CHAPTER-I INTRODUCTION In modern concepts

CHAPTER-I
INTRODUCTION
In modern concepts, mental health is not merely absence of mental illness. Some psychologists have defined mental health as the ability of the individual to make personal and social adjustments. These adjustments relate to one’s daily life in relation to others, at home and at work. Health in its modern concepts as defined by WHO implies complete physical, mental, and social well being and not merely an absence of diseases. Mental health contributes to physical health and vice-versa.

In India, the family is an inevitable part of the entire course of the illness that affects its members. More than 70% of the users living and experiencing the illness in its several ways of family joys, sarrows, emotions and rivalries, politics and economics. Mental health statistics in India, the treatment gap in even severe mental disorders is approximately 50%. In case of common mental disorders it is over 50%. One in a 5 has some sort of emotional and behavioral problems. Burden of these disorders is likely to increase to 15% by 2020 (World health Report, 2001). More than 70% of mentally challenged patients live with their families and family is the 24 x 7 care provider. Hence unless the family base is strengthened, the care and rights of the mental patients are likely to be compromised irrespective of the national programmes by the Govt. of India. World health organization estimates that 10% of the world’s population has some form of mental disability and 1% suffers from severe incapacitating mental disorders. Community based surveys conducted during the past two decades in India showed that the total prevalence of psychiatric disorders was around 5.8%. Schizophrenia is a serious disorder of the mind brain but it is also highly treatable, although there is no cure (as of 2007) for schizophrenia, the treatment success rate with antipsychotics medications and psycho-social therapies can be high. If the appropriate level of investment is made in research, it has been estimated that a cure for schizophrenia could be found within 10 years (by the year 2013). Traditionally, however, schizophrenia has only received a small fraction of the amount of medical research dollars that go into other serious diseases and disorders.

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Schizophrenia is one the most costly and inadequately treated mental illness, its prevalence across life span and lack of compressive and effective treatment expand its maximal morbidity. One in 100 people in the world has the illness of schizophrenia (Torry, 1998). Thus about 40 million families worldwide have a family member with the disorder (Walsh, 1985).The emotional and physical losses clients and families experience are tragic (Andresean, 1991: Mueser et al, 1992).

The main aim of the study is to investigate the effectiveness of the psycho- education on schizophrenia for caregivers of patients with schizophrenia on perceived burden and knowledge regarding schizophrenia of caregivers. In this chapter, firstly, the concept of Schizophrenia and history of Schizophrenia, definition of Schizophrenia diagnostic criteria and subtypes of Schizophrenia, epidemiology and etiology will be presented. Then the burden and knowledge regarding Schizophrenia of caregivers, the relationship between Schizophrenia relapses were presented. The scope of the study was presented by in the aspect of psycho-education intervention, concept, history, how it importance was presented. Finally, concept and procedure of research work will be revealed.

SCHIZOPHRENIA
1.1.1 Early concept
Historically, the most ancient document on Schizophrenia like illness is the one by charka, in Ayurveda, written, about 33 centuries ago, which described the patient as one “who is gluttonous, filthy, walks naked, has lost his memory and moves about in an uneasy manner”(TN Srinivasan, 2008).

Accounts of Schizophrenia like syndrome are thought to be rare in the historical record before 19th century, although reports of irrational, unintelligible or uncontrolled behavior were common. A detailed case report in 1797 concerning James Tilly Mathews, and accounts by Phillipe Pinel published in 1809, are often regarded as the earliest cases of the illness in the medical and psychiatric literature. Schizophrenia was first described as a distinct Syndrome by Benedict Morel in 1853, termed “demence precoce” (literally early dementia).The term dementia praecox was used in 1891 by Arnold Pick in a case report of psychotic disorder. In 1895 Emil Kraepeline introduced a broad new distinction in the classification of mental disorders between dementia praecox and mood disorder.

One outcome of such an observation was the approach to diagnosis based on symptoms, rather that outcome, adopted by Eugen Bleuler, he coined the term schizophrenia which translates roughly as “Splitting of the mind” and comes from Greek roots Schizein (“to split”) and phren- (“mind”) in 1908 and intended to describe the separation of function between personality, thinking, memory and perception. Bleuler described the main symptoms as 4 A’s; flattened Affect, Autism, impaired Association of ideas and Ambivalence. The core of the disorder which underlie the clinical manifestations like delusions and hallucinations (TN Srinivasan, 2008).1.1.2 Recent Concepts
The boundaries of Schizophrenia have expanded and contracted during this century. This variability of Schizophrenia has thus provided a fertile ground for the proposal of several diagnostic criteria. At least 15 such criteria are in use. Each of these diagnostic systems was validated by its proponents claiming that they identify the disorders. One can perceive in the last 2 decades and polarization of diagnostic approaches towards the American DSM criteria. The ICD system of WHO is probably the only contender at an international level to the DSM system. The 10th revision has taken on much of the character of DSM criteria. During this century, the definition of schizophrenia has travelled a full circle starting from Kraepelin to DSM-IV. The other choice of having varied description of the disorder is as much handicapping as one will not know if the same disorder is being studied across the world (TN Srinivasan, 2008).

1.1.3 Definition of Schizophrenia
Schizophrenia is initially defined by Emil Kreaplin (1856-1926) who suggested the first comprehensive definition of Schizophrenia by using the term dementia praecox (Stone, 2006). In referring to mental detoriation. He also emphasized the family history, temperament, premorbid personality to distinguish between the dementia praecox and manic depressive disorder (Kreapline, 1919, in Mckee 1996). Eugen Bleuler (1857-1939) he suggested the term Schizophrenia emphasizing the “splitting of the mind” and focused on symptoms rather than the prognosis to complement Kreapling’s description. He described a group of symptoms including affective blunting, autism, a violation, impaired attention and ambivalence as “fundamental” to the disorder. His fundamental symptoms were widely accepted as 4 A’s (associations, affective flattening, autism, ambivalence) of Bleuler and today they are still used in clinical practice (Bleuler, 1911).

A German Psychiatrist Kurt Schneider (1887-1967) defined a group of delusions and hallucination and considered them to have “first rank” significance in the disorder but not basic to the disorder (Schneider, 1979). The First rank Symptoms are thought insertion, thought withdrawals, thought broadcasting voices communicating with or about the person and delusions of being externally controlled. Although an exact definition of Schizophrenia still evades medical researchers, the evidence indicates more and more strongly that Schizophrenia is a severe disturbance of the brain’s functioning. The schizophrenic disorders are characterized in general by fundamental and characteristics distortions of thinking and perception and by in appropriate or blunted affect. Schizophrenia is a chronic, severe, and disabling mental disorder characterized by deficits in thought characterized by deficits in thought processes, perceptions, and emotional responsiveness (ICD-10, WHO, Geneva).
1.1.4 Diagnostics Criteria
According to the Diagnostic and statistical manual of mental disorders (DSM IV-TR), the disturbance should last for six months. In the first month, at least two of the following delusions, hallucinations, disorganized speech, disorganized or catatonic behaviors should be observed in addition to the negative symptoms (APA, 2007). International Statistical classification of diseases, F20-F29 Schizophrenia, Schizotypal and delusional disorders. The purposes for practical useful divide the symptoms into groups that have special importance for the diagnosis and often occur together a) thought disorder, b) Delusions (c) hallucinations (d) catatonic behavior, (e) negative symptoms. The normal requirement for diagnosis of Schizophrenia is that a minimum of one very clear symptom belonging to any one of the groups listed as (a) to (d) above or symptoms from at least two of the groups referred to as (b) to (c) should be diagnosed, in the first instance as acute Schizophrenia (F20-29) (WHO 2002).
1.1.5 Subtypes of Schizophrenia
According to ICD-10 and DSM- IV indentify the five subtypes of Schizophrenia which are Paranoid Schizophrenia, disorganized Schizophrenia, Catatonic Schizophrenia, undifferentiated Schizophrenia, and residual Schizophrenia. Paranoid Schizophrenia is defined by the features of delusions or auditory hallucinations, but without prominent disorganized speech or behavior, catatonic behavior or flat or inappropriate affect. Disorganized subtype of Schizophrenia is defined by the features of prominent disorganized speech or behavior and flat or inappropriate affect without catatonic behavior. Catatonic subtype of Schizophrenia is characterized by immobility that may include catalepsy or stupor, or apparently purposeless excessive motor activity, extreme negativism or mutism posturing, stereotyped movements, mannerisms or grimacing and echolalia and echopraxia. The defining features of undifferentiated Schizophrenia are active phase symptoms without the prominent symptoms of the paranoid disorganized or catatonic types. Lastly, in residual type there are no prominent active phase symptoms, nor gross disorganization or catatonia but there may be negative symptoms or attenuated active phase symptoms.

There are two replicable psychopathological domains of symptoms; there are positive and negative symptoms domains in Schizophrenia. Many systems have been proposed to define positive and negative symptoms. In these systems, generally, the positive symptoms are acknowledged as hallucinations delusions, conceptual disorganization, grandiosity, persecution and hostility. Whereas the negative symptoms are acknowledged as blunted affect, emotional withdrawal, poverty of speech and difficulty in abstract thinking (Andreasen 1995).

1.1.6 Epidemiology of Schizophrenia
1.1.6.1 Incidence and prevalence
The distribution of a disorder in a given population is measured in terms of incidence and prevalence. Incidence refers to the proportion of new cases per unit of time (usually one year), while prevalence refers to the proportion of existing cases (both old and new). Incidence studies of relatively rare disorders, such as Schizophrenia are difficult to carry out. Survey have been carried out in various countries, however and almost all show incidence rates per year of Schizophrenia in adults within a quite narrow range between 0.1 and 0.4 per 1000 population. This has been the main findings from the WHO 10- country study. ( Jablensky et al., 1992).
Taking into account difference in diagnostic assessment, case-finding methods and definition of adulthood, we can say that the incidence of Schizophrenia is remarkably similar in different geographical areas (Warner and de Girolama 1995). Exceptionally high rates that emerged from the epidemiological catchment Area. Study in the United States may be due to based assessment. (Tien and Eaton,1992). Although few data are available on incidence in developing countries, early assumptions on consistently lower rates outside the Western industrialized countries have not been confirmed by recent, through investigation in Asian countries (Linebal, 1989, Jablensky et al, 1992, Rajkumar et al, 1997).

High incidence figures have recently been reported in some disadvantaged social groups especially ethnic minorities in Western Europe, such as Afro Caribbean communities in the United Kingdom and immigrants from Surinam in the Netherlands (king et al, 1994, Selten and Sijben, 1994).

The WHO has undertaken three multicentre studies and epidemiology of Schizophrenia across cultures. A number of investigations have been carried out in the third world countries, a majority of those in India and China. India and Sri Lanka have a higher prevalence rate of Schizophrenia.
India, a more recent one has been the longitudinal “study of functional psychoses in an urban community”(SOFPUC) in Madras. The prevalalence rate of Schizophrenia was estimated as 2.62 per 1000 (265 uses in a population of 1.01.229). The age corrected rate was 3.98 per 1000 (Padmavathi R, 1988). There is no consistent rural-urban difference in the frequency of the illness. A pattern of increased prevalence of Schizophrenia in the rural area contangious to a major city in North India has been reported (Dube KC, Kumar N, 1972). Factors, influencing the frequency of Schizophrenia, such as age, sex, marital status, social class, effect of seasonality have been discussed in epidemiological studies. An earlier age of onset has been noted in males in the Western studies whereas no such differences have been demonstrated in India. Incidence rates reported from India have been higher than in the west. The significant ones from India have been from West Bengal, Chandigarh and Madras. The lack of incidence studies in India could be due to the absence of poor health services delivery, lack of case registers and cost effectiveness of conducting a community survey (JN Vyas, Niraj Ahuja, 2008).

The number of people with Schizophrenia around the world can be estimated at about 29 million, of whom 20 million live in developing or least developed countries.(Padmavathi R, Rajkumar S, et al 1988). Schizophrenia is serious disorder of the mind and brain. It is commonest disorder among other mental illness. It ranks among the top ten causes of disability in developed countries worldwide. In India 4.3 to 8.7 million people a rough estimated based on population were suffers with Schizophrenia (NIMH 2008).

Schizophrenia is considered the most chronic, deliberately and costly mental illness. People with the condition have a 50 times higher risk of attempting suicide than the general population. 90% of people with Schizophrenia are untreated in developing country (NIMH 2008).

1.1.6.2 Causes and Risk factors for Schizophrenia
Today, the most acceptable etiologic model is accepted as “diathesis –stress model” which emphasizes the interaction between social factors and genetic, prenatal and premorbid factors according to this model, a person can develop Schizophrenia as a result of an environmental stress that interacts with an underlying predisposition in the individual. (Barrow clough, 1992)
Schizophrenia is acknowledged to have multiple etiological factors. Although genetic liability is the most important risk factor, neurodevelopmental, neurological, prenatal and social factors are also being investigated as possible causes that may play a role in the etiology of Schizophrenia (Eaton, 2006). One of the important causative factor was studied is family history which was found as an for leading the Schizophrenia (Sullivan, 2006) The incidence is 2% in third degree relatives, as first cousins, of an individual with Schizophrenia, 2-6% in second degree relatives as nieces/nephews; and 6-17% in first degree relatives, such as parents, siblings or children (Lewis and Lieberman, 2000).

Twin studies supported the relationship between genes and Schizophrenia they showed a 50% in monozygotic twins, and among dizygotic twins rate is about 15% (Lewis and Lieberman, 2000). There are several bio-chemicals that play a role in the etiology of Schizophrenia such as dopamine, serotonin, glutamate and GABA (Javitt, 2006). Risk Factors for Schizophrenia can be grouped according to Cooper (1978) in three categories. Socio-demographic characteristics like, lower social class, urban areas of developed countries, lower class neighbour-hoods, occupational hazards, poor maternal and obstestric care and high psychosocial stressors can play role in causing Schizophrenia. Predisposing factors, genetic once are most important. The third risk factors like interpersonal, social and cultural variables postulated as precipitating factors.

1.1.7 Prognosis of Schizophrenia and factors related to relapse
Early intervention and early use of medications lead to better medical outcomes for the individual. The earlier same one with Schizophrenia is diagnosed and stabilized on the treatment, the better the long-term prognosis for their illness. Then suicide is growing problem and teens with Schizophrenia have approximately 50% risk of attempted suicide. Antipsychotic medications are the generally recommended treatment for Schizophrenia. If medication for Schizophrenia is discontinued, the relapse rate is about 80% within 2 years, with continued drug treatment; only about 40% of recovered patients will suffer relapses. Approximately 6% are house less, 6% live in jails, 5 to 6% live in hospitals, 10% live in Nursing homes, 25% live with a family member, 28% are living independently and 20% live is supervised housing, most Schizophrenia patients are never able to work they must be supported for life by Medicaid and other forms of public assistance. People with Schizophrenia have a 50 times higher risk of attempting suicide than the general population (NIMH 2008).

Pharmacological therapies play a role in the prognosis of Schizophrenia as an essential component of a comprehensive Schizophrenia treatment. Cessation of antipsychotic therapy for one month or more was considered to indicate that patient was not continuous medication. Patients who did not take medication continuously showed relapse rates of 48% at the one year follow up, 82% at the end of the five years life time (Kissling, 2001).

Mental health resources in India are limited. The treatment primarily focused on symptoms with drugs. Rehabilitation and psychological interventions are frequently neglected and rarely available (Ranga swamy Thara & Sujit John 2006). There have not been found methodologically refined, prospective, follow-up studies of schizophrenia in India. Mortality rates were quite high with the average age of death being 34.2 years, much below the average Indian life span of 60.5 years in 2002. Suicides accounted for 7 out of 16 deaths (SCARF-Rangaswamy Thara 2005). Schizophrenia was found to be the population with the highest re-admission rate. Although such patients received drug therapy and psychological and social support in hospital.Once they were discharged, many of these treatments ceased. Many patients did not maintain follow-up appointments and preferred to return to routines they had followed prior to hospitalization. Returning for follow up-care or maintaining medication was often viewed as a sign of weakness or illness by both patients and their families. The hospital professional teams become very aware that the families and friends lack of knowledge about Schizophrenia and its treatment resulted in misunderstandings that triggered the Schizophrenia stress state making re-admission necessary.
First there is a stigma attached to the mental illness, especially Schizophrenia, that often in hit, family’s willingness to talk about their thoughts and feelings, second as complete biological factors of the illness interfere with the memory and language system, which in turn affects the process of sharing information by the all family member (Deborah Antai otonga 1995).

The care givers distress and coping strategies of Schizophrenia clients were assessed and reported that there is a connections between distress and coping strategies of relatives, expressed motions, distress of patients caused by family life and their influences on the cause of Schizophrenia with the focus on their prognostic values. One major issue was investigated that question about distress factors and coping behavior of low and high emotional exhausted in families. (Schermman TE 1995)
The study investigated to know the burden on the families with Schizophrenia; the burden, the coping strategies and the social network of a sample of 236 relatives of patients with Schizophrenia living in fire European countries, were explored by well validated assessment instruments. In all centers relatives experienced higher levels of burden when they had poor coping resources and reduced social support. These data indicate that family burden and coping strategies can be influenced by cultural factors and suggest that family interventions should have also a social focus, aiming to increase the family social network and to reduce stigma (Magliano.I., Fadden G, 1998).

This study investigates that the relatives beliefs about the causes of Schizophrenia, based on a representative survey among the members of German and Australia associations of relatives of mentally ill people, this paper examines the beliefs commonly on held by relatives of persons suffering from Schizophrenia concerning the causes of this disorder. A comparison of the information gathered in the course of this survey with the results of representative survey conducted among the general public in Germany shows that relatives will usually look to biological factors when searching for the cause of Schizophrenia, while the general public tends to Psychosocial factors, especially stress related factor in order to explain the development of this illness we attribute this discrepancy to relatives greater exposure to the knowledge of psychiatric experts as well as their having to deal with their own feelings of guilt (Angermeyer M.C, Mastchinger H. 1996).

1.2 ROLE OF CARE GIVERS IN MANAGEMENT OF SCHIZOPHRENIA
Every human being is born brought up in family; it is an architect of an individuas of personality. A family prepares an individual to perform this multiplicity of roles, which requires stable states of mind and good family environment. Historically, the proposition that family was the cause of a child’s developing Schizophrenia based primarily on the concepts developed by Bateson et al .(1956) on the “double bind” Lidz (1963) on “marital skew” and Lynne and Singer (1963) on “pseudo mutuality”; these concepts created an extremely non-therapeutic and destructive atmosphere between hospitalized clients and their family members and mental health professional.
The past few decades have seen a gradual change in the philosophy of management of Schizophrenia with increasing attention to community care of the patients and the involvement of the family there has been much consideration on understanding the impact of Schizophrenia on the family and the effects of a care giving role. Early psychogenic models of the family members there is a progressive acceptance of an interactive model between family stress and patient functioning. The knowledge of how family adjusts to or copes with a members illness may assists the nurse in understanding these needs of the family during a time of crisis and facilitate adaptive responses in family members (Perry, 1983).

1.2.1 Expressed emotions in care givers
Emotional climate within the family is powerful predictor of relapse and remission in Schizophrenia disorder. High level of expressed emotions is related to higher relapse rates and poorer out come in Schizophrenia. The concept of Expressed emotions has five dimensions which are criticism, hostility, emotional over-involvement, warmth and positive remarks only the first three were found to be related to Schizophrenia relapse. The most popular assessment of expressed emotions is conducted with an interview, The Camber well Family Interview, will be described in the subsequent section. Here, it is important to note that the assessment done with interviews evaluates both the content of the interview and the tone of voice in determining the expressed emotions components.

Several studies across the world have provided between expressed emotions levels and patients relapse. Trans-culturally, high expressed emotions is also seen to predict relapses in mixed races in the United States and in India (R Padmavathi, 1999). Much of the recent psychosocial interventions aim at reducing expressed emotions as a means of decreasing relapse rates (Hograty G .E, 1986).

1.2.2 Distress and Burden in caregivers
Family members of patients with Schizophrenia experience a lot of subjective distress. Several studies have found that nearly two thirds of the families of Schizophrenia experienced some behavioral disturbances, with nearly 15% expressing severe distress (Birchwood M.J. 1983).
Diverse sources of difficulties reported by families included uncertainty in handling patient’s inactivity, confusion about unpredictable behaviors, worries about the patient’s long term care, etc.,(Creer C, 1974).

The concept of family burden was first clarified as subjective and objective burden (Hoenegy, 1966). Objective burdens referred to the adverse effects on financial costs, health of the care giver, intrusion and disruption of family lives, etc. Subjective burden was defined as a sense of loss, grief, and guilt and anxiety due to abnormal behavior in the primary care giver. Subjective burden was described as affective burden (Doll, 1976).

The Family Burden Scale was developed to measure the felt burden in family members of psychiatric patients. Six sub-scales are used to elicit the objective burden in career’s focusing on areas like financial burden, disruption of family interaction, family leisure and effect on physical and health of others. It was focused that in the Indian population, financial cost was most commonly experienced as ‘felt burden’. Despite limited data on the reliability and validity of the this instrument, it has been widely used for research purposes in several studies(Pais, Kapur R.L. 1981). Various studies showed that family care givers of persons with a severe mental illness suffer from significant stress, experiences high level of burden and expressed emotions often receive inadequate assistance from mental health professionals. An expressed emotion contributes one of the main causes for relapse in psychological disorder.

Treatment of Schizophrenia is focused primarily on the management of symptoms with drugs. Rehabilitation and Psychosocial interventions are frequently neglected and rarely available. Among psychological interventions, psycho-education is one type of intervention is used to treat schizophrenia patients as well to caregivers.

1.3 PSYCHO-EDUCATION
1.3.1 Concept of Psycho- Education on Schizophrenia
Early theories of the family as an etiological factor give rise to a number of intervention modalities, predominantly psychoanalytic in approach and aimed at correcting the hypothesized family pathology. This resulted in generating a lot of guilt and shame in the family members.

The painful experience of the family members was augmented by such approaches, such measures failed to provide the care–givers with practical solutions to handle the problems (Beels CC,1982).

The growing acceptance of the interactive model of family stress and patient functioning has led to the development of educational and psychotherapeutic interventions. The main component of educational programs have been educating the family members about the illness, reducing the stress in families, and teaching the family problem focused coping approach.

The psycho-education was first noted in medical literature, in an article by John E Donley “Psycho therapy and education” in the journal of Abnormal psychology. Thirty years later that the first use of the word psycho education appeared in the medical literature in title of the book “The Psycho educational clinic” by Brain E Tomlinson, New-York., N Y Macmillan Co. The population and development of term psycho education into its current form is widely attributed to the American researcher (M Anderson in the context of treatment of Schizophrenia). Psycho Education can take place in one to one discussion or in groups and by any qualified health educators as well as health professionals such as nurses, social workers, psychologists and physicians. It can be explained systematically used and structured forms of information which are meant for informing the client and their family members. Psycho education can be provided in different forms, are lectures, in groups, Consultation, counseling. Psycho education can be group based family based, parent based or individually implicated. It can involve indirect ‘free flowing’, discussing, a certain amount of structure needs to be involved in order to make sure the program stay on track. Each psycho education will have specific goals and content. The structure of psycho education is determined by whether the program involves the clients or family members. (Virtual media.com ; Wikipedia, Psycho education).1.3.2 Role of Psycho-education on caregivers of clients with schizophrenia.

Nurses and mental health professionals need to collaborate with patients and families to educate and assist them in understanding and coping effectively with mental illnesses. A number of families experience feelings of hopelessness, self blame, embarrassment, anger, and sense of loss when faced with mentally ill member. Clients with schizophrenia often mirror these feelings. Additionally, patients and caregivers of patients with schizophrenia experiences pervasive feelings of low self esteem, ineffective coping skills, cognitive impairments and lack of support. Families often look to nurses for answers and empathy in dealing with these issues. This study showed that 487 family members believed that the illness factual information about illness, socialization, building insight of the family and increased understanding and awareness of the biological basis of mental illness reduced the stigma of mental illness. (Seely, 1992)
Falloon et al (1981) designed a study to compare family therapy and individual therapy in reducing expressed emotion level of the families and changing their critical and negative attitude towards patients. The family therapy sessions were conducted at home and psycho education for Schizophrenia; problem solving skills and communication skills were given to the families and their patients. The results of this study demonstrated that the patients who did not participate in family therapy sessions had much higher relapse rates than the patients who participated in the program for 9 and 24 months follow-up periods. The families improved at problem solving skills and coping strategies after the intervention program and reported that their subjective burden was reduced. (Barrow clough and Tarrier, 1984. 1992)
Chien wt et al (2003) investigated the study reveals that educational needs of families caring for Chain’s patients with Schizophrenia, The 204 samples was took by cross sectional survey at Hong Kong. Family members caring for relative with Schizophrenia. The modified educational needs questionnaire was used. The findings are the educational needs are more significantly importance.
Gutierrez – Maldonado, Caqueo-Urizar (2007), conducted a study with forty five care givers. A Psychoeducational family intervention group and a control group were compared. The family program was held once a week for 5 months. In the control group the care givers received standard intervention, caparisoning periodical meetings with the staff to monitor the effects of the medication. Burden was measured before and after the intervention. This study revealed that burden decreased significantly in the psycho educational group; means scores on the Zarit caregiver burden scale fell from 85-06 pre-intervention to 52-44 post intervention, while scores, fell only slightly in the control group, from 87-65 to 87-22. Treatment was especially effective in mothers and caregivers with lower educational levels. This intervention program for reducing care giver burden in developing Latin American countries was effective.
In family interventions, a mental health professional provides support and understanding of the illness for affected individual and family members.

They work together on planning treatment; provide mutual support and understanding of the disease. Family intervention gives the family insight into the symptoms that warn of an impending acute episodes so that medication may be adjusted with the aim of averting a relapse. Family interventions also help the family to cope with a chronically mentally ill members as well as reduce the burden faced by the families.

The family therapy adopted in the family ward at the National Institute of mental health and Neuro sciences (NIMHANS), Bangalore (India) is based on the system theory (Varghese M, 1991).
Psychoeducational Interventions planned and adapted based on family intervention and support in Schizophrenia, A manual on family intervention for the mental health professional developed by Mathew Varghese, Anisha Shah and GS Udaya Kumar, Family Psychiatric centre, NIMHANS Bangalore 2002. The manual comprises eleven chapters, chapters Introduction, Chapter II describes the basic theoretical knowledge about family interventions, chapter III describes skills and techniques that intervention worker should follow, chapter IV to IX describes the contents of the family intervention sessions, chapter X address certain relevant issues for the intervention worker, Chapter XI describes application of the family interventions through case vignettes, remaining chapter and modules briefs about outline of Intervention, module I and module II (Psycho-educational booklet), Bibliography, Appendix.
The investigator during her service in Psychiatric hospitals were observed that there were number of schizophrenia cases admitted to the hospitals and caregiver of patients with Schizophrenia were found inadequate knowledge about Schizophrenia management and also observed burden.

The investigator believes that caregivers are the best persons who can identify the symptoms as early as possible can bring the client to hospital for better treatment. If they obtain proper knowledge about Schizophrenia, they can assess the relative in time and will be able to prevent complications and relapses.

The investigator assessed knowledge and attitude of family of schizophrenic clients in her master level for partial fulfillment of M.Sc(N) degree course submitted to RGUHS, Bangalore, the study results were revealed and proved that greater need for psycho-education on schizophrenia to caregivers of patients with schizophrenia, made wide interest to select present study, which help to reduce the morbidity and mortality to a greater extents and also improve the prognosis and reducing relapses.

Therefore the aim of the present study is to investigate the effectives of the Psycho-education on Care givers of patients with Schizophrenia and burden’ of caregiver assessing Burden and knowledge regarding management of Schizophrenia by pre-test before implementing Psycho-education which was developed and modified based on Module II Psychoeducational booklet from A Manual on Family Interventions for schizophrenia for the Mental health professional developed by Mathew Verghese, 2002, from NIMHANS, Bangalore and validated experts, later post–tests will be administered ,and findings will be analyzed to test the hypotheses of present study.