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Psm1100283 1.10
Psychological Medicine, Page 1 of 10. f Cambridge University Press 2011
Motivational interviewing and interaction skillstraining for parents to change cannabis use in youngadults with recent-onset schizophrenia: a randomizedcontrolled trial
M. Smeerdijk1*, R. Keet2, N. Dekker1, B. van Raaij3, M. Krikke1, M. Koeter1,4, L. de Haan1,C. Barrowclough5, G. Schippers1,4 and D. Linszen1
1 Department of Psychiatry, Academic Medical Centre, Amsterdam, The Netherlands2 Mental Health Service North Holland North, Alkmaar, The Netherlands3 Training Company ‘ Bureau de Mat ’, Haarlem, The Netherlands4 Amsterdam Institute for Addiction Research, Amsterdam, The Netherlands5 School of Psychological Sciences, University of Manchester, UK
Background. Cannabis use by people with schizophrenia has been found to be associated with family distress andpoor clinical outcomes. Interventions to reduce drug use in this patient group have had limited efficacy. This studyevaluated the effectiveness of a novel intervention for parents of young adults with recent-onset schizophreniaconsisting of family-based motivational interviewing and interaction skills (Family Motivational Intervention, FMI) incomparison with routine family support (RFS).
Method. In a trial with 75 patients who used cannabis and received treatment for recent-onset schizophrenia, 97parents were randomly assigned to either FMI (n=53) or RFS (n=44). Assessments were conducted at baseline and 3months after completion of the family intervention by an investigator who remained blind throughout the studyabout the assignment of the parents.
Results. At follow-up, patients’ frequency and quantity of cannabis use was significantly more reduced in FMI thanin RFS (p<0.05 and p<0.04 respectively). Patients’ craving for cannabis was also significantly reduced in FMIwhereas there was a small increase in RFS (p=0.01). There was no difference between FMI and RFS with regard topatients’ other substance use and general level of functioning. Both groups showed significant improvements inparental distress and sense of burden.
Conclusions. Training parents in motivational interviewing and interaction skills is feasible and effective in reducingcannabis use among young adults with recent-onset schizophrenia. However, FMI was not more effective than RFS inincreasing patients’ general level of functioning and in reducing parents’ stress and sense of burden.
Received 13 July 2011 ; Revised 10 November 2011 ; Accepted 10 November 2011
Key words : Cannabis, family intervention, interaction skills, motivational interviewing, schizophrenia.
that carers tend to be more critical and hostile if theirfamily member with schizophrenia uses drugs (Lopez
Cannabis use is highly prevalent in people with the
et al. 1999 ; Barrowclough et al. 2005). A critical attitude
diagnosis of schizophrenia (Mueser et al. 1990). In this
approach has been thought to increase patients’
population, the use of cannabis has been consist-
defensive reactions and to reduce the likelihood that
ently associated with treatment non-adherence and
they would change their behaviour (Miller et al. 1993).
increased risk of psychotic relapse (Linszen et al. 1994 ;
Studies have also found that a critical attitude in carers
Zammit et al. 2008). Given these negative relationships,
is associated with an increased risk of psychotic re-
it is likely that there are high levels of interpersonal
lapse (Butzlaff & Hooley, 1998). One study showed that
conflicts in households in which a family member
high levels of criticism within the family were the main
with schizophrenia uses cannabis. It has been found
predictor of psychotic relapse (Linszen et al. 1997).
Although there is clear need for interventions that
help patients with schizophrenia to reduce their
* Address for correspondence : M. Smeerdijk, M.Sc., Department of
substance use, currently the evidence for effective
Psychiatry, Academic Medical Centre, Meibergdreef 5, 1105 AZ,
interventions is very limited (Cleary et al. 2009), and
there has been little attention paid to family-based
approaches (Mueser et al. 2009). Motivational inter-
standard treatment programme for recent-onset
viewing (MI) is a well-studied method to overcome
schizophrenia, consisting of in-patient treatment last-
resistance and increase the motivation to change
ing 2 months, followed by out-patient treatment for a
substance use (Hettema et al. 2005). Although MI
maximum of 12 months. The content of the patients’
was originally developed for use by professionals
treatment programme has been described elsewhere
(Miller & Rollnick, 2002), training parents in MI might
(Linszen et al. 1996), and included psycho-education,
change their critical response to cannabis use and
medication management, stress reduction and relapse
help them to overcome patients’ resistance to change.
prevention. The primary hypothesis was that FMI
Accordingly, we developed an intervention pro-
would be more effective than RFS in reducing patients’
gramme consisting of family-based motivational
cannabis use. The secondary hypotheses were that FMI
interviewing and interaction skills, called Family Moti-
would be superior to RFS in (1) decreasing patients’
vational Intervention (FMI), for parents of patients
substance use other than cannabis, (2) decreasing
with recent-onset schizophrenia and co-occurring
craving for cannabis use, and (3) increasing patients’
cannabis use. The programme was adapted from the
quality of life. With regard to parents, the secondary
Interaction Skills Training (IST) programme for
hypothesis was that FMI would be superior to RFS in
schizophrenia (Kuipers, 2003 ; van Meijel et al. 2009) to
decreasing parents’ distress and sense of burden re-
provide parents communication and problem-solving
sulting from their child’s symptoms and cannabis
skills to reduce stress and resolve conflicts within the
family. This was combined with training parents inskills from MI to enhance patient motivation for
changing cannabis use. FMI was delivered in additionto mental health standard care for patients. The aim
Patients were invited to participate after being fully
of the present study was to determine whether FMI
informed about the content and aims of the study.
would be more effective than routine family support
Parents were not approached for the study before the
(RFS) in reducing patients’ cannabis use. Several sec-
patient had given written informed consent. Patients
ondary outcomes were also examined, including
and parents were assured that family support would
(1) patients’ substance use other than cannabis, their
continue to be offered regardless of whether they
craving for cannabis use and their quality of life, and
agreed or refused to participate in the study. Although
(2) parents’ distress and sense of burden.
both parents were approached about participating, itwas possible for only one of them to do so. After in-formed consent had been given, parents and patients
were assessed separately at two time points : within 4
weeks before the start of FMI and RFS (baseline) and 3months after FMI and RFS had ended (follow-up : 9
Patients were recruited from two psychiatric services
months post-baseline). The baseline assessment was
in The Netherlands : the Academic Medical Centre of
planned within the first month of hospitalization.
the University of Amsterdam (AMC-UvA) and the
Allocation of the parents to FMI or RFS was based on
Mental Health Service North Holland North (GGZ-
the randomly assigned condition of their child. The
NHN). Patients with the following selection criteria
assessments were conducted by the first author, who
were eligible : (1) DSM-IV diagnosis (APA, 1994) of
was blind to participants’ treatment allocation. Efforts
schizophrenia or psychotic-related disorder, based on
were made to maintain blindness, including the use of
the Comprehensive Assessment of Symptoms and
separate locations for therapy and research staff and
History (CASH ; Andreasen et al. 1992) ; (2) age 16–35
reminding participants before and at the start of the
years ; (3) onset of schizophrenia or psychotic-related
follow-up assessment not to disclose their treatment
disorder within the previous 5 years ; (4) antipsychotic
allocation. As a standard component of our treatment
medication prescribed or indicated ; (5) cannabis use
programme, all parents were invited for two sessions
for at least 2 days/week in the previous 3 months ; and
of group psycho-education, which were given in the
(6) having contact with a parent for at least 10 h/week
first month of hospitalization. After psycho-education,
parents received either FMI or RFS over a period of6 months.
A single-blind randomized controlled trial was con-
ducted in which parents were allocated to either FMI(the experimental condition) or RFS (the control
Patients’ use of cannabis, alcohol, cocaine, ampheta-
condition). In both conditions patients received a
mines, opiates and psychedelic drugs was assessed
Skills training for parents to change cannabis use in young adults
with the Timeline Followback (TLFB-90) interview
With this method the following key skills were prac-
(Sobell & Sobell, 1992). This structured interview uses
tised : active listening, sending clear signals, and
a calendar method to identify and quantify the re-
maintaining boundaries. MI was based on counselling
spondent’s self-reported alcohol and drug use during
techniques and addressed stages identified as those
the previous 90 days. For the present study, measures
that trainees needed to become competent in MI
derived from the TLFB-90 were the mean frequencies
(Miller & Moyers, 2006). Parents were trained in the
of use in days for cannabis, alcohol and other sub-
following techniques : asking open questions, using
stances, the mean amount of use in grams for cannabis
reflections, providing summaries, and overcoming
and in glasses for alcohol and percentage of patients
resistance. Parents were allowed to practise these
in each condition being abstinent from cannabis at
techniques by focusing on identifying and eliciting
follow-up. To validate the patients’ self-reports, urine
patients’ self-motivational statements (i.e. ‘ change
samples were taken for cannabis, cocaine and amphet-
talk ’) about changing cannabis use. Full details of the
interventions can be found in the manuals for IST
As an important mediator of continued substance
(Kuipers & Raaij, 2006) and MI (Smeerdijk et al. 2007).
use and relapse after abstinence, craving was assessed
The intervention was conducted by two highly ex-
with the self-report Obsessive Compulsive Drug
perienced family therapists who were trained by cer-
Use Scale (OCDUS ; Anton et al. 1996 ; Schippers et al.
tificated professionals in IST and MI. To facilitate
1997). The OCDUS measures three factors of craving
treatment fidelity, six pilot sessions of FMI were car-
for cannabis in the past 7 days : (1) thoughts about
ried out and recorded on videotape. These tapes were
cannabis and interference they cause, (2) desire to use
then viewed in supervision sessions to discuss with
cannabis and control over the desire, and (3) resistance
the trainers their compliance with the treatment man-
to thoughts about cannabis and intentions to use.
uals. Supervision sessions were continued throughout
Patients’ subjective quality of life was measured
with the short form of the widely used World
RFS consisted of individual meetings between the
Health Organization Quality of Life self-report ques-
parent(s) and an experienced family therapist. RFS
tionnaire WHOQOL-BREF (de Vries & van Heck,
was designed to be supportive and encouraging for
the parent(s) and consisted of providing the oppor-
For the assessment of stress in relation to caring
tunity to talk freely about their feelings, answering
for someone with a schizophrenic disorder who
uses cannabis, parents completed three self-report
Meetings were commonly focused on topics such as
questionnaires : the Experience of Caregiving In-
emotional processing of grief and loss, medication and
ventory (ECI), the Family Questionnaire (FQ) and
crisis management, and social rehabilitation. Parents
the General Health Questionnaire 28 (GHQ-28). The
determined their own topics and there were no formal
ECI (Szmukler et al. 1996) measure the positive and
skills provided during the intervention period. In ac-
negative appraisal of caring for someone with mental
cordance with the FMI, RFS was held twice a month,
health problems. The FQ (Quinn et al. 2003) measures
three dimensions of parents’ perception : frequencyof symptoms, concern about symptoms and ability
to cope with symptoms. The GHQ-28 (Goldberg &Hillier, 1979 ; Koeter & Ormel, 1991) is an established
All data were analysed using SPSS version 17 for
brief self-report questionnaire that screens for
Windows (SPSS Inc., USA). To compare the conditions
on baseline characteristics, continuous data were ana-
assessing the person’s mental health during the
lysed using independent t tests (normally distributed
data) and Mann–Whitney U tests (non-normally dis-tributed data). Categorical data were analysed withPearson’s x2 test or with Fisher’s exact test when fre-
quencies were low. All analyses of changes from
FMI consisted of 12 group sessions scheduled every
baseline to follow-up were conducted on an intention-
other week. The training provided parents with skills
to-treat (ITT) basis. Missing data from the TLFB,
adapted from the IST and MI. The IST programme was
developed by the training company Bureau de Mat1.
means of the multiple imputation method for missing
The purpose was to help parents to practise interac-
values. Consistent with the standard practice in sub-
tion skills and problem-solving techniques by using a
stance abuse trials, missing urine samples were
red- and green-coloured mat to visualize interaction
imputed as positive. To assess patients’ improvement
problems between child and parent (Kuipers, 2008).
from baseline to follow-up, independent t tests were
parents refused participation, n=32
Fig. 1. CONSORT diagram. FMI, Family Motivational Intervention ; RFS, routine family support.
conducted comparing the experimental and control
approve of their parent’s participation. Of the 75
conditions on patients’ change scores in self-reported
remaining patients who were randomized, 25 (33 %)
substance use, craving for cannabis use and quality of
refused to take the baseline assessment but agreed that
life. Differences in urine values between the conditions
their parent(s) would participate. Of the participating
at follow-up were analysed with the x2 test. With
patients, nine partners and 16 single parents were in
regard to the parents’ outcomes, a linear mixed model
the FMI group, and seven couples and 16 single par-
was used to correct for differences between patients in
ents were in the RFS group. Of the non-participating
the number of participating parents. The level of sig-
patients, five couples and nine single parents were in
nificance (a) was set for all outcomes at p<0.05, using
the FMI group, and three couples and eight single
two-sided tests. Effect sizes (Cohen’s d) were calcu-
parents were in the RFS group. Of the 53 parents as-
lated for significant outcomes, with d=0.2, 0.5 and 0.8
signed to FMI, 92 % attended at least eight of the 12
considered to be a small, medium or large effect
sessions. Of the 44 parents assigned to RFS, 89 %
attended at least eight sessions over the 6-month per-iod of the trial. Baseline and follow-up data were col-lected from 46 carers (87 %) in the FMI group and from32 carers (73 %) in the RFS group. For the patients, the
follow-up rates were 17 patients (71 %) in the FMI
group and 20 patients (77 %) in the RFS group.
Figure 1 shows the progress of the patients and par-ents through the trial. Of the 149 patients meeting the
inclusion criteria, 74 did not participate because : (1)they were not willing to take part in the study or (2)
The demographic and clinical characteristics of
they were excluded because their parents were not
patients and parents at baseline are shown in Table 1.
willing to participate. Of the 194 eligible parents, 97
At baseline, patients in the two conditions were not
did not participate because : (1) they were not willing
significantly different on the following variables : age,
to take part in the study or (2) the patient did not
gender, race, marital status, years of secondary
Skills training for parents to change cannabis use in young adults
Table 1. Participants’ characteristics at baseline for Family Motivational Intervention (FMI) and routine family support (RFS)
First treatment for schizophrenia, n ( %)
education, employment status, primary schizophrenia
number of days in treatment before the baseline as-
diagnosis, prior treatment experience for schizo-
sessment point between the FMI group [33.08
phrenia, treatment status and duration, or type of
(¡22.80)] and the RFS group [31.54 (¡21.49)]. Because
medication use (all p’s>0.05). Parents in the two con-
the follow-up assessment was planned to occur 3
ditions did not significantly differ in terms of gender,
months after the end of the 6-month family inter-
marital status or number of contact hours with the
ventions, it was possible for patients to still be in
patient (all p’s>0.05). Within the conditions, patients
treatment at this evaluation point. However, none of
who were lost to follow-up did not significantly differ
the patients were still receiving the out-patient phase
from those who completed the follow-up assessment
of the intervention when they were seen at the follow-
with respect to any of the demographic and clinical
up. During the 9-month study period, one patient in
characteristics. Because the opportunity was given to
the FMI group and one patient in the RFS group
participate in the study at a later time in the patients’
were readmitted to hospital. With regard to the other
treatment programme, 28 % (n=14) of the patients and
patients, there was no significant difference in the
25 % (n=24) of the parents had the baseline assess-
mean number of treatment weeks from baseline to
ment after the first month of the in-patient admission.
out-patient discharge between the FMI group [20.71
There was no significant difference in mean (S.D.)
(¡5.73)] and the RFS group [18.75 (¡5.16)]. In
Table 2. Patients’ cannabis, alcohol and other drug use from the Timeline Followback (TLFB-90)
Standard deviations are given in parentheses.
addition, no significant difference was found in the
(58.8 % v. 25.0 %, x2=3.07, p=0.08). In addition, at
mean number of weeks from out-patient discharge to
follow-up there was no significant difference between
follow-up between the FMI group [20.54 (¡6.65)] and
the groups in abstinence rates for alcohol use and drug
use other than cannabis. Among the patients seen atfollow-up, seven patients (41 %) in the FMI group and
nine patients (45 %) in the RFS group refused to givea urine sample. All missing urine samples were im-
Table 2 shows the baseline and follow-up mean scores
puted as positive for cannabis. There was no signifi-
on the patients’ self-reported frequency and quantity
cant difference between the FMI and RFS groups at
of cannabis, alcohol and other substance use prior to
follow-up with regard to the proportion of patients
the multiple imputation analyses. At baseline, there
with a negative urine test result for cannabis use
were no significant differences between the groups
(28.0 % v. 17.9 %, x2=0.78, p=0.51).
in mean days of use of cannabis, alcohol and other
Scores on the OCDUS at baseline revealed no sig-
substances during the 3-month period preceding the
nificant difference between the FMI group and the RFS
assessment (all p>0.05). On change scores in mean
group in patients’ craving for cannabis use. Change
days of cannabis use from baseline to follow-up, a
scores on the OCDUS from baseline to follow-up,
significant difference was observed between the
however, showed a significant difference between the
groups (t51=2.00, p<0.05, Cohen’s d=0.56). Specifi-
groups (t51=2.75, p=0.01, d=0.77) ; there was a de-
cally, the mean number of days of cannabis use
crease in craving in the FMI group [x8.13 (¡8.29)
was decreased in the FMI group by 40.89 (¡36.47)
points] and a very small increase in craving in the RFS
days and in the RFS group by 12.83 (¡33.25) days.
The two groups did not differ significantly in the
At baseline, there was no significant difference in
change in alcohol and other substance use from base-
scores on quality of life between the FMI group and
line to follow-up (p>0.05). At baseline, there were
the RFS group. There was also no significant difference
no significant differences between the groups in
in the increase in scores on quality of life from baseline
mean daily cannabis or alcohol use. There was, how-
to follow-up between the FMI group [+6.19 (¡10.02)
ever, a significant difference between the groups in
points] and the RFS group [+6.26 (¡14.32) points].
changes from baseline to follow-up in mean gramsof cannabis used (t51=2.06, p=0.04, Cohen’s d=0.58).
Specifically, in the FMI group the mean use ofcannabis was reduced by 0.53 (¡0.67) g whereas in
There were no significant differences between the FMI
the RFS group there was a small increase by 0.08
group and the RFS group in baseline scores on the
(¡0.62) g. The groups did not differ in change from
GHQ, the FQ and the ECI. After imputation of missing
baseline to follow-up in mean number of glasses of
values, linear mixed model analyses revealed that
there were also no significant differences between the
Complete abstinence from cannabis during the
groups in change scores from baseline to follow-up
3-month period preceding the follow-up assessment
on any of these questionnaires. More specifically, there
was reported more frequently in the FMI group than
was a significant decrease in both groups in total
in the RFS group, although this was not significant
scores on the GHQ and the FQ, and on the negative
Skills training for parents to change cannabis use in young adults
Table 3. Parents’ means scores at baseline and at the 10-month follow-up, and comparison of their change scores
FMI, Family Motivational Intervention ; RFS, routine family support ; ECI, Experience of Caregiving Inventory ;
GHQ-28, General Health Questionnaire 28 ; FQ, Family Questionnaire ; df, degrees of freedom.
Values given as mean (standard deviation).
scale of the ECI (Table 3). These scores indicate that
long-term efficacy of FMI, as craving is an important
both parents groups improved from baseline to
mediator of relapse after abstinence from cannabis
follow-up on their levels of distress and sense of bur-
(Anton et al. 1996). No consistent evidence exists to
den. Exploratory analyses with dependent t tests
date to support the effectiveness of pharmacological
revealed that these improvements were all significant
and psychosocial interventions to reduce cannabis use
for the FMI parent group (GHQ : p<0.01, FQ : p=0.01,
by people with schizophrenia (Cleary et al. 2009 ;
ECI : p<0.01) and also for the RFS parent group (GHQ :
Hjorthøj et al. 2009). Although randomized trials have
p=0.02, FQ : p=0.02, ECI : p<0.01).
repeatedly shown that family interventions are effec-tive for persons with schizophrenia (Pharoah et al.
Relationship between patients’ and parents’
2006) and for persons with substance use (O’Farrell &
Fals-Stewart, 2006), to our knowledge only two otherstudies have evaluated a family intervention pro-
Pearson’s correlation coefficient (r) was computed to
gramme for their co-occurrence (Barrowclough et al.
examine the relationship between the significant out-
2001 ; Mueser et al. 2009). The first study demonstrated
comes for patients and parents. To correct for differ-
that a 9-month programme that included psycho-
ences between patients in the number of participating
education and support for carers resulted in a signifi-
parents, parents’ mean change scores were used if
cant increase in the percentage of days participants
both parents had participated. Contrary to expec-
were abstinent from alcohol and other drug use over a
tation, improvements in parents’ levels of stress and
12-month period from baseline to follow-up. The
sense of burden (as measured by the GHQ, FQ and
second study also included psycho-education and
ECI) were not significantly related to reductions in
support for carers and, like the present study, trained
either patients’ frequency or amount of cannabis use.
carers in communication and problem-solving skills. It
These associations were not found for the sample as a
revealed that successful involvement of carers in the
whole or for the FMI and RFS group separately.
programme was strongly associated with less severe
Parents’ attendance rates at FMI and RFS sessions
drug abuse among patients ; however, the impact of
were also not significantly correlated with patients’
the intervention on patients’ substance use has not yet
changes in frequency or amount of cannabis use or
with parents’ improvements in levels of stress and
On the other outcomes, no additional benefits were
obtained in the FMI group beyond those achieved inthe RFS group. In both groups there were no effects onpatients’ alcohol use and drug use other than canna-
bis. However, on these outcome measures it was
This study demonstrated that training parents of
difficult to establish any changes because excessive
patients with the diagnosis of recent-onset schizo-
alcohol use and substance use other than cannabis was
phrenia in FMI led to significantly greater reductions
rare among the patients in this present study. In
in patients’ frequency and amount of cannabis use
addition, both FMI and RFS led to significant im-
than providing parents RFS for at least 3 months. In
provements in patients’ quality of life status and in
addition, patients’ craving for cannabis decreased to a
parental sense of burden and stress. These improve-
significantly greater extent in the FMI group than in
ments could be due to short-term benefits achieved
the RFS group. These results offer promise for the
with the treatment that the patients had received
before the follow-up assessment, which included
use in people with a severe psychiatric disorder
pharmacotherapy and psychosocial interventions. In
(Carey et al. 2004 ; Stasiewicz et al. 2008). More specifi-
this case, it would have been difficult to establish any
cally, for patients with psychosis, the TLFB-90 shows
benefits of FMI on the quality of life beyond those
good concurrent validity (Barrowclough et al. 2001),
and findings even suggest that it may be a more sen-
The findings of this study should be discussed in
sitive measure for detecting cannabis use in this
the context of its limitations. First, 45 % of the patients
patient group than hair analysis (Haddock et al. 2009).
meeting the inclusion criteria and almost one-third of
In both groups there was an improvement in
the parents who were asked to participate refused to
patients’ quality of life status and in parents’ stress
do so. However, those parents who did participate
and sense of burden, but only FMI showed an im-
showed a high level of commitment, which was
provement on cannabis use and craving for cannabis
shown in both groups. In addition, there was a high
use. This is an important finding because FMI did
response rate among patients and parents in both
have a particular focus on changing cannabis use
groups at follow-up. However, the high rate of initial
whereas RFS did not. Therefore, it is recommended
refusal opens the possibility that the sample was
that, if cannabis use is present in schizophrenia, in-
biased towards patients who were already considering
terventions for family members should include train-
changing their cannabis use and therefore found it
ing in interaction and motivational skills that target
meaningful to participate. This also raises the concern
the cannabis use of the patient. Other authors also
over the small sample size of patients, which makes it
mention that psychosocial treatments for psychosis
difficult to find any statistical differences and reduces
should maintain a well-defined focus (Garety et al.
the statistical power. Given the high intensity of FMI
2008). It could be argued, however, that the effects on
(12 sessions provided over a 6-month period, each
cannabis use were due to the greater efforts parents
lasting 3 h), it is understandable that the most often-
made in the FMI condition rather than to the specific
mentioned reason for parents not participating was
skills they were taught. At the same time, parents’ ef-
their inability to integrate the training into their daily
forts to help patients abstain or cut down their canna-
activities. This reflects the fact that FMI might not be
bis use could be counterproductive, leaving the carers
feeling frustrated and stressed because of their failed
Second, because the follow-up assessment occurred
attempts. FMI aims to teach parents to leave the re-
3 months after the end of the family intervention, more
sponsibility for changing to the patient, and that at-
research is warranted to determine whether the posi-
tempts to argue with the patient and persuade them to
tive results in changes in patients’ cannabis use and
change only create resistance. Trainers’ anecdotal re-
cannabis craving will be sustained after longer
ports confirmed that changing carers’ attitude about,
and their approach to, the patients’ cannabis use was
Third, this study included only patients who had
the major achievement of FMI. Further trials are nee-
contact with a parent for at least 10 h/week. Therefore,
ded to identify what the active and most important
it is difficult to know whether the results can be gen-
ingredients are in FMI, and to examine the long-term
eralized to patients who have less substantial contact
effects of the involvement of parents in the treatment
with their families. Furthermore, because within the
of patients with recent-onset schizophrenia.
patients’ family only the parents were asked to par-ticipate, it is unclear whether our intervention wouldhave similar benefits if family members other than
Fourth, compared to treatment for schizophrenia in
other countries such as the UK and the USA, the
Organization for Health Research and Development,
in-patient phase of our treatment programme is rela-
grant no. 100003014) and by Eli Lilly. We are grateful
tively long (2 months). Therefore, future studies are
to all of the participants. We also thank K. Hulstijn,
warranted to determine whether the observed benefits
F. Lobban and T. Kuipers for their scientific contri-
found in our study can also be attained by mental
butions and A. de Jager for delivering the MI training.
health services with a short in-patient phase.
A final concern in this study is the high rate of
patients who refused to take the urine test at follow-
up. Therefore, the results were largely dependent onthe patients’ self-reports by administrating the TLFB-
B. van Raaij was invited by AMC-UvA to deliver the
90 questionnaire. However, the TLFB-90 has good
IST programme on behalf of the training company
reported reliability and validity to assess substance
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SPRING 2013 Plum Park Farm, Watling Street, Paulerspury, Towcester, Northants NN12 6LQ Equine gastric ulceration Practice News The hidden health threat Until recently it was thought that gastric ulcers only affected racehorses. goodbye to Hannah Hughes who is However, through better diagnostics and a more detailed understanding of the leaving the nursing team
MARCH 2011 MARCH 201 UPDAT The Tyrrelstown art competition will take place on Saturday 2nd April Well done to our chess players who took part in the in Tyrrelstown Educate Dublin Finals on 28th January. They played extremely Together National School well on the night and got through a few rounds. Con-sidering they had only 3 practice sessions and this was their fi rs