Effect of a multichannel psychoeducation program on caregiving burden among caregivers of persons with schizophrenia: Randomized controlled trial

Abstract

Background

Long-term caregiving for individuals with schizophrenia, who typically present with cognitive deficits and reduced emotional expression, can result in significant caregiver burden when adaptation to caregiving roles proves challenging.

Objective

To evaluate the effectiveness of a novel multichannel psychoeducation program in reducing caregiving burden among caregivers of individuals with schizophrenia.

Design

A randomized controlled trial study employing a pretest-posttest design with intervention and control groups.

Setting

Psychiatric outpatient department of Thammasat University Hospital in Pathum Thani, Thailand.

Participants

Initially, 50 caregivers of individuals with schizophrenia with mild to moderate caregiving burden (scores ≥11) without comorbidities were recruited. Five participants withdrew due to inconvenience and loss of contact, resulting in 45 completers (23 intervention, 22 control).

Methods

Participants were purposively selected based on inclusion criteria and matched in pairs according to caregiving burden scores, Brief Psychiatric Rating Scale scores of care recipients, age, and gender before random allocation. The intervention consisted of a seven-session multichannel psychoeducation program delivered over 3–4 weeks: one initial 60-minute face-to-face session followed by six 40-minute video conference sessions via the Line application. The control group received only usual care. Caregiving burden was assessed at baseline and one month post-intervention.

Results

The intervention group demonstrated significantly reduced caregiving burden scores from pre-test to post-test (t=10.278, p<0.001). Moreover, between-group comparison revealed significantly lower caregiving burden in the intervention group compared to the control group one month post-intervention (t=3.711, p=0.001). While both groups showed some reduction in burden, the intervention group achieved low burden levels, whereas the control group remained in the moderate range.

Conclusions

This innovative multichannel psychoeducation program shows promise in reducing caregiving burden among caregivers of people with schizophrenia. The integration of both face-to-face and digital delivery methods enhanced accessibility and appeared to support caregiver outcomes. While these findings are encouraging, the study design limits the strength of causal inferences. Further studies with more rigorous methodologies are recommended to confirm effectiveness and guide integration of this approach into standard care for caregivers in Thailand.

What is already known.

•Caregiving burden stems from caregivers' perceptions of their situation and its impact on their lives.

•Psychoeducation can be effectively delivered in various formats.

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What this paper adds.

•A multichannel psychoeducation program—combining digital and remote delivery—significantly reduced caregiving burden compared with usual care

•The blended delivery format was feasible to implement and maintained effectiveness despite technical challenges, suggesting potential adaptability for diverse care contexts.

•The predominantly digital model showed resilience against healthcare service disruptions during and after the COVID-19 pandemic, supporting its use when in-person services are limited or unavailable.

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1. Introduction

Schizophrenia is a severe, chronic mental disorder affecting approximately 24 million people worldwide, impairing cognition, behavior, emotional expression, and perception of reality (WHO, 2022). Ranked as the 12th leading cause of years lived with disability globally (Charlson et al., 2018), schizophrenia contributed to 15.1 million disability-adjusted life years in 2019, with 1.3 million new cases reported that year (Solmi et al., 2023). In Thailand, where the prevalence rate is 0.7 %, nearly 300,000 patients received psychiatric care in 2022 (Department of Mental Health, 2022). The disorder's chronic nature is evidenced by its high relapse rate—81.9 % within five years of treatment—and low annual recovery rate of just 1.37 % (Kwansanit and Srisurapanont, 2018), necessitating long-term care and monitoring (Koujalgi and Nayak, 2016).

Caregivers are indispensable in the management of schizophrenia, with up to 70 % of affected individuals in Asian countries depending on them for daily activities and responsibilities (Gopal et al., 2017). However, this caregiving role exacts multidimensional impacts: physical (fatigue, care difficulties, illness), emotional (exhaustion, anxiety), social (reduced interactions), work-related (increased responsibilities), and personal (disrupted routines) (Rofail et al., 2016).

Caregiver burden—the perceived challenges related to the caregiving role—can be understood through Pearlin's stress process model (1990), which comprises background/context, stressors, mediators, and outcomes. When caregivers face overwhelming demands without adequate resources or social support, they experience increased burden and risk developing depression. Addressing these challenges is therefore crucial for caregiver wellbeing and sustainable patient care.

Psychoeducation offers a promising intervention, providing systematic education about schizophrenia, treatment options, medication, side effects, and problem-solving skills (Suwan and Keawkingkeo, 2020). Originating in German-speaking countries in the 1980s, it combines cognitive-behavioral approaches with therapeutic expertise and empowerment strategies, that the cognitive-behavioral methods included training in clarification and coping competence, problem-solving, self-assertiveness, and behavioral techniques to help manage symptoms and life stressors. Additionally, empowerment strategies were utilized to enhance self-competency, enabling patients and their families to become proficient in self-care. The approach emphasized family involvement and fostered a positive emotional perspective when discussing schizophrenia, aiming to reduce feelings of isolation and encourage active participation in the therapeutic process (Bäuml et al., 2006). By enhancing caregivers' knowledge and competence, psychoeducation helps reduce stress and perceived burden.

Traditional psychoeducation approaches have limitations, including lengthy face-to-face sessions exceeding 90 min, programs extending beyond 10 sessions, and telephone-based interventions that prevent observation of caregiver reactions (Martín-Carrasco et al., 2016). Furthermore, effects may not persist long-term, with increased burden often observed at six-month follow-ups. A multichannel approach utilizing various media (PowerPoint, videos, websites) addresses these limitations. Online psychoeducation particularly reduces stigma through anonymity (Alasmee and Alhadi Hasan, 2020) while enhancing accessibility and adaptability (Sin et al., 2017).

From the systematic review of telehealth tools and interventions to support family caregivers by Chi and Demiris (2015), 65 research studies were included in the systematic review: 33 studies specifically recruited family caregivers of adult and older patients; the remaining 32 focused on parental caregivers of pediatric patients. Information and communication technology-based psychoeducation has demonstrated effectiveness in reducing caregiver burden, increasing caregiver knowledge, and improving management confidence (Chi and Demiris, 2015), with participants reporting satisfaction regarding accessibility, flexibility, and customization (Sin et al., 2017). Recent comparative research by Karagiozi et al. (2022) found that both face-to-face and online psychoeducation significantly reduced caregiving burden (p < 0.0001).

This study adapts Seyedfatemi et al.'s (2021) virtual social network-based psychoeducation framework, which originally measured hope in caregivers of clients with severe mental disorders. Our adaptation applies Pearlin's (1990) stress process model to examine caregiving burden instead, focusing on seven key areas: (1) understanding schizophrenia, treatment, care planning, and burden; (2) self-awareness; (3) problem-solving; (4) stress management; (5) anger control; (6) effective communication; and (7) positive thinking. This comprehensive approach aims to improve caregivers' appraisal of their situation and reduce perceived burden.

Therefore, this study implements a multichannel psychoeducation program for caregivers of patients with schizophrenia at a university hospital in Thailand. By enhancing caregivers' ability to manage challenging behaviors and associated problems, we aim to improve their caregiving experience and reduce burden, ultimately benefiting both caregivers and the individuals they support.

2. Methods

2.1. Study design and setting

This study compared caregiving burden scores in caregivers of individuals with schizophrenia before and after a one-month intervention using a two-group pretest-posttest control group design. The researcher selected the sample group using purposive sampling based on the inclusion criteria. The research assistants helped verify that the participants were from the medical records of patients at the psychiatric outpatient department at xx University Hospital between March and October 2024. This study was conducted and reported in accordance with the CONSORT 2025 guidelines (Hopewell et al., 2025) for transparent reporting of interventional trials, with adaptations made for the randomized controlled trial.The study was conducted after obtaining approval from relevant Research Ethics Committees: 1) Research Ethics Office, Faculty of Nursing, xx University in February 2023 (021/2566), and 2) The Human Research Ethics Committee of xx University Hospital in October 2023 (022/2566).

2.2. Participants

Participant recruitment occurred from March to October 2024, with the intervention period running from November to December 2024. The inclusion criteria were: (1) primary caregivers providing care for at least 6 months; (2) aged 18–60 years; (3) consent to participate; (4) mild to moderate or higher caregiving burden (score ≥11 on the Thai version of the Zarit Burden Interview Scale); (5) absence of physical comorbidities (diabetes, cerebrovascular/heart diseases, emphysema, cancer, hypertension); (6) absence of cognitive issues (MMSE-Thai 2002 score ≥23 for education above elementary level, or ≥18 for elementary education); (7) ability to communicate in Thai; (8) ownership of an electronic communication device with LINE application and internet connectivity; and (9) caring for individuals with schizophrenia experiencing severe psychiatric symptoms (Brief Psychiatric Rating Scale score ≥36) without physical comorbidities.

Participants were excluded if they were currently participating in other research projects or had recently completed participation in other studies related to mental health programs or caregiving burden. Discontinuation criteria included missing two or more intervention activities or voluntary withdrawal.

Of the 50 participants enrolled, all had been randomized equally to the intervention (n = 25) and control groups (n = 25). In the intervention group, 23 participants had completed the intervention, with two withdrawing due to inconvenience. In the control group, 22 participants had completed follow-up, with two withdrawing and one lost to contact. The flow diagram is presented in Fig. 1.

Fig. 1.

Trial flow diagram of study enrolment, allocation and follow-up.

2.3. Study procedures

A research assistant with a Bachelor's degree in Nursing Science, valid nursing license, and at least three years of psychiatric experience was trained in electronic communication tools and the Thai version of the Zarit Burden Interview. Participants who met inclusion criteria were matched in pairs and randomly assigned to intervention or control groups. The intervention group received multichannel psychoeducation plus usual care, while the control group received only usual care. Caregiving burden scores were assessed at baseline and one month after the intervention.

2.4. Matching and group allocation

Fifty participants were matched in pairs based on caregiving burden scores (11–29 or 30–48), brief psychiatric rating scale of care recipients (36–72 or 73–108), age (20–40 or ≥41 years), and gender (female or male). After creating 25 matched pairs, group assignment was conducted using a lottery method. Participants were randomly assigned to either the control group (n = 25) or intervention group (n = 25) using simple random sampling, where each participant had an equal probability of being assigned to either group.

2.5. Usual care

Both groups received usual care, which included psychiatric evaluation and treatment for the individuals with schizophrenia, and psychoeducation or mental health guidance for the caregivers. This guidance covered information about schizophrenia, warning signs requiring medical attention, medications, and potential side effects.

2.6. Multichannel psychoeducation program

The intervention, adapted from Seyedfatemi et al.'s (2021) online social network-based psychoeducation program, consisted of seven sessions. The first session (60 min) was delivered face-to-face at a psychiatric outpatient department, covering schizophrenia, care planning, and caregiving burden concepts. The subsequent six sessions were conducted via video conference through the Line application, with two 40-minute sessions per week in small groups of 12–13 participants. These sessions focused on: (2) self-awareness skills, (3) problem-solving skills, (4) stress management skills, (5) anger control skills, (6) effective communication skills, and (7) positive thinking skills. Materials included electronic media (infographics and videos) and a psychoeducation handbook.

Several practical challenges were encountered during implementation. Some participants were requested to deactivate their cameras when participating from public locations, and intermittent internet connectivity issues prevented continuous full attendance for certain participants. To address these limitations and ensure consistent access to intervention content, supplementary learning materials, including videos and infographics, were distributed through the LINE application. These resources allowed participants to review session content at their convenience, reinforcing key learning objectives and compensating for any missed portions of the synchronous sessions.

2.7. Outcome measures

The primary outcome was caregiving burden, assessed using the Zarit Burden Interview (Thai version) through a telephone interview one month after the completion of the intervention.

2.7.1. Personal information questionnaire

A researcher-developed questionnaire collected demographic and caregiving characteristics, including gender, age, marital status, relationship with the individual with schizophrenia, education level, occupation, income, caregiving duration, daily sleep hours, hospitalization history of the care recipient, additional caregiving support, responsibility for other dependents, and caregiver health conditions.

2.7.2. The Zarit Burden Interview (Thai version)

This validated 12-item scale by Silpakit et al. (2015) measures three dimensions of caregiver burden: impact (items 1, 7–10), stress (items 2–6), and perceived care (items 11, 12). Items are rated on a 5-point scale (0 = never, 1 = rarely, 2 = sometimes, 3 = quite often, 4 = almost always). Score interpretation categorizes burden as: no burden to minimal burden (0–10 points), minimal to moderate burden (11–20 points), and severe burden (>20 points). The Zarit Burden Interview (Thai Version) has been validated for its content and demonstrated good internal consistency, with a Cronbach’s alpha coefficient of 0.88 (Silpakit et al., 2015). The researcher tested the reliability of the Zarit Burden Interview 12-item scale with caregivers who were similar to the study sample, consisting of 30 individuals at another hospital, but with a similar service. The reliability was measured using the Cronbach’s alpha coefficient, which yielded a value of 0.92, indicating an acceptable level of reliability.

2.8. Statistical methods

2.8.1. Sample size calculation

Sample size was calculated based on Seyedfatemi et al.'s (2021) study examining the effect of virtual social network-based psychoeducation on family caregivers' hope. Using Cohen's formula (Cohen, 1988; Lakens, 2013), an effect size of 2.9 was derived from their reported means (intervention: 8.53, control: 0.19) and standard deviations (intervention: 3.35, control: 2.28). The required sample size was calculated as 21 participants per group (42 total). To account for potential attrition, the sample size was increased by 20 % (Polit and Beck, 2008), resulting in 25 participants per group (50 total).

2.8.2. Data analysis

Data analysis was performed using SPSS Version 29.0:

1. Descriptive statistics (frequency distributions, means, standard deviations) characterized the sample demographics.

2. The Kolmogorov-Smirnov test confirmed normal distribution of caregiving burden scores.

3. Between-group differences in caregiving burden were assessed using Independent Samples t-tests.

4. Within-group changes in caregiving burden (pre-test to post-test) were analyzed using Paired Samples t-tests.

2.9. Intervention fidelity

To ensure consistency and integrity in delivering the intervention as designed, several measures were implemented. All intervention sessions followed standardized protocols with clearly defined content and delivery methods. Participants received detailed instructions on using the LINE application for video conferencing, including information on privacy procedures such as changing display names and managing camera permissions. The research team established strict confidentiality guidelines that prohibited the recording of sessions. Participants were instructed to participate from private locations to maintain privacy and minimize distractions. These procedures ensured that the intervention was delivered uniformly to all participants in the experimental group, supporting the internal validity of the study.

2.10. Blinding

Blinding was not applied in this study due to the nature of the intervention, which required active participation in face-to-face and online psychoeducational sessions. Consequently, both participants and researchers were aware of group assignments.

3. Results

3.1. Recruitment

From the initial 50 caregivers who met inclusion criteria and were randomly assigned to intervention (n = 25) or control (n = 25) groups, 45 participants (90 %) completed the full study protocol through the 8-week follow-up assessment. The attrition was minimal and relatively balanced between groups, with dropout rates of 4 % (n = 2) in the intervention group and 6 % (n = 3) in the control group. This resulted in final analytical samples of 23 participants in the intervention group and 22 in the control group (Fig. 1).

Reasons for discontinuation included loss of contact with participants, self-withdrawal due to scheduling conflicts or personal inconvenience, and geographical relocation for medical treatment.

3.2. Baseline characteristics

Analysis of demographic data revealed comparable characteristics between the intervention and control groups, confirming effective randomization (Table 1). The mean age was nearly identical between groups (intervention: 49.56 years; control: 49.64 years). Both groups had a female predominance, with women comprising 65.20 % of the intervention group and 72.72 % of the control group. Participants were primarily parents of individuals with schizophrenia in both the intervention (30.4 %) and control (40.9 %) groups.

Table 1.

Demographic and characteristics (N = 45).

Variables	Control group (n = 23)	Intervention group (n = 22)				X2	p-value
	n	%	n	%
Age
18–29	2	8.7	0	0.0		0.002	0.966
30–39	3	13	5	22.7
40–49	3	13	4	18.2
50–59	8	34.8	7	31.8
60 up	7	30.4	6	27.3
Sex
Male	8	34.8	6	27.3		2.766a	0.7
Female	15	65.2	16	72.7
Marital status
Single	6	26.1	5	22.7		3.695	0.336
Married	13	56.5	14	63.6
Divorced	1	4.3	3	13.6
Widowed	3	13	0	0.0
Relationship to the Person with Schizophrenia
Father	4	17.4		2		9.1	6.352	0.655
Mother	3	13		7		31.8
Offspring	2	8.7		3		13.6
Husband	3	13		3		13.6
Wife	2	8.7		2		9.1
Older sister/brother	3	13		4		18.2
Younger sister/brother	4	17.4		1		4.5
Uncle/Aunt	1	4.3		0		0.0
Education level
Primary School	5	21.7		6		27.3	0.871	0.916
Secondary School	7	30.4		8		36.4
Associate degree or Equivalent	2	8.7		1		4.5
Bachelor's degree	9	39.1		7		31.8
Occupation
Government Employee	2	8.7		0		0.0	5.086	0.873
Farmer	0	0		1		4.5
Own Business	4	17.4		5		22.7
Labourer	1	4.3		0		0.0
Regular Employee	2	8.7		3		13.6
Freelance	1	4.3		1		4.5
Student	1	4.3		0		0.0
Other	12	52.2		12		54.5
Monthly Income
<10,000 Baht	6	26.1		3		13.6	2.611	0.663
10,001 - 20,000 Baht	7	30.4		9		40.9
20,001 - 30,000 Baht	5	21.7		7		31.8
30,001 - 40,000 Baht	2	8.7		2		9.1
Monthly Income
>40,000 Baht	3	13		1	4.5
Duration of Caring for a Person with Schizophrenia (Years)
<1 year	1	4.3		0	0.0		2.722	0.458
1 - 5 years	5	21.7		3	13.6
5 - 10 years	5	21.7		9	40.9
>10 years	12	52.2		10	45.5
Number of Hours of Sleep per Day
5 - 9 h	23	100		21	95.5		1.069a	0.489
>9 h	0	0		1	4.5
Other People Helping with Care
No	21	91.3		21	95.5		0.311a	1.000
Yes	2	8.7		1	4.5
Also, must take care of disabled people or other patients
No	22	95.7		21	95.5		0.001a	1.000
Yes	1	4.3		1	4.5
Number of hospital admissions for patients with schizophrenia
Never	8	34.8		9	40.9		0.118	0.733
1 - 3	13	56.5		10	45.5
3 - 6	2	8.7		1	4.5
>6	0	0		2	9.1

Note. Data analyzed using descriptive statistics (frequency distribution, mean, and standard deviation). N indicates the total number of participants; n indicates the number of participants in a subgroup.

Educational attainment was similar between groups, with bachelor's degree holders representing the largest segment in both the intervention (39.1 %) and control (31.8 %) groups. Self-employment was the most common occupational category (intervention: 17.4 %; control: 22.7 %), and monthly income predominantly fell within the 10,001–20,000 baht range (intervention: 30.4 %; control: 40.9 %).

Regarding caregiving characteristics, most participants had provided care for >10 years (intervention: 52.2 %; control: 45.5 %). Sleep patterns were consistent across groups, with 100 % of the intervention group and 95.5 % of the control group reporting 5–9 h of sleep daily. Most care recipients had been hospitalized 1–3 times (intervention: 56.5 %; control: 45.5 %). The vast majority of participants in both groups were sole caregivers without additional assistance (intervention: 91.3 %; control: 95.5 %) and had no other caregiving responsibilities for persons with disabilities or other patients (intervention: 95.7 %; control: 95.5 %).

Statistical analysis confirmed no significant differences in any demographic or caregiving variables between groups (p > 0.05 for all comparisons).

3.3. Outcomes

3.3.1. Comparison of caregiving burden scores between groups

Both intervention and control groups exhibited comparable moderate caregiving burden at baseline, confirming successful randomization. Following the one-month intervention period, a dramatic divergence in burden scores emerged between groups. It was analyzed using the Independent Sample t-test. (Table 2).

Table 2.

The Comparison of the average caregiving burden scores between the intervention and control groups.

Time	Group	n	Mean	Std. Deviation	t	p-value
Pre-test	Intervention	23	16.609	3.714	0.311	0.758
			(moderate)
	Control	22	16.273	3.535
			(moderate)
Post-test	Intervention	23	7.609	3.381	−6.211	< 0.001
			(mild)
	Control	22	13.500	2.956
			(moderate)

The intervention group demonstrated a substantial and clinically meaningful reduction in caregiving burden, with mean scores decreasing from the mild-to-moderate burden range (Mean = 16.61, SD = 3.12) to the no-to-minimal burden range (Mean = 7.61, SD = 3.54), representing a 54.2 % reduction. In contrast, the control group experienced a more modest improvement, with burden scores decreasing but remaining within the mild-to-moderate range (Pre-test Mean = 16.27, SD = 3.08; Post-test Mean = 13.50, SD = 4.21), representing only a 17.0 % reduction.

Between-group analysis confirmed that the intervention group exhibited significantly greater reductions in caregiving burden compared to the control group (t = 6.211, p < 0.001), with a large effect size (Cohen's d = 1.84).

3.3.2. Comparison of caregiving burden scores before and after intervention within the intervention group

Within-group analysis of the intervention group revealed a statistically significant reduction in caregiving burden scores from baseline to post-intervention assessment at one month. The mean pre-intervention score was 16.61 (SD = 3.12), which decreased to 7.61 (SD = 3.54) post-intervention, resulting in a mean difference of 9.00 points (SD = 4.19).

Paired samples t-test analysis confirmed that this reduction was highly significant (t = 10.278, p < 0.001). This represents a 54.2 % decrease in caregiving burden scores after participants received the multichannel psychoeducation program in addition to usual care. The complete pre-post intervention data for the intervention group are presented in Table 3.

Table 3.

The Comparison of the average caregiving burden scores before and after 1 month of the intervention within the intervention group.

Intervention group (n = 23)
Time	Mean	Std. Deviation	t	p-value
Pre-test	16.609	3.714	t = 10.278	< 0.001
Post-test	7.609	3.381

3.3.3. Comparison of caregiving burden scores before and after intervention within the control group

Within-group analysis of the control group also revealed a statistically significant reduction in caregiving burden scores from baseline to the one-month assessment point. The mean pre-intervention score was 16.27 (SD = 3.08), which decreased to 13.50 (SD = 4.21) at follow-up, resulting in a mean difference of 2.77 points (SD = 3.52).

Paired samples t-test analysis confirmed that this reduction was statistically significant (t = 3.711, p = 0.001). This represents a 17.0 % decrease in caregiving burden scores among participants who received only usual care. The complete pre-post intervention data for the control group are presented in Table 4.

Table 4.

The Comparison of the average caregiving burden scores before and after 1 month of the intervention within the control group.

Control group (n = 22)
Time	Mean	Std. Deviation	t	p-value
Pre-test	16.272	3.535	t = 3.711	0.001
Post-test	13.500	2.956

3.4. Safety and intervention engagement

The implementation of the multichannel psychoeducation program proceeded without any reported adverse events. All video conferences conducted through the LINE application adhered to Personal Data Protection Act requirements to safeguard participant privacy and confidentiality.

To optimize engagement and interaction, the intervention group (n = 23) was divided into two smaller subgroups, enabling the researcher to provide individualized attention to each participant across all sessions. This approach facilitated active participation and personalized support throughout the intervention.

4. Discussion

4.1. Effect of the multichannel psychoeducation program

This study using a pretest-posttest control group design demonstrated the efficacy of a multichannel psychoeducation program in reducing caregiving burden among caregivers of individuals with schizophrenia. The homogeneity between groups strengthens the internal validity of the study by minimizing potential confounding factors, thereby allowing any observed differences in caregiving burden to be more confidently attributed to the multichannel psychoeducation intervention rather than to pre-existing group differences. The comparable dropout rates between groups and the overall high retention rate (90 %) strengthen the validity of our findings by minimizing potential selection bias that could arise from differential attrition. This robust participation rate also suggests the feasibility and acceptability of the multichannel psychoeducation program among caregivers of individuals with schizophrenia. The intervention group exhibited a statistically significant reduction in caregiving burden scores post-intervention compared to baseline (p < 0.001) and achieved significantly lower burden scores than the control group (p < 0.001).

The intervention group demonstrated a dramatic 54.2 % reduction in burden scores, transitioning from moderate to minimal burden levels—a clinically meaningful improvement that likely translates to enhanced quality of life and psychological wellbeing. While usual care alone produced modest improvements, the addition of structured psychoeducation yielded substantially superior outcomes, highlighting the value of this targeted intervention.

The multichannel delivery model represents a particularly promising innovation in caregiver support. By combining an initial face-to-face session with subsequent video-based interactions, this approach balances the benefits of personal connection with enhanced accessibility and convenience. Such flexibility is especially valuable for caregivers who face significant time constraints and logistical challenges due to their caregiving responsibilities.

The observed therapeutic effect can be conceptualized through Pearlin's (1990) stress process model, which posits that psychosocial interventions function as mediators between stressors and outcomes. The multichannel psychoeducation program equipped caregivers with specialized knowledge and adaptive skills to manage care recipients' challenging behaviors. By enhancing caregiver competence and self-efficacy, the intervention enabled participants to appraise caregiving situations more positively and deploy effective coping strategies, thereby mitigating stress and perceived burden.

Notably, the control group also demonstrated a significant, albeit smaller, reduction in caregiving burden. This improvement likely stems from the usual care components, which included basic information about schizophrenia, medication management, and general caregiver guidance. This finding underscores that even minimal psychoeducational interventions can yield modest benefits, though comprehensive programs produce superior outcomes.

Although usual care alone (control group) produces some improvement in caregiving burden, the addition of the multichannel psychoeducation program yields significantly superior outcomes, enabling caregivers to transition from moderate to minimal burden levels. The magnitude and statistical significance of this difference highlight the robust therapeutic efficacy of the multichannel psychoeducation program in addressing caregiving burden among caregivers of individuals with schizophrenia, beyond what can be achieved through usual care interventions alone.

Our results align with and extend previous research. Laorsuwan and Jiratjintana (2018) similarly found significant reductions in caregiver burden following face-to-face psychoeducation. However, our study advances the field by demonstrating comparable efficacy with a more accessible multichannel delivery model that reduces participation barriers. Similarly, Iyidobi et al. (2022) reported substantial reductions in caregiver burden (η² = 0.39) following outpatient psychoeducation, and Tessier et al. (2023) documented significant burden reduction (p = 0.031) after family psychoeducation.

In contrast to our findings, Yasuma et al. (2024) observed non-significant reductions in burden at both one-month (aMD = 0.27; 95 % CI: −5.48 to 6.03; p = 0.93) and six-month follow-ups (aMD = −2.12; 95 % CI: −7.80 to 3.56; p = 0.45) in their cluster-randomized trial. This discrepancy may reflect differences in intervention intensity, content focus, or measurement sensitivity. Our intervention's superior efficacy might stem from its comprehensive skill-building components and multichannel delivery format, which enhances accessibility while maintaining therapeutic intensity.

The transition from moderate to minimal burden levels in our intervention group represents not merely a statistically significant change but a clinically meaningful improvement that likely translates to enhanced quality of life for caregivers. The multichannel format offers particular advantages in resource-constrained settings and during healthcare disruptions, making it a pragmatic, scalable approach for supporting this vulnerable population.

4.2. Limitations

This study has several methodological limitations that warrant consideration when interpreting the findings:

First, the remote data collection methodology may have introduced social desirability bias. Due to participants' inability to attend in-person follow-up assessments, caregiving burden was evaluated via telephone and LINE calls rather than self-administered questionnaires. This interviewer-administered approach may have prompted participants to provide responses they perceived as socially acceptable or pleasing to the researcher. Although this limitation affected both intervention and control groups equally, potentially mitigating differential bias, it may have influenced the absolute burden scores reported.

Second, the study lacks the full randomization of a true experimental design. Despite careful matching of pairs based on multiple variables before randomization, unmeasured confounders may still have influenced outcomes.

Third, the relatively short one-month follow-up period limits our understanding of the intervention's long-term sustainability. Previous research suggests that psychoeducation effects on caregiving burden may diminish over time, warranting extended follow-up assessments to determine whether booster sessions might be necessary to maintain benefits.

Fourth, the sample was drawn from caregivers of individuals receiving outpatient treatment at a university hospital, potentially limiting generalizability to caregivers of individuals with more severe presentations requiring inpatient care or those without access to specialized psychiatric services.

Fifth, the multichannel delivery format, while innovative, faced implementation challenges including connectivity issues and occasional participant absence. Although supplementary materials were provided, the impact of these technical difficulties and missed content on intervention efficacy is unclear.

Finally, despite the intervention's effectiveness in reducing overall caregiving burden, our analysis did not examine differential effects on the specific dimensions of burden as measured by the Zarit Burden Interview (Thai version). A more granular analysis might reveal which specific aspects of burden are most responsive to psychoeducational intervention, potentially informing more targeted approaches in future research.

5. Conclusion

This study demonstrates that a multichannel psychoeducation program can significantly reduce caregiving burden among caregivers of individuals with schizophrenia. While the findings are encouraging, they should be interpreted with caution due to methodological limitations, including the study lack of blinding, reliance on interviewer-administered assessments, and a relatively short follow-up period. Nevertheless, the results suggest that structured psychoeducation may be a valuable adjunct to standard mental health services, with potential to enhance family support in outpatient care settings.

Future research should extend follow-up assessments to evaluate the sustainability of intervention effects over 3, 6, and 12 months, explore differential impacts on specific dimensions of caregiving burden, and examine cost-effectiveness across delivery models. Such studies will be critical to refining implementation strategies and informing policy on the integration of psychoeducational programs into routine psychiatric care.

Declaration of AI-assisted technologies in the writing process

During the preparation of this work, the authors used ChatGPT and Claude to paraphrase a few statements generated by the authors. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

CRediT authorship contribution statement

Anassaya Chueachalad: Writing – original draft, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Chalinee Suvanayos: Writing – review & editing, Validation, Supervision. Patraporn Bhatarasakoon: Writing – review & editing, Visualization, Validation, Supervision, Methodology, Funding acquisition, Data curation, Conceptualization.

Declaration of competing interest

None