapse pre-vention. The PE might reduce the number ofcontacts with the emergency services throughimproved problem-solving strategies within thefamily, as it was specifically designed to em-power families in conflict resolution to face crisissituations more efficiently. With regard to theimplications of the use of written material in theresults, it is important to bear in mind that, inthe PE group, the psychoeducational materialincluded 3 chapters about medication, side ef-fects, and crisis management; these topics werethen discussed in the problem-solving strategygroups. The NS group had the opportunity to askquestions about any topic that they consideredimportant during the group sessions. In fact,some participants in the NS group demandedmore information about these issues. In contrastto PE group therapy, the information in the NSgroup was transmitted differently, according tothe demands of participants and did not follow awritten guide, as in the case of the PE group. Thisdifference might be related to the number of visitsto the emergency department, with more patientsin the NS visiting the emergency departmentbecause of poorer understanding of medicationside effects.

The number of visits to the emergency de-partment is 1 way to measure relapse, evenwhen the patient is not hospitalized. However,

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TABLE 4 Patients’ Perceptions of Family Environment

Characteristics

Pretreatment: FES, Mean (SD) Posttreatment: FES, Mean (SD)

PE NS p Value PE NS P Value

C 44.35 (7.57) 41.74 (10.20) .519a 44.50 (7.27) 43.00 (9.50) .687a

EX 49.35 (9.73) 48.17 (9.95) .638a 49.13 (8.99) 46.41 (9.73) .389a

CON 52.52 (7.32) 55.61 (10.34) .276a 51.13 (7.59) 54.11 (9.82) .352a

IND 46.13 (9.72) 44.35 (10.18) .623a 47.44 (8.54) 49.00 (6.59) .618a

AO 45.48 (9.10) 50.09 (6.61) .051a 47.27 (5.95) 49.59 (8.41) .535a

ICO 49.43 (10.21) 46.43 (9.35) .321a 48.81 (12.75) 49.76 (8.18) .584a

ARO 55.57 (8.14) 55.09 (7.89) .713a 61.43 (7.37) 55.76 (7.36) .035a,*

MRE 45.09 (8.11) 48.13 (8.07) .320a 47.75 (6.71) 45.76 (10.45) .336a

ORG 47.52 (10.59) 46.83 (11.62) .982a 50.56 (8.39) 47.29 (10.28) .463a

CTL 50.52 (8.19) 51.74 (7.82) .582a 49.31 (7.63) 52.88 (7.44) .191a

Note: Boldface p value indicates significance. AO ¼ achievement orientation; ARO ¼ active-recreational orientation; C ¼ cohesion; CON ¼ conflict;CTL ¼ control; EX ¼ expressiveness; FES ¼ Family Environment Scale; ICO ¼ intellectual-cultural orientation; IND ¼ independence; MRE ¼ moral-religious emphasis; NS ¼ nonstructured intervention; ORG ¼ organization; PE ¼ psychoeducational intervention.aManneWhitney test.*p � .05.

CALVO et al.

hospitalization is more expensive than visits tothe emergency department, and can increasepersonal and family suffering and resource use.We did not find statistically significant differ-ences between the PE and NS groups duringfollow-up because of the small sample size andbecause the NS group intervention was also apsychological intervention. In addition, frequentmonitoring in the NS group could have acted as aprotective factor; nevertheless, it is important tohighlight that the number of patients hospitalizedwas nearly triple that of the NS group (11.1%versus 32.1%).

Negative SymptomsNegative symptoms are associated with relapse,poor social and occupational functioning, cogni-tive impairment, lower subjective quality of life,and poor long-term prognosis.41,42 The decreasein the number and intensity of negative symp-toms in patients in the PE group suggests thatstructured psychotherapeutic interventions couldhelp to reduce symptoms that are refractory to ph-armacological treatments. Other studies that eval-uated structured interventions such as cognitivebehavioral therapy for first-episode psychosis43

and multiple-family groups in patients with sc-hizophrenia44 replicate this hypothesis.

Family EnvironmentAdolescents with mental illness may have altereddevelopmental skills, such as increased difficultysocializing with friends, attending school, and/orpursuing vocational goals. In an exploratory

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analysis, we obtained differences in “active-rec-reational orientation” in PE patients only after theintervention. This finding should be interpretedwith caution, but could indicate that adolescentsdevelop their ability to become involved in socialactivities while they are undergoing the PEintervention. We were not able to demonstratedifferences in the parents’ perception of thefamily environment between the 2 study groupsafter the intervention. The first direct exposure tosymptoms of mental illness may be difficult forfamilies to grasp, and a longer assessment periodis necessary before transformations can be de-tected in the family environment.

Treatment AdherenceClient engagement can be 1 of the biggest chal-lenges in group programs. The first stage of thedisease is difficult for both parents and adoles-cents, and the denial that they often feel mayadversely affect adherence to treatment.

No differences were found between the 2 studygroups with respect to the number of participantscompleting treatment. However, 60% of the NSgroup dropped out before finishing group ther-apy, compared with 37% of the PE group. Apotential explanation is that the PE approachprovides participants with a clear framework(structure and consultation material) that couldhelp them to improve their commitment to tr-eatment and contain their extreme emotionswithout “acting out” on them. Families mayhave dropped out because of the adolescents’lack of autonomy, which made it difficult for





them to attend the sessions without their par-ents in a city as large as Madrid, where trans-fers from home to hospital are usually long andexpensive. Some families do not have sufficienteconomic resources, and most of the parentshad to be at work when the sessions werescheduled. The fact that parents attended, onaverage, 1.5 more sessions than adolescentscould be because parents have a higher demandfor treatment.

Antipsychotic medication is an important co-mponent of treatment. Adherence to prescribedmedication was good at baseline and after theintervention in both groups.

This is a pilot study and subject to several limi-tations. First, the indicators used to assess relapseprevention, such as number of admissions orquantitative symptom scales, might not be ascomprehensive as the global impact on psychoso-cial functioning that a group intervention can pro-duce. Future studies should address this matter byincluding coping skills or well-being questionna-ires. It would be interesting to conduct qualitativeresearch regarding the above-mentioned issues.Second, we performed a short-term follow-upassessment. Data on the long-term effects of theintervention are necessary. Third, not consideringAxis II pathology is also a limitation of the study.Fourth, the lack of control for the use of cannabis inadolescents might constitute a limitation. Finally,the small sample size may have precluded findingmore significant differences between the groups(with trends toward better outcomes in the PEgroup).

In conclusion, the PIENSA program is a com-prehensive pioneer intervention and pilot studyin Spain. It centers on problem-solving strategiesfor adolescents and their families, and is thereforeinteresting in terms of research and of its suit-ability for clinical practice. The present studyshows that a comprehensive PE might help ad-olescent patients and their families to managecrises, to improve negative symptoms, and toincrease patient involvement in social activities.



Such an intervention would be of the utmostimportance in clinical practice, as it precedes so-cial and functional recovery. &

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Accepted March 7, 2014.

Drs. Calvo, C. Moreno, Arango, Mayoral, and Ms. S�anchez-Guti�er-rez are with Hospital General Universitario Gregorio Mara~n�on Schoolof Medicine, Universidad Complutense, Instituto de Investigaci�onSanitaria Gregorio Mara~n�on (IiSGM), and Centro de Investigaci�onBiom�edica en Red de Salud Mental (CIBERSAM), Madrid, Spain.Dr. Rapado-Castro is with Hospital General Universitario GregorioMara~n�on School of Medicine, Universidad Complutense, IiSGM,CIBERSAM, Orygen Youth Health Research Centre, Centre for YouthMental Health, and Melbourne Neuropsychiatry Centre, the Universityof Melbourne, and Melbourne Health, Australia. Dr. M. Moreno iswith Gipuzkoako Osasun MentalekoSarea, Red de Salud Mental deGuipuzcoa, San Sebastian, Spain. Dr. Ruiz-Sancho is with VocAcci�onDirector-Group Processes and Institutional Consulting, Madrid, Spain.

This work was supported by the Spanish Ministry of Economy andCompetitiveness, Instituto de Salud Carlos III, CIBERSAM, the MadridRegional Government (S2010/BMD-2422 AGES), the EuropeanUnion Structural Funds, Fundaci�on Alicia Koplowitz, Fundaci�on MutuaMadrile~na, and a predoctoral fellowship award from Gobierno de LaRioja, Spain (A.C.).

The authors thank all participants in this study: the adolescents, families,and the team members of the Programa de Intervenci�on en PsicosisAdolescente (PIENSA) program. The authors are grateful to MarioAlvarez-Jimenez, PhD, of Orygen Youth Health Research Centre, Uni-versity of Melbourne, Australia, for advice on an earlier version of thismanuscript and to Manuel Desco, PhD, of Universidad Carlos III,Hospital General Universitario Gregorio Mara~n�on (HGUGM), andCIBERSAM, Madrid, Spain for advice on data analysis.

Disclosure: Dr. Calvo has received a predoctoral fellowship award fromGobierno de La Rioja, Spain, and a grant for short-term placementsfrom IiSGM. Dr. Rapado-Castro has received a Sara Borrell HealthResearch Fellowship from Instituto de Salud Carlos III, Spanish Ministryof Economy and Competitiveness, an Alicia Koplowitz research grant,and a short-term fellowship from the Alicia Koplowitz Foundation. Dr. C.Moreno has served as a consultant to Janssen. Dr. Arango has servedas a consultant to or has received honoraria from AstraZeneca, Bristol-Myers Squibb, Janssen-Cilag, Lundbeck, Otsuka, Pfizer, Roche, Servier,and Schering-Plough. Ms. S�anchez-Guti�errez has received a HealthResearch Predoctoral Fellowship grant (PFIS) and a grant for short-termplacements, both from Instituto de Salud Carlos III, Spanish Ministry ofEconomy and Competitiveness. Drs. M. Moreno, Ruiz-Sancho, andMayoral report no biomedical financial interests or potential conflicts ofinterest.

Correspondence to Ana Calvo, PhD, Child and Adolescent PsychiatryDepartment, Instituto de Investigaci�on Sanitaria Gregorio Mara~n�on(IiSGM), Hospital General Universitario Gregorio Mara~n�on, CIBERSAM,C/ Ibiza 43, 28009 Madrid, Spain; e-mail: [email protected]

0890-8567/$36.00/ª2014 American Academy of Child andAdolescent Psychiatry

http://dx.doi.org/10.1016/j.jaac.2014.04.004

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