Psychosocial Adaptation in Dealing with Psychosocial Problems on Family Caregivers of Schizophrenic Patients: A Systematic Review Adaptasi Psikososial dalam Mengatasi Masalah Psikososial pada Family Caregiver Pasien Skizofrenia: A Systematic Review

Schizophrenia is a serious mental disorder that requires long-term care and treatment. The treatment requires caregivers who may come from the family. A caregiver's daily tasks can be overwhelming, leading to psychosocial problems. This study aims to identify the effectiveness of psychosocial adaptation interventions in overcoming psychosocial problems in family caregivers of schizophrenic patients. This study used a systematic review approach. The literature search was sourced from five databases: Wiley Online Library, ScienceDirect, ProQuest, EMBASE, and Sage Journals. The keywords used were family caregiver, schizophrenia patient, psychosocial adaptation, and psychosocial problem. The results of a literature search obtained 448 articles then were screened with the criteria of articles published in 2018-2023, open access, full-text articles, original articles with a randomized controlled trial study design, discussing psychosocial adaptation interventions and psychosocial problems in schizophrenic family caregivers, and English. The


INTRODUCTION
Mental disorders are conditions of psychological dysfunction experienced by individuals related to the distress experienced (Stuart, 2013).Mental disorders globally reach 300 million diagnosed with depression, bipolar, dementia and schizophrenia (World Health Organization, 2022).Mental disorder cases in Indonesia increased in 2018 per 1000 households.There are 7 households with severe mental disorders (Riskesdas, 2018).Symptoms that appear in mental disorders are hallucinations, illusions, delusions, and disturbances in thought processes, thinking abilities, and behavior.One of the most common forms of mental disorders is schizophrenia.
Schizophrenia is a clinical condition characterized by cognitive, perceptual, and emotional changes that lead to changes in social behavior and personal functioning (Kaplan, H.I. Sadock, 2010;Mendes Braga et al., 2015).One-third of schizophrenia has occurred in developing countries of all countries in the world.Twenty million people experience schizophrenia worldwide (World Health Organization, 2019).In the United States, 1.1% of the population, or around 2.8 million adults, had schizophrenia in 2020 (World Health Organization, 2020).In Asia, the prevalence of schizophrenia in East, South and Southeast Asia reached 8 million people, 4 million people and 2 million people (Charlson et al., 2018).The prevalence of schizophrenia in Indonesia has increased to 7% per 1000 households compared to 2013 of 1.7% (Riskesdas, 2018).The high prevalence and increasing number of schizophrenia cases demand special attention in treatment management.
Long schizophrenia treatments may cause psychosocial problems for caregivers.Schizophrenia caregivers, in general, may be part of a family member known.The uncertain condition of schizophrenia makes family caregivers feel excessively stressed and burdened.Previous research explained that family caregivers needed special time to care for schizophrenia at home, with 71.2% of family caregivers providing an average of five hours of daily care.Longer care for it aligns with a higher stress level (Darwin P, 2013) because schizophrenic patients at home become a stressor for family caregivers (Zahid, M.A.;Ohaeri, 2013).
Other research found that the impact of caring for schizophrenia at home can make family caregivers experience stress and burdens, which include mental, social, and economic burdens (Suryaningrum & Wardani, 2013).The increasing burden felt by family caregivers creates conflict with schizophrenic patients due to the inability to care for them and the patient's condition.These conditions make family caregivers feel anxious, lack socialization, and disrupt sleep patterns daily (Wan & Wong, 2019).The high level of psychosocial problems experienced by family caregivers requires efforts to manage these problems through appropriate coping strategies and adaptation of family caregivers to the conditions they experience.
Coping strategies commonly used by family caregivers are seeking support from religion, social workers, community services, and therapy from health workers (Wan & Wong, 2019).However, apart from coping strategies, psychosocial adaptation skills are also important for family caregivers.
The process of psychosocial adaptation can occur when a change occurs, then proceed to adapt, is maintained, forms continuity, interacts, and exerts influence (Rodgers, B., 2000).However, in processes related to health problems, psychosocial adaptation occurs when individuals experience life changes related to health problems, demanding changes in roles and lifestyle.Previous research explained that psychosocial adaptability is related to family caregivers' quality of life and life satisfaction (Londono, Y. & McMillan, D.E., 2015).There is a need to strengthen psychosocial adaptation abilities in schizophrenic family caregivers.
Psychosocial adaptation of family caregivers is crucial in helping family caregivers survive and form resilience (Mathé, 2013).The resilience of family caregivers affects the ability to deal with stress and the burden of family caregivers in caring for schizophrenic patients (Zauszniewski et al., 2010).Low resilience is caused by inadequate knowledge, social stigma, stress, poor relationships and communication, and blaming behavior (Fernandes, J.B. et al., 2021).Family caregivers survive by adapting physically and psychologically to the stress and discomfort experienced (Mathé, 2013).
Based on the background above, the researcher is interested in conducting a systematic review to identify the effectiveness of psychosocial adaptation interventions in overcoming psychosocial problems in family caregivers of schizophrenic patients.

METHOD
This study used a systematic review approach with the PICO framework to formulate research questions.The researcher used covidence.orgto screen articles.The process of screening articles up to finding articles for a systematic review is documented in the PRISMA flowchart, as shown in Figure 1.The final results of screening articles based on title, abstract, and inclusion criteria obtained six articles that met as literature in this systematic review.The six articles obtained were then subjected to critical appraisal using the JBI Critical Appraisal Checklist for Randomized Controlled Trials (Barker TH; Stone JC; Sears K; Klugar M; Tufanaru C; Leonardi-Bee J; Aromataris E; Munn Z, 2023) the results obtained were that all articles were in grade A category (3 articles met the 100% YES answer criteria and 3 articles met the 96.15%YES answer criteria).The researcher then extracted data (Table 4) from the six met articles.

Randomized controlled trial
Family caregivers of patients with mental disorders (including schizophrenia) / Convenience sampling method then followed by randomization / 241 respondents.

Caregiver psychological burden
Intervention with a control group.The intervention group was given psychosocial adaptation therapy: Participatory care model intervention.The control group was not given any action.Pre-post tests were measured before and after the action and compared the results in the two groups.
There were significant differences in the burden experienced by caregivers between the control and intervention groups.The psychological burden felt by caregivers in the intervention group was lower than that in the control group.

Characteristics of the article
The articles used in this systematic review were published in the 2020-2023 range, and 50% originate from Iran.All articles were randomized controlled trial studies with each psychosocial adaptation intervention adapted to the psychosocial problems faced by schizophrenia caregivers.Table 5 is an overview of the characteristics of the articles included in the systematic review.

Characteristics of respondents in the article
In six studies, 898 schizophrenia caregivers who were informal caregivers from family members joined.In both the control and intervention groups, the average age of the respondents was in the late adult age group.The majority were women, had an upper secondary education level, were married, and were not/not yet working.Table 6 is an overview of the characteristics of schizophrenia caregivers from six studies.

Test the effectiveness of psychosocial adaptation interventions
The analysis in the six studies showed that psychoeducation, in a nutshell, could not reduce caregiver psychosocial problems, but other psychosocial adaptation interventions, such as A cognitivebehavioral conference call intervention (CBCC), A spirituality-based educational intervention, Enhancing Contact Model (ECM) intervention, the Participatory care model intervention, and emotion regulation training were significantly effective in overcoming caregiver psychosocial problems, including self-stigma, signs and symptoms of depression, anxiety, stress, psychosocial burden, emotions, feelings of worthlessness, and helplessness as presented in Table 7.

Code
Author/ Year

A1
Zhang Participatory care model intervention There were significant differences in the burden experienced by caregivers between the control and intervention groups.The psychological burden felt by caregivers in the intervention group was lower than that in the control group.
Schizophrenic patients require long-term care and regular uninterrupted medication.Therefore, caregivers are needed to accompany schizophrenia in carrying out care and treatment.Besides hospital care and treatment, schizophrenia requires care and treatment at home with caregiver assistance and support (Guan et al., 2016;Jagannathan et al., 2014).One of the ideal caregivers in assisting in treating schizophrenia patients is the family caregiver.As in the six articles reviewed, caregivers are informal caregivers from family members, totaling 898 family caregivers.
Family caregivers require support in doing their roles from health workers so that they are ready and trained in caring for patients at home and can deal with psychosocial problems that arise as a result of caring for schizophrenic patients at home (Stanley et al., 2017;Vermeulen et al., 2015;Winahyu & Hemchayat, 2015;Zeng et al., 2017).The roles of the family caregiver include providing direct care, assistance with daily activities, emotional and social support, and helping financially and meeting the daily needs of schizophrenic patients (Kamil, Saher Hoda, Velligan, 2019).From this role, family caregivers with schizophrenia are prone to experiencing psychosocial problems.Family caregivers with schizophrenia experience high psychosocial problems compared to family caregivers who care for patients with other chronic illnesses (Gupta et al., 2015;Stanley et al., 2017).These psychosocial problems include stress, psychological burden, frustration, feelings of anger, anxiety, and depression (Kamil, Saher Hoda, Velligan, 2019).This review showed that family caregivers experience self-stigma, signs and symptoms of depression, anxiety, stress, psychosocial burdens, emotions, feelings of worthlessness, and powerlessness.
Some family caregivers can adapt to these psychosocial problems, while others cannot (Ntsayagae et al., 2013).Therefore, schizophrenia family caregivers need optimal support to adapt to the psychosocial problems they experience.Among the aspects that can help family caregivers to adapt to psychosocial problems are stress management and improving the skills of family caregivers in finding sources of support (Kamil, Saher Hoda, Velligan, 2019).
A review of the six articles found that interventions that can improve psychosocial adaptation skills and overcome family caregiver psychosocial problems are adapted to the psychosocial problems they experience.These psychosocial adaptation interventions include the Mindfulness-based family psychoeducation (MBFPE) program to address the psychosocial burden of caregivers, stigma, stress, depression, and anxiety (Zhang et al., 2023).A cognitive-behavioral conference call intervention (CBCC) to treat caregiver signs of depressive symptoms (Vázquez et al., 2020).The spiritualitybased educational intervention to overcome depression, anxiety, and stress caregivers (Khosravi et al., 2022).Enhancing Contact Model (ECM) intervention to overcome caregiver self-stigma (Ran et al., 2022).Participatory care model intervention to overcome the psychological burden of caregivers (Zoladl et al., 2020).The emotion regulation training to overcome emotions, feelings of worthlessness, and caregiver helplessness (Behrouian et al., 2021).However, not all these psychosocial adaptation interventions can address psychosocial problems due to patient and family caregiver factors themselves.
Psychosocial adaptation in overcoming family caregiver psychosocial problems is related to identifying factors related to the psychosocial problem.Previous research explained that the psychosocial problems of family caregivers with schizophrenia are increasingly related to the characteristics of the patients themselves, where the patient is male (Souza et al., 2017), younger than family caregivers, diagnosed quite badly (Yu et al., 2017), repeated hospitalizations (Yazıcı et al., 2016), and long-term illness (Siddiqui & Khalid, 2019).Meanwhile, the psychosocial problems experienced by family caregivers are increasingly related to the characteristics of the family caregivers themselves, including those who are older than the patient (Souza et al., 2017;Yazıcı et al., 2016), female (Opoku-Boateng et al., 2017;Yu et al., 2017), low economic status (Siddiqui & Khalid, 2019;Yazıcı et al., 2016), and having other dependents besides schizophrenic patients at home (Souza et al., 2017;Yu et al., 2017).Thus, the characteristics of the patient and the family caregiver are related to the psychosocial problems experienced by the family caregiver with schizophrenia.
A review of the six articles found that in both the intervention and control groups, the average age of the respondents was in the late adult age group.The majority were women and did not/had not worked.This finding follows previous research that the patient is older than the patient, the family caregiver is female and has a low social status which is identified with an unemployed status which increases the psychosocial problems experienced (Opoku-Boateng et al., 2017;Siddiqui & Khalid, 2019;Souza et al., 2017;Yazıcı et al., 2016;Yu et al., 2017).
Schizophrenia family caregivers can improve psychosocial adaptation in overcoming psychosocial problems experienced with psychosocial adaptation interventions, according to the results of this review.Psychosocial problems in the form of signs of depressive symptoms are effectively reduced by psychosocial adaptation interventions with A cognitive-behavioral conference call intervention (CBCC) (Vázquez et al., 2020).Providing telephone interventions facilitates family caregivers to reach healthcare providers easily without being limited by distance, time, and energy.Implementation of therapy that is easy and can be done at any time optimizes the benefits of therapy in reducing symptoms of depression.In addition, symptoms of depression, anxiety, and stress experienced by family caregivers also effectively decreased when given The spirituality-based educational intervention (Khosravi et al., 2022).Spiritual-based intervention approaches such as gratitude and prayer can provide positive experiences for schizophrenia family caregivers, such as accepting life experiences as positive aspects and part of life that must be lived to be enjoyed as part of gratitude.
Other psychosocial adaptation interventions state that the Enhancing Contact Model (ECM) intervention is effective in dealing with caregiver self-stigma (Ran et al., 2022), and the Participatory care model intervention is effective in dealing with the psychological burden of caregivers (Zoladl et al., 2020).Psychological and self-load -family caregivers feel stigma because the social support received is low (Korkmaz & Küçük, 2016).The ECM psychosocial adaptation intervention invites family caregivers to direct contact with schizophrenia patients, neighbors around the house, and the wider community so that family caregivers can optimally receive social support (Ran et al., 2022).
The participatory care model focuses on providing interventions to family caregivers trained to apply adaptive coping strategies, improve communication and problem-solving abilities, and care for patients (Zoladl et al., 2020).
Another psychosocial adaptation intervention that is part of stress management is emotion regulation training which has proven effective for dealing with emotions, feelings of worthlessness, and caregiver helplessness (Behrouian et al., 2021).This intervention invites family caregivers to adapt to the psychosocial problems they experience by focusing on positive and enjoyable things about themselves, planning goals to be achieved, carrying out positive self-evaluations, making modifications due to evaluations, and making efforts to overcome problems effectively adaptive.This psychosocial adaptation intervention can increase self-awareness and control the psychosocial problems encountered in treating schizophrenic patients by re-focusing on what has been planned and the positive aspects they have.
A review of the six articles found that psychosocial adaptation interventions in overcoming the psychosocial problems of schizophrenia family caregivers can be combined according to the psychosocial problems encountered.Implementation can be facilitated by telephone, with a spiritual approach, involving direct contact with patients, families and the community, prioritizing increased direct involvement of family caregivers and focusing on positive aspects and goals the family caregiver wants to achieve.Thus, the family caregiver can still assist in treating schizophrenia patients in a healthy condition and avoid psychosocial problems.

CONCLUSIONS AND SUGGESTIONS
Psychosocial adaptation interventions in a cognitive-behavioral conference call intervention (CBCC) effectively treat caregiver signs of depression.The spirituality-based educational intervention effectively treats depression, anxiety, and caregiver stress.Enhancing Contact Model (ECM) intervention is effective in addressing caregiver self-stigma, Participatory care model intervention is effective in dealing with the psychological burden of caregivers, and emotion regulation training is effective in dealing with emotions, feelings of worthlessness, and helplessness of family caregivers.Therefore, psychosocial adaptation interventions for schizophrenia family caregivers can be facilitated by telephone, with a spiritual approach, involving direct contact with patients, families, and the community, prioritizing increasing the direct involvement of family caregivers, and carried out by focusing on the positive aspects and goals achieved by the family caregiver.Thus, the family caregiver can still assist in treating schizophrenia patients in healthy conditions and avoid psychosocial problems.