Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11820 Parenting style, family support, and relapse among schizophrenia patients: a literature review AV Sri Suhardiningsih,1 Dya Sustrami,1 Mundakir Mundakir2 1College of Health Science, Sekolah Tinggi Ilmu Kesehatan Hang Tuah, Surabaya; 2Faculty of health Science, Universitas Muhammadiyah Surabaya, Indonesia Abstract Schizophrenia is a mental health problem that is quite widespread in Indonesia. Relapse among patients with Schizophrenia is related to parenting style and family support. This study aimed to present a literature review that address parenting style, family support, and relapse among schizophrenia patients. Three databases were used in this study, ProQuest, Google Scholar, and PubMed. The keywords were used according to the Medical Subject heading (Mesh): Parenting and families support or emo- tional support and family functioning and relapse and Schizophrenia. We limited the articles from 2020-2022 and in English. We obtained 434 articles which divided into Google Scholar 214 articles, ProQuest 134 articles, and PubMed 86 arti- cles. In the end, we obtained six articles. The methodology of arti- cles was evaluated using JBI Critical checklist. Scores less than 50% were excluded from the study to ensure the quality of the arti- cles. The review results showed that parenting style and family support are risk factors contributing to relapse among schizophre- nia patients. However, there was one article showed that there was no correlation between family cohesion and relapse among schizophrenia patients. Parenting style and family support has a function in preventing relapse among schizophrenia patients. So, parenting style and family support management are needed to address intervention for preventing relapse among schizophrenia patients. Introduction Globally, the prevalence of mental health problems is escalat- ing. In 2019, approximately one in eight individuals, totaling 970 million people worldwide, were reported to have a mental condi- tion.1 Mental health issues now contribute to one in every five years of disability. Surprisingly, 20% of the world’s children and adolescents are grappling with a mental health disorder, and sui- cide ranks as the second leading cause of death among those aged 15 to 29, making it a critical concern.2–4 Schizophrenia stands out as a prominent global mental disorder affecting numerous coun- tries and is recognized as one of the top fifteen causes of disability worldwide.5 The impact of Schizophrenia extends to adding 13.4 million years of disabled life to the global disease burden.6 In Indonesia, Schizophrenia is a widespread mental health problem, evidenced by an increase in reported cases by 7 per thousand indi- viduals.7 Specifically, Menur Mental Health Hospital in Indonesia recorded 9,994 outpatients with schizophrenia.8 Relapse is a significant focus in Schizophrenia, causing adverse outcomes among individuals with the condition.9 Over a one-year period, 59 out of 323 (18.3%) patients experienced a recurrence.10 Research has established a correlation between relapse among patients with Schizophrenia and their parenting style as well as family support.11 Specifically, an overprotective parenting style has been found to impact schizophrenia,12 while a lack of support contributes to relapse among Schizophrenia patients.13,14 The influence of parenting style on the growth and development of children is well-documented.15,16 Previous studies have categorized parenting styles into four types: authoritative, democratic, permissive, and neglectful.17 Notably, authoritarian and permissive parenting styles have been associated with harm to individuals with schizophrenia.18 Schizophrenia patients also face stigma from the community and their families.19 Stigma has been linked to relapse among schizophrenia patients,20 underscoring the importance of a robust Correspondence: Dya Sustrami, College of Health Science, Sekolah Tinggi Ilmu Kesehatan Hang Tuah, Surabaya, Indonesia. E-mail: dyastaufan@gmail.com Key words: family; mental disease; parenting; relapse; schizophrenia; support. Contributions: ASS, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; DS, conceptualization, investigation, methodology, valida- tion, and writing – original draft, review and editing; MM, conceptual- ization, methodology, formal analysis, validation, and writing – original draft, review and editing. All the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. Conflict of interest: the authors declare no potential conflict of interest. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Funding: none. Acknowledgements: the authors would like to thank Hang Tuah Surabaya, College of Health Science, Surabaya, Indonesia for their valu- able support. Received: 15 September 2023. Accepted: 19 December 2023. Early access: 30 January 2024 This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:11820 doi:10.4081/hls.2024.11820 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:11820] [page 181] Non -co mmerc ial us e o nly support system from their families.21 Paradoxically, families of individuals with Schizophrenia may themselves exhibit discrimi- natory behaviors, including isolating patients and restricting their mobility, reflecting internalized stigma.21,22 Family support encom- passes various forms, such as emotional support, informational support, instrumental support, and appraisal support,23 all of which are crucial for individuals with schizophrenia.24 These forms of support have been shown to alleviate symptoms in schizophrenia patients and contribute to preventing relapses. Based on this back- ground, this study aimed to present a review that address parenting style, family support, and relapse among schizophrenia patients. To the best of our knowledge, there are only a few studies related to family intervention25 and none specifically addressing parenting style. Therefore, this study is essential to identify relevant articles concerning parenting style and support from the family to mitigate relapses among schizophrenia patients. Materials and Methods Research design This study employed a literature review that addressed parent- ing style, family support, and relapse among schizophrenia patients.26 The inclusion criteria for this study were limited to orig- inal articles in English, with the study population consisting of schizophrenia patients. The study specifically concentrated on exploring the relationships among parenting style, family support, and relapse in schizophrenia patients. The primary outcome of interest was relapse among schizophrenia patients. Articles were excluded if they did not involve human subjects, were not master’s or dissertation papers, or were not full-length articles. Search strategy and sources This study utilized three databases: ProQuest, Google Scholar, and PubMed. The search was limited to articles published between 2020 and 2022. The review was conducted from July 21 to October 25, 2021. The keywords were selected based on the Medical Subject Heading (Mesh) terms and included: parenting AND fam- ily support OR emotional support AND family functioning AND relapse AND Schizophrenia. Tables were created to present the results of the study. Risk of bias The methodologies of the articles were evaluated using The Joanna Briggs Institute (JBI) Critical Appraisal checklist.27 Articles with scores less than 50% were excluded from the study to ensure the quality of the included articles. Results Records identified through databases yielded 434 articles (Figure 1). Figure 1 outlines the article selection procedure and extraction process. The original articles included in the review were 214 articles from Google Scholar, 134 articles from ProQuest, and 86 articles from PubMed. Duplicate articles were removed, and two researchers independently screened titles and abstracts. Articles had to meet eligibility criteria based on popula- tion, study type, and outcome. As a result, only six articles were included in the final record. Table 1 presents a study on the relationship between parenting style and relapse among schizophrenia patients. Parenting styles Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [page 182] [Healthcare in Low-resource Settings 2024;12:11820] Table 1. Relationship between parenting style and relapse among schizophrenia patients. Author Year Study Country Total Age Outcome Family Conclusion design sample support or parenting style Khoshgoftar 2022 Descriptive Iran 15 > 18 age Schizophrenia Early mother-child Early mother-child et al., 2022 study years old symptoms relationship in patients with Schizophrenia was associated with Schizophrenia. Ishii et al., 2020 Prospective 89 40.1 Recovery and Parental bonding Overprotective parent was 2020 research non-recovery instrument (PBI) associated with group to assess parental non-recovery in patients care and overprotection with Schizophrenia. Abbaspour et al., 2021 Cross- Iran 130 30.51 Psychiatric disorder Parental bonding Most of the patients with 2021 sectional support psychiatric disorders were affected by ineffective parenting styles. Figure 1. Flow chart of the study selection.Non -co mmerc ial us e o nly examined in the articles included early mother-child, parental care, and parental bonding.28–30 The outcomes assessed in the articles were the symptoms of Schizophrenia, recovery, and psychiatric disorders. All studies indicated that parenting style was related to the study outcomes (Table 1). Table 2 displays a study on the relationship between family support and relapse among schizophrenia patients. Family support in the articles encompassed relationship with family, multifamily psychoeducation, and family support. The outcomes considered in the articles were the recurrence of Schizophrenia, relapse rate, and adaptation mechanisms. All studies demonstrated that family sup- port was related to the study’s outcomes (Table 2). Discussion Schizophrenia poses a severe mental health challenge with the risk of lifelong relapse for affected patients.31 Ineffective parenting styles impact individuals with Schizophrenia, where parenting involves interactions between parents, children, and the family.32 Parenting is closely tied to parental attitudes and behaviors, shaped by factors such as maintenance, care, support, and punishment.33 Previous research has classified parenting styles into four cate- gories: authoritative, democratic, permissive, and neglectful.17 The study titled “Associations between Parental Bonding dur- ing Childhood and Functional Recovery in Patients with Schizophrenia”29 demonstrated that parental bonding during child- hood influences the onset of Schizophrenia. An overprotective parental style was linked to relapses among schizophrenia patients. Ineffective parenting could result in children becoming overly dependent on others. The family’s role is crucial in shaping parent- ing, ultimately influencing the development of children. The con- clusion drawn was that schizophrenic patients benefit from posi- tive parenting, leading to improved socialization skills and pre- venting relapses. The parenting styles provided by families to schizophrenia patients encompass attitudes, behavior, care, patience, perseverance, and affection. The study “Parental Bonding Styles in Schizophrenia, Depressive and Bipolar Patients: a Comparative Study”30 suggest- ed that parenting patterns could serve as predictors for children’s mental disorders. Ineffective parenting styles were prevalent among patients with psychiatric disorders, with the mother’s role being particularly critical. The study “Analysis of the Early Mother-Child Relationship in Schizophrenic Patients”28 also emphasized the crucial role mothers play in a child’s behavior, development, and language. The early association between moth- ers and children in schizophrenia patients was characterized by emotions, ranging from hatred to love. Lack of attention from mothers was identified as a contributing factor to emotional prob- lems among children. One of the family’s functions is to care for its members.34,35 Family support is anticipated to enhance the potential recovery of schizophrenia patients and aid in their adaptation to symptoms.36 Patients lacking support from their families are more prone to relapse. Family support includes emotional, informational, instru- mental, and appraisal support.23 The study “Correlation Between Family Cohesion and Recurrence in Schizophrenics at the Dr. Soetomo Hospital Psychiatric Clinic”37 aimed to assess the corre- lation between family cohesion and relapse among schizophrenia patients. However, this study showed no correlation between these two variables, deviating from other studies. The study “The Effectiveness of Relapse Prevention Intervention on the Ability of Patients and Their Families to Prevent Psychotic Symptoms of Relapse among Patients with Schizophrenia: Systematic Literature Review”26 demonstrated that family support, especially through family-focused therapy and family psychoeducation programs, could prevent relapses among schizophrenia patients. The study “Family Support And Adaptation Mechanisms Of Adults Outpatients With Schizophrenia”38 explained that emotion- al support from the family could enhance coping mechanisms for patients with Schizophrenia. Emotional support comprises affec- tion, trust, attention, listening, and being listened to.9 Information support involves advice to improve health and motivation among patients.39 Instrumental support encompasses providing shelter, food, and transportation, reflecting the family’s economic and healthcare functions.40,41 Thus, the family plays a crucial role in preventing relapses among schizophrenia patients. Several limitations of this study should be considered. This study conducted a review and has not yet measured the quantita- tive effect of parenting style on relapse among schizophrenia patients and family support on schizophrenia patients. Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 2. Relationship between family support and relapse among schizophrenia patients. Author Year Study Country Total Age Outcome Family Conclusion design sample support or parenting style Texaga and Rejeki, 2022 Cross- Indonesia 40 16-40 Recurrences of Brief family There is no significant 2022 sectional schizophrenia patients relationship scale relationship between family (times per year) cohesion and the recurrence of Schizophrenia. Abu Sabra and 2021 Systematic - 12 - Relapse rate Multifamily The relapse prevention Hamdan-Mansour, review psychoeducation intervention increases 2021 for patients and their families to minimize and prevent psychotic symptoms. Widiyawati 2020 Cross Indonesia 101 15-75 Adaptation mechanism Family support The positive influence et al., 2020 -sectional to the symptom of of family support on Schizophrenia the adaptability of schizophrenia outpatients [Healthcare in Low-resource Settings 2024;12:11820] [page 183] Non -co mmerc ial us e o nly Conclusions The review findings suggest that parenting style and family support have been identified as significant risk factors contributing to relapse among schizophrenia patients. To address this issue, it is crucial to incorporate family support management as part of the treatment approach to effectively prevent relapse in individuals with Schizophrenia, such as by enhancing family relationships and providing psychoeducation. 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