This single-arm clinical trial using pre- and post-research design was conducted among patients diagnosed with schizophrenia disorder in the three biggest cities of Pakistan (i.e. Lahore, Faisalabad, & Karachi). Participants were recruited from different primary psychiatric settings, psychiatric clinics, and tertiary care hospitals between June 2017 and January 2022.

In this study, 400 patients diagnosed with schizophrenia disorder were taken and they were assessed for eligibility assessment. In this process, 145(36.25%) patients were excluded due to reasons of 1) who did not meet the inclusion criteria n=130, 2) who provided incomplete information= 10 and who left due to other reasons were 5 participants. Finally, 255(63.75%) respondents met the eligibility criteria and were enrolled in the experimental group. The respondents’ age-ranged was between 18-50 years, with M ± SD=35.45 ± 0.27. In addition, one of the family members that he/she is closer to the patients was also taken in this study to fulfill the purpose of supporting and assistance in medication, and daily life activities to the patients at home.

Based on the DSM-V’s inclusion and exclusion criteria, the study took on subjects who had been given a diagnosis of schizophrenia disorder. Subjects who had psychotic symptoms and had had their condition for at least 6 months qualified as participants. However, a few exclusion criteria were used; a) patients availing in-patients’ facility, b) with severe symptoms, c) patients with multiple relapses, d) duration of illness > 1 year and above, e) patients with comorbid conditions; and f) patients with injury/disability. Participants from various socioeconomic backgrounds were included without any particular educational requirements.

The assessment and screening process was initiated from an outdoor patient’s psychiatric setting. After getting consent from the patient and his/her close family members than a psychological assessment was completed by the clinical psychologists. This process started with a) complete history taking form, b) a structured clinical interview, c) relevant assessment measures, and d) patients were diagnosed according to DSM-V diagnostic criteria for schizophrenia disorder. Participants who qualified for the diagnostic criteria of schizophrenia disorder were enrolled in experimental groups.

Participants first filled out a demographic questionnaire and a history-taking form was completed. Details information was taken from the patients regarding the symptoms, duration illness, number of episodes, age at onset and related inform to confirm the diagnosis and associated factors to formulate treatment plan.

The Positive and Negative Syndrome Scale (PANSS): The PANSS is comprised to 30 items with 7 positive, 7 negative, and 16 general psychopathological symptoms to assess symptom severity (38). It covers three areas: general psychopathology, negative symptoms, and positive symptoms. Usually, the PANSS administration lasts between 40 and 50 minutes. In the current investigation, a licensed clinical psychologist administered the PANSS during a clinical interview. Reliability estimation of positive (α=0.73), negative (α=0.83) and general psychopathology subscale (α=0.79) which indicates scale has sound psychometric properties.

The Mental Help-Seeking Attitude Scale (MHSAS): The MHSAS was developed to patients attitude toward treatment (39). This nine-item self-report test is intended to gauge patients’ views toward therapy in terms of positive and negative outcomes. Patients’ low scores on the help-seeking attitude scale reflected that patients have a low attitude toward seeking help and that high scores showed parents have a positive attitude toward receiving treatment. The MHSAS has high internal consistency (α=0.94).

Patients-Motivation for Treatment Checklist (PMTC): The PMTC was prepared to evaluate patients’ level of motivation toward treatment. The checklist was comprised of 11 statements. Each statement was rated between “0” to “10” was used to rate each item. A score on each statement close to 0 suggests resistance to receiving treatment, score between 4 to 6 indicates a readiness to do so despite some reluctance, and a score of near to 10 indicates a strong desire to get treatment right away.

Socioeconomic status (SES) was assessed depending on the participants’ household income. Low-income patients were those whose family income per month was under 50,000 PKR, middle-income patients were those whose family income per month was between 50,000 and 90,000 PKR, and high-income patients were those whose family income per month was above 90,000 PKR.

Psychotropic Medication: In the management of patients with schizophrenia disorder “first-generation” and “second-generation” antipsychotics play an important role for the successful recovery process (40, 41). Similarly to this, antipsychotic medications are frequently administered as the first line of treatment for schizophrenia in Pakistan (42). According to an estimate, 30 to 40% of patients respond poorly to medicine because they have low motivation, and do not receive psychotherapy (42). Antipsychotic medications’ primary goal is to reduce symptoms and allow people with schizophrenia to go about their daily lives (43). Another study reported psychotherapeutic interventions, rehabilitation, and awareness programs improve recovery along with medication and some without medication (44). This psychoeducation program was structured as a supportive intervention to improve patients’ recovery process and treatment adherence.

Psychoeducational program: This study’s psychoeducational program, based on the principles of cognitive behavior therapy, aims to inform, direct, inspire, and improve patients’ understanding of their situation (42). According to Yesilyaprak et al. (45), the treatment also addressed the patients’ dysfunctional beliefs, cognitive distortions, and low motivation. Table 1 provides a summary of the psychoeducation program’s objectives. The course was broken down into 10 sessions, each of which focused on a different subject “i.e. psychoeducation, adherence training, motivation, cognitive conceptualization, insight development, stress management, socialization, skill training, lapse prevention, & relapse prevention”. These subjects were chosen from two main sources: 1) Cognitive Behavior Therapy-Basic and Beyond (46) and 2) schizophrenia psychoeducation program for individual with recent onset (47). where therapists can find specialized psychoeducational techniques for people with schizophrenia (48). Group activities were incorporated to encourage social interaction and networking among the patients, such as role-playing, table discussions, sharing life stories, and music and yoga exercises. The psychoeducational program’s second goal was to lessen the stigma and sense of isolation that people with schizophrenia often feel. The time between pre- and post-testing was roughly three months. Moreover, as our study involved an intervention (albeit in the pilot phase), we followed the CONSORT guidelines for reporting our study (49). Description of psychoeducation program sessions with particular goals and details are available (see Table 1 ). In addition, each patient’s family member/caregiver was approached to participate in this program for two individual sessions. The purpose of the caregiver involvement was to guide and instruct the family members about medication on time, spend quality time with patients, social and emotional support, understand and guide the patients (50). Moreover, therapist guided the family members about patients’ mental health conditions and train them to handle the patients during difficult conditions (51).

This study proposal was approved by Government College University, Faisalabad’s Institutional Review Board (IRB) in June 2017 and the study was completed in January 2022. A researcher then contacted the administrators at each institution to learn more about the settings and participant availability. The enrollment process was initially started by a researcher stationed in each participating hospital’s Out-Patient Department (OPD) by evaluating and screening patients. As previously described, individual clinical interviews and standardized tests were used to select subjects. The researcher reassured the patients of anonymity at the first session and highlighted their right to leave the study whenever they choose. A diagnostic interview and a series of self-report tests, as detailed in the measures section, were both components of the initial screening procedure. The DSM-V criteria were used to diagnose the participants, and depending on their presenting issues, they were subsequently assigned to the relevant therapies. Over the course of ten therapy sessions, participants received both medication and psychoeducation programs; in addition, two psychoeducational sessions were held with their families. The same battery of self-report measures was used for post-assessment after a period of 16 weeks.

Upon completing the 16-week psychoeducation program, participants were asked to share your experience and feedback on the checklist. The purpose of this checklist was collecting patients’ feedback and their treatment experience with the therapist. each statement was rated from one (very poor) to five (very good), and participants were asked to rate each statement. The results indicated that 71% participants reported this program remain helpful for us to overcome psychological disturbance. 65% participants rated the quality of the sessions was very good, 84% expressed satisfaction with the session timing and frequency, and 59% reported we easily understand the session concept and content. 73% participants reported therapist’s behavior and handling during sessions were adequate and respecting. Almost 94% participants acknowledged, therapist properly maintained the privacy and confidentiality throughout the program. Similarly, 73% patients expressed that the involvement of family members in the treatment was good and 83% patients expressed satisfaction with the overall layout of the program.

Using G-Power software (version 3.1.9.7), the sample size for this investigation was calculated. According to Faul et al. (52), an a priori effect size of 0.50, an error probability of 0.001, and a power of 0.99 led to a target sample size calculation of 138 participants using G-Power. However, 220 people in total participated in our study. Descriptive statistics (M, SD) was used to examine the sample’s demographic makeup. We used frequency distribution statistics to look at the severity of the symptoms as determined by PANSS. In order to evaluate the variations in participants’ pre- and post-test scores on the PANSS, MHSAS, and PMTC, a Wilcoxon’s Signed-Ranked test was used. We used significance level of p <0.05 and all analyses were made using IBM-SPSS version 24.

A total 255 participants were assigned to the intervention. 20 out of 235 participants were excluded due to the following reasons (i.e. 15 patients did not complete the pre-assessment, 3 participants admitted into the in-patients setting for extensive treatment care, and 2 patients shifted to another city). At the follow-up stage 15 participants were also excluded from the analysis due to the reason of 5 participants left program after three sessions, 2 respondents move abroad with family, 3 due to relapse condition, 5 participants did not appears in post-assessment.

Each patient received a total of 10 therapeutic sessions. In terms of the sample characteristics, 56.08% of the participants were male and 43.82% were female. Among the participants, 48.24% were single, 38.43% were married, and 13.33% were divorced or widowed. The age of the patients ranged from 18 to 52 years, M ± SD= 35.45 ± 10.27 years. Table 1 is list program goals and Table 2 cover the patients’ demographic characteristics and the patients’ CONSORT flowchart presents patents’ information from enrollment to analysis ( Figure 1 ).

After being evaluated and screened, 235 volunteers who had been diagnosed with schizophrenia disorder were added to the study. The PANSS was used to assess the degree of their symptoms, and it was decided that participants with mild severity would take part in the psychoeducation program. We also concentrated on evaluating the participants’ treatment-related motives and attitudes. Participants were characterized as having a poor level of attitude toward getting help if their attitude score fell below 18, and they were categorized as having low motivation for treatment if their motivation score fell below 5 on a scale of 0–10.

The test ‘Wilcoxon signed rank’ showed a significant decrease in positive symptoms severity subsequent to our intervention. Most of the variables the effect size falls between small to medium range which reflects that the psychoeducation program was remain successful to address psychiatric symptoms in schizophrenia patients. This program brought substantial improvement in positive symptoms management i.e. delusions (51%), hallucinatory behavior (48%), suspiciousness (41%), and conceptual disorganization (40%), excitement (33%), hostility (34%) and grandiosity (29%) which shows the higher impact of the program. Program remain less effective for negative symptoms of stereotyped thinking (9%), social withdrawal and lack of spontaneity (10%) and relative better improvement was seen on blunted affect (42%), poor rapport (32%), difficulty in abstract thinking (31%) and emotional withdrawal (30%). Similarly, on general psychopathological symptoms this program significantly improves patients’ judgment and insight (53%) which was more relevant aspect to nature of the program. In addition, significant improvement was seen on depressive symptoms (49%), disturbance of volition (46%), poor impulse control and somatic concerns (42%) and on rest of the symptoms there no significant improvement was seen (see Table 3 ).

The findings show that a significant difference between pre- and post-assessment scores was found after applying psychoeducation program on patients with schizophrenia disorder. For example, positive, negative and general pathological symptoms (M ± SD=21.05 ± 6.91; 15.74 ± 5.33; 38.32 ± 9.25) compared to before (M ± SD=25.00 ± 8.89; 17.44 ± 5.19; 43.40 ± 10.73) with (i.e. z =-12.47, p<.001, z=-9.52, p<.001; z =-12.72, p<.001) and i.e. r(effect size)= .59,.45 and.61 respectively. Similarly, significant improvement was found on HSAT i.e. (before M ± SD=28.27 ± 12.89) and (after M ± SD=39.03 ± 13.27) with z =-10.43, p<.001 and r(effect size)= .50. On PMFT significant improvement was observed after the implementation psychoeducation program i.e. before (M ± SD=4.85 ± 1.98) and after (M ± SD=5.69 ± 2.05) with z =-12.43, p<.001 and r(effect size)= .59 respectively (see Table 4 ).

After the implementation of the psychoeducation program patients significantly improve the positive motivation toward treatment. Findings show that on high level of motivation there 53(24.08%) participants at pre-assessment and after psychoeducation program they improve to 98(44.55%), which shows that 45(20.45%) participants improved. Similarly, 10(4.55%) improve their level of moderate motivation and almost 55(25.00%) participants improve their level of motivation from low to moderate and higher level of motivation (see Table 5 ).

Moreover, findings indicate patients with the low-income group was found significantly different as compared to patients with a middle and high-income group on positive (F= 224.70; p <. 001), negative (F= 99.71; p <.001) and general psychopathological symptoms scale (F=203.94, p <.001) among patients with schizophrenia disorder ( Table 6 ).

Results ( Figure 2 ) show that after 16 weeks of sessions, the psychoeducation program significantly reduced symptom severity, which shows that the psychoeducational program was found an effective intervention to developing insight, understanding, motivation, and positive change in cognitive and behavioral domains.

Findings show that the psychoeducation program significantly reduced positive, negative and general symptoms severity among all income groups while the significant improvement was observed among individuals with low income which reflects that the psychoeducation program was an effective and convenient intervention for low-income group (see Figure 3 ).

Results indicate that minor differences are seen in PANSS among patients with schizophrenia disorder after the implementation of a psychoeducation program (see Figure 4 ).

The design of the current study has certain inherent limitations. The first thing to be aware of is that this pilot trial used a single-arm design and included people with schizophrenia who were already on medication. Because there was no control group for comparison, the efficacy of our psychoeducation program cannot be evaluated with certainty. Therefore, to establish the effectiveness of our therapy, further confirmatory trials involving a control group are required. Another limitation of the study is the psychoeducation program focuses on people with the early onset. In addition, study on emphases on symptoms severity, motivation and help-seeking which are the main factor but study does not explain the other factors such as, chronicity, comorbid conditions, in-patients treatment etc. Although, this psychoeducation program remain successful; however, it need further implementation on the factors that are not addressed in this study that would determine program further efficacy and potential. Further, research may examine the feasibility of developing this psychoeducational curriculum into a stand-alone therapy intervention. In addition, while other factors that may affect treatment outcomes were not expressly targeted, the study placed a strong emphasis on patients’ treatment motivation and attitudes. These variables include the social and emotional support networks of the patients, their cognitive abilities, their emotional quotient, their general wellbeing, and other related variables. Future studies might take into account including these components in the intervention to offer a more thorough approach to treatment. Addressing these limitations, this program may be more comprehensive in nature and it can be emerged as a evidence-based psychoeducation program for patients with schizophrenia disorder.

The findings of this psychoeducation program might be effective for therapist, practitioners and policymakers who are working with patients with schizophrenia disorders. Findings of this program promote the trends of psychotherapy and psychosocial interventions for schizophrenia patients which lacks currently in Pakistan. This pilot study sought to examine how a psychoeducation program affected schizophrenia patients’ motivation, attitudes, and symptom severity. The program’s early findings showed promising improvements in symptom severity reduction. This study’s significance comes from its ability to direct and investigate additional psychoeducation program alternatives for patients in Pakistan. For practitioners and physicians involved in the treatment of schizophrenia in Pakistan, it can be a useful resource. The study also stresses how crucial it is to start treating patients with psychotropic drugs and psychosocial assistance as well. Additionally, the results imply that psychoeducation is a powerful tool for addressing problems with treatment resistance, low motivation, and unfavorable attitudes regarding getting assistance. The motivation and attitude of patients can be addressed, which will increase therapy engagement and result in better treatment outcomes. Clinicians can modify the psychoeducation curriculum created in this study for use with other psychiatric patients who display a lack of insight and motivation for treatment. Future researchers are urged to perform comprehensive randomized control trials utilizing our program as a model using the findings of this pilot study as the basis for a useful psychoeducation program in Pakistan.