Asian Journal of Psychiatry xxx (xxxx) xxxx

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Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Transformation of attitude through brief psychoeducation program for the

husbands of women with postpartum psychiatric disorders
Veenashree Anchan, Navaneetham Janardhana
Department of Psychiatric Social Work, National Institute of Mental Health & Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India

ARTICLE INFO ABSTRACT

Keywords: According to existing literature on Perinatal Psychiatric Services, husbands have not often been involved in the
Postpartum psychiatric disorders treatment of their spouses with Perinatal Psychiatric disorders, especially in India, despite the advantages as an
Attitude adjunctive form of therapy. The current study aimed at evaluating the effectiveness of brief psychoeducation on the
Brief psychoeducation attitude of husbands of women with postpartum psychiatric disorder through a biopsychosocial based informative
Husbands
and supportive model of intervention. A 3 session based Brief Psychoeducation Program (BPP) was developed for
the targeted population and its effectiveness was evaluated through quasi-experimental research design. Using
Community Attitude towards Mentally Ill Scale (CAMI) assessment of the outcome variable was done at 3 levels
i.e., Pre (baseline), Post (immediately after the intervention) and Follow-up post (1 month after the intervention).
A total of 21 participants were recruited meeting the study criteria. Friedmans test and descriptive statistics were
used to analyze the data. Results indicated the transformation in the attitude of the participants in all the 4
domains of the scale from pre-intervention to post-intervention phase. The study has a strong implication for
mental health professionals in this area at both clinical (medical and psychiatry settings) and nonclinical settings.

1. Introduction
With the shift to the next stage of life cycle, pregnancy and birth of a
child prescribe new roles and responsibilities along with certain challenges
in the couple subsystem (Belsky and Rovine, 1990). This new switch
further might get exacerbated when a woman is affected with perinatal
psychiatric disorder due to its diverse and complex nature in the form of its
manifestation and consequence at individual, familial and societal level
(Ganjekar et al., 2013; Tareen and Tandon, 2018; Thippeswamy et al.,
2015) resulting in wide range of psychological, physical and social
changes in the family functioning at the larger level (Nielsen et al., 2000;
Tareen and Tandon, 2018). To get adapted to such changes most often
these women require a great deal of support from their husbands and other
immediate spheres (Tammentie et al., 2004; Tarkka et al., 2000).
In contrast to the western ‘technocentric’ culture, in Asia ‘ethnokinship’
culture with prescribed form of organized family support rituals are prac-
ticed during postpartum period for a more protracted time (Dennis et al.,
2007). Most often such supportive rituals are performed by the family of
origin. Development of mental illness during this period might significantly
affect such ritualistic practices. When a husband typically turns out for his
partner's emotional support and play a critically important role in the lives
of women affected postpartum psychiatric disorders (PPDs) they are at risk
for mental health problems (Ballard and Davies, 1996; Goodman, 2004;
Lovestone and Kumar, 1993) because of the fact that husband's role is not
just limited as a relative of a person having PPD but they undergo a
transition period as a father (Bielawska-Batorowicz and Kossakowska-
Petrycka, 2006; Soliday et al., 1999). In addition studies have found that
apart from role strain and societal demands associated with masculine
norms of stoicism, having inadequate knowledge on condition of the
spouse may lead to developing negative attitude towards mental illness
which in turn trigger the relationship issues between the couple (Condon,
2006; Engqvist and Nilsson, 2011; Genesoni and Tallandini, 2009; Habel
et al., 2015; O’Brien et al., 2017) which further escalates husbands risk of
developing psychiatric conditions (Condon et al., 2004).
NICE guideline states that “health professionals should assess, and
address the needs of the partner, family members and carers of a woman
with mental illness." Similarly as generated by the evidence, along with
screening the mental health condition in men, providing timely support
is essential as a part of different services prescribed for PPD (Fletcher
et al., 2015; Ong et al., 2019). Unfortunately, the whole stretched ma-
ternity mental health services do not provide husbands with information
and support, despite the buffering effect this would have on the treat-
ment process of the women with PPDs and their families.
Studies evaluating the effectiveness of psychoeducational program
for the caregivers of different types of mental illnesses found to be ef-
fectual in enhancing the knowledge & attitude about the condition,

E-mail address: veenashreeanchan@gmail.com (V. Anchan).

https://doi.org/10.1016/j.ajp.2019.101841
Received 7 August 2019; Received in revised form 15 October 2019; Accepted 15 October 2019
1876-2018/ © 2019 Elsevier B.V. All rights reserved.

Please cite this article as: Veenashree Anchan and Navaneetham Janardhana, Asian Journal of Psychiatry,
https://doi.org/10.1016/j.ajp.2019.101841
V. Anchan and N. Janardhana
better prognosis and relapse prevention of the persons with mental
illness (Kulhara et al., 2009; Lukens and McFarlane, 2004; Navidian
et al., 2012; Thornicroft et al., 2016). However there are few efforts
have made in the area of PPDs with the similar objectives which proven
its efficacy favoring to the overall wellbeing of both women with PPD
and their husbands in both Asian & other western countries (Alliance,
2013; Consortium, 2008; Fisher et al., 2010; Ragesh et al., 2016;
Gajaria and Ravindran, 2018; Hogg, 2013; O’Brien et al., 2017).
As a whole literature implies two major observations; first, the lack
of knowledge hinders the ability of the husband to understand his wife’s
behavior leading to develop negative attitude; and second, the father
himself may suffer from depression, resulting in furthermore changes in
his attitude towards his wife (Khan et al., 2009). As implied by number
studies there is a great need for involving husbands in the process of
non-pharmacological interventions (Das and Phookun, 2014; Gawlik
et al., 2014; Ong et al., 2019), in the form of providing sensitively
understandable information and also acknowledging their concerns in
many areas of uncertainty as a part of optimal care of women with PPD
and their caregivers (Dudley et al., 2001; Jones et al., 2014). Hence
there is a great need to establish the effectiveness of psychoeducation
with limited sessions considering the practical issues of the husbands of
women with PPD based on their level of knowledge and attitude about
the mental illness as a whole with the special focus on PPDs. As there is
no standardized module developed in this area to provide psychoedu-
cation especially in Indian context this study would contribute in terms
of assessing the knowledge and attitude of the spouse, developing an
intervention package for providing brief psychoeducation and bridging
the gap in the literature.
Therefore the current research was done with the aim to evaluate
the effectiveness of brief psychoeducation on the attitude of husbands
of women with postpartum psychiatric disorder through a biopsycho-
social based informative and supportive model of intervention. The
study also hypothesized that Brief psychoeducation will enhance the
positive attitude of the participants towards mental illness.
2. Methodology
2.1. Research design and measures
Quasi-Experimental research design only with the intervention
group was adopted for the present study. Total 21 participants who
were the husbands of women with PPDs admitted under inpatient care
of Mother-Baby Ward (MBW) of NIMHANS, Bengaluru, India, between
the timeframe of 1st October 2016, to 31st March 2017 (6months) re-
cruited for the study. Participants reported to have active psychiatric
disorders and those were husbands of women below 18 years of age
diagnosed with PPDs were excluded from the study.
A Semi-structured interview schedule was developed for capturing
the socio-demographic details (SDD) of the participants and their
spouse, along with a brief profile of the illness as observed by the
participants. A 22 item semi-structured interview schedule was pre-
pared by the researcher to assess the knowledge of the participants on
PDDs. A detailed article on this variable (knowledge) is in the process of
Fig. 1. Outline of the intervention process.
2
Asian Journal of Psychiatry xxx (xxxx) xxxx
publication (Veenashree and Navaneetham, 2019). To assess the atti-
tude which is the focus of this article, Community Attitude towards the
Mentally Ill scale (CAMI, 1979) developed by Michael J. Dear and S.
Martin Taylor was used. It consists of 40 items aiming at measuring the
attitude towards mental illness in 4 main domains i.e., Authoritar-
ianism, Benevolence, Social Restrictiveness, and Community Mental
Health Ideology. Each of these domains consists of 10 items in which 5
are anti scoring (forward scoring 1–5) and 5 are pro scoring (backward
scoring 5-1) on a 5 point Likert type scale ranging from strongly agree
to strongly disagree.
3. Study process
3.1. Development and validation of a Brief Psychoeducation Programme
(BPP)
Literature review was done on a different interventional study
aiming at providing psychoeducation to the caregivers of persons with
PPD's and other types of severe mental illnesses. Based on which an
informative and supportive model of a brief psychoeducation program
for the current study was developed targeting 3 sessions which could be
given on a daily or weekly basis as per the convenience and availability
of the participants with the duration ranging from 1 h to 1 h 30 min.
The first session focuses on orienting the participants about BPP,
dealing with misconceptions on PPDs, nature and common signs and
symptoms of PPD; the second session deals with educating participants
on Biopsychosocial Model of illness; and the last session aims at
building understanding of the participants regarding their role in
management of PPD along with taking care of one's health. Once BPP
was developed it has been face validated by the 5 experts working in
the area of Perinatal Psychiatry.
3.2. Process of intervention
After gathering the socio-demographic variables of the participants'
baseline assessment of the attitude and other targeted variable was
done. Followed by this psychoeducational intervention was delivered to
the participants using the Brief Psychoeducation Programme developed
by the researcher. Although initially group methodology was planned
due to the practical difficulties individual mode was adopted for the
delivery of the intervention. These 3 sessions were provided both on a
daily and weekly basis as per the time convenience of the participants.
Post assessment was done immediately after completion of all the 3
sessions and after 1 month of completion of the intervention, follow-up
post-assessment was using the same set of measures. Fig. 1. 0 gives a
clear picture of the process of intervention.
3.3. Data analysis
The data gathered was coded and entered in the Statistical Package
for Social Sciences (SPSS) IBM 22.0 version. Shapiro – Wilk (SW) test
was performed for the variables of interest at baseline and it was ob-
served that the variables do not follow a normal distribution. Thus,
V. Anchan and N. Janardhana
nonparametric tests i.e., Friedman test and pair-wise comparison were
used to analyze the data.
3.4. Ethical considerations
Ethical approval from the institute ethics committee was obtained.
Before enrolling in the intervention debriefing session was done and
written informed consent was obtained from the participants.
Appropriate individual referrals were made to the adult psychiatry
units as and when observed to be necessary for the participants.
4. Results
4.1. Socio-demographic characteristics of the participants and their spouse
(WWPPD) along with a brief illness profile
Among the participants more than half (66.7%) were belonging to
the age group between 31–40 years, on the other hand, a vast number of
the women with PPD (WWPPD) (95.2%) who were the spouse of the
participants were belonging to the age group ranging from 20 to 30
years. Comparatively a good number (42.9%) of participants were edu-
cated up-to 7th standard and more than half i.e., 66.7% of WWPPD were
studied ranging from 10th -12th standard. Little more than half (57.1%) of
the participants were holding an elementary. On the contrary, none of
the WWPPD was engaged in any sort of income-generating employment
with a total score of 100.0% in the homemaker category.
Slightly more than half (61.9%) of them were residing in an urban
area. A good number of respondents (66.7%) were hailing from a below
poverty line (BPL) family with the annual family income ranging from
1000-20,000/- rupees.
Little less than half (47.6%) of the WWPPD had developed sub-acute
onset ranging from 2weeks to 1 month, followed by which 42.9% of them
had insidious onset i.e., more than 1 month for its syndromal level of
manifestation. A very limited number (9.5%) of them had an acute onset
of illness ranging from 48 h to 2 weeks as observed by the participants.
Slightly more than half (52.4%) of the respondents started obser-
ving behavioral changes in their spouses within a year after delivery. A
good number (38.1) of women also started showing behavioral changes
during pregnancy ranging from conception up-to delivery; on the other
hand, a small number (9.5%) of women had demonstrated behavioral
changes even before delivery which continued thereafter as observed
by the participants.
4.2. Distribution of attitude of the participants at 3 phases (Pre, Post, and
Follow-up post) in 4 domains
Table 1 denotes the distribution of attitude of the participants to-
wards persons with mental illness in 4 main domains i.e., authoritar-
ianism, benevolence, social restrictiveness, and community mental
health ideology, at pre (Phase 1), post (Phase-2) and follow-up post
(Phase-3) level by performing the Friedman's Test.
The median difference between Phase-1 and Phase-2 in all the 4
domains shows the change in the attitude of the participants towards
the persons with mental illness from pre-intervention level to post-in-
tervention level. In the domains of benevolence and community mental
health ideology, the change occurred after the intervention had sus-
tained even after 1 month of the intervention as indicated by the
median score which remained the same at Phase-3 in those domains.
4.3. Pairwise comparison of Attitude of the participants at 3 phases (Pre,
Post, and Follow-up post) in 4 domains
To test the research hypothesis Freidman's pair-wise comparison
(Table 2) was done at different phases in all the 4 domains as there was
a difference noticed as explained in Table 1.
In against the null hypothesis, pairwise comparison observed to be
3
Asian Journal of Psychiatry xxx (xxxx) xxxx
statistically significant between Phase-1 to Phase-2 and Phase-1 to
Phase-3, in the domains of authoritarianism and community mental
health ideology (.000 in both the pairs) and also in the domain of social
restrictiveness (.002 and .026 respectively). In the domain of bene-
volence, although the results are not statistically significant in both
Phase-1 to Phase-2 and Phase-1 to Phase-3 as in the other 3 domains, it
remains significant by supporting the hypothesis.
As the study doesn’t aim at measuring the difference between Phase-
2 to Phase-3, in against to the results which are not statistically sig-
nificant at this pair, still it go in accordance with the hypothesis which
looks at the sustenance of the attitude change occurred immediately
after the intervention to after 1 month of intervention, in all the 4
domains.
5. Discussion
It's a well-established fact that during the period of evolution to the
parenthood men and women have equal risks of getting perinatal psy-
chiatric disorders. In Indian set up there is en number of rituals per-
formed in association with pregnancy and childbirth (Choudhry, 1997;
Dennis et al., 2007; Rodrigues et al., 2003; Thippeswamy et al., 2015).
In this phase when a woman unexpectedly develops PPD automatically,
husbands are expected to play vital roles that are often culturally pre-
scribed (Rahman et al., 2003). Unpreparedness combined with lack of
awareness about the condition and also not having accurate under-
standing on their role in management may influence the husbands in
developing negative attitude towards the spouse which further esca-
lates the problem and pose a great threat on the family functioning at
larger level (Engqvist and Nilsson, 2011; Genesoni and Tallandini,
2009; Habel et al., 2015; O’Brien et al., 2017).
As knowledge and attitude are two inseparable constructs in the
current study by providing knowledge through the BPP assessment was
done to observe the attitudinal change among the participants. In
comparison to baseline scores in the CAMI scale in both post and post-
follow-up phases, there were changes in the scores in all the 4 domains.
In support of the study hypothesis, pairwise comparison brought out
statistically significant results. Thus this results explain that compara-
tively there was a positive change in the attitude among the partici-
pants immediately after the intervention, with the increase more em-
pathetic and receptive (benevolence) attitude and considering their
spouse in more inclusive and integrative manner as a person who is a
part of their life and the larger community with equal dignity and re-
spect (community mental health ideology). At the same time not con-
sidering the person with mental illness as inferior to others with more
warmth (authoritarianism) and considering them with more positive
regard without posing threat to their right to freedom and participation
in the normative activities (social restrictiveness). Involving the com-
ponent of facts about mental illness, role of negative expressed emotion
in maintenance of symptoms and relapse as a part of the role of spouse
in management, giving the rationale for their (WWPPD) behavioral
change as a part of symptomatology would have helped the participates
in developing more inclusive attitude in against to the restrictive and
authoritative behavior. It might have also facilitated their sense of re-
sponsibility but acknowledging the need for their involvement in the
treatment of their wife. It is also established by the research that hus-
bands' positive involvement in the treatment of their spouse plays a
vital role in the mental health of the women (Fletcher et al., 2015; Ong
et al., 2019). A similar study was done in India by Ragesh et al (2016)
using single session based group psychoeducation revealed the differ-
ence in the attitude of the participants post-intervention in terms of
acceptance and supportive gesture.
Parallel results found in several other intervention studies done in
the west. In a study (Davey et al., 2006) combination of psychoedu-
cational and cognitive-behavioral components was used for the inter-
vention and it was found that with the enhancement in factual
knowledge about the condition the stigma and shame surrounding PPD
V. Anchan and N. Janardhana Asian Journal of Psychiatry xxx (xxxx) xxxx

Table 1
Distribution of attitude of the participants at 3 phases (Pre, Post and Follow-up post) in 4 domains.
Phases Domains N Minimum Maximum Percentiles p value
25th 50th (Median) 75th

P-1 Authoritarianism 21 22.0 34.0 25.000 28.000 31.000 .000

P- 2 21 16.0 31.0 18.000 19.000 22.000
P- 3 21 16.0 29.0 19.000 21.000 24.500
P- 1 Benevolence 21 30.0 44.0 35.000 41.000 43.500 .035
P-2 21 31.0 44.0 36.000 42.000 43.500
P- 3 21 33.0 44.0 38.500 42.000 43.000
P-1 Social 21 14.0 32.0 17.000 18.000 26.000 .000
P-2 Restrictiveness 21 14.0 29.0 15.000 16.000 18.000
P- 3 21 14.0 28.0 16.000 16.000 19.000
P-1 Community 21 23.0 48.0 30.000 35.000 41.000 .000
P-2 Mental health 21 33.0 48.0 41.000 44.000 45.500
P-3 Ideology 21 36.0 48.0 37.500 43.000 44.500

Table 2 fostering positive attitude about their spouse beyond the illness (Davey
Pairwise comparison of Attitude of the participants at 3 phases (Pre, Post and et al., 2006; Lukens and McFarlane, 2004; O’Brien et al., 2017; Ong
Follow-up post) in 4 domains of CAMI Scale. et al., 2019; Tareen and Tandon, 2018)
Phases Test Statistics p

Authoritarianism 5.1. Implication of the study

Phase 1 – Phase 2 1.738 .000**
Phase 2 – Phase 3 −.476 .368 This type of brief psychoeducation program (BPP) could be adopted
Phase 1 – Phase 3 1.262 .000**
Benevolence
as an independent or adjunctive husband inclusive method in the pro-
Phase 1 – Phase 2 −.286 1.000 cess of nonpharmacological treatment both in the medical and psy-
Phase 2 – Phase 3 −.429 .495 chiatry settings which in turn facilitate holistic care delivery. Apart
Phase 1 – Phase 3 .714 .062 from clinical settings this BPP also could be used in different other
Social Restrictiveness
community-level setups as a promotive and preventive means. This
Phase 1 – Phase 2 1.048 .002**
Phase 2 – Phase 3 −.238 1.000 study is one of the initial attempts in this area from India not only
Phase 1 – Phase 3 .816 .026** contributes to literature for mental health professionals and the pol-
Community Mental Health Idealogy icymakers but also paves the way to future researchers.
Phase 1 – Phase 2 −1.381 .000**
Phase 2 – Phase 3 .190 1.000
Phase 1 – Phase 3 −1.190 .000**
5.2. Limitations of the study
The test significance level is .05 (** indicates the statistical significance).
Some of the limitations of this study include a smaller sample size,
absence of control group and brief follow up period.
was reduced. In another study (Fisher et al., 2010) using an innovative
psycho-educational program named What Were We Thinking! (WWWT)
6. Conclusion
participants were given half-day psychoeducation. The study estab-
lished that a universal, brief psycho-educational group program for
The development of PPDs in women has an equal impact on their
first-time parents and babies in primary care reduces the chances of
family as a whole, especially husbands. Unfortunately, the literature
postpartum mental disorders in women. Simultaneously it improved the
suggests that often men have not been involved in the treatment of their
effectiveness of the treatment outcome for women with a psychiatric
wives and not been provided with adequate information about the
history through the supportive and accepting attitude of their partners.
condition of their wives. Thus in the current study efforts have been
Partner assisted psychotherapy also proved its efficacy in dealing with
made to evaluate the effectiveness of brief psychoeducation in enhan-
maternal distress (Brandon et al., 2012).
cing the positive attitude among the husbands of women with PPDs.
Studies (Brandon et al., 2012; Davey et al., 2006; Fisher et al., 2010;
The results strongly supported that the BPP helped in changing the
Ragesh et al., 2016; Veenashree, 2017) have proved that increase in
attitude of the participants about the condition of their spouse. Despite
knowledge of the partners has strong correlation with attitudinal
all the limitation this study has its strong implication for mental health
change in the form of enhanced acceptance and positive gesture to-
professionals in this area at both clinical (medical and psychiatry set-
wards persons with mental illness.
tings) and nonclinical settings at the preventive, promotive and cura-
Some of the other Randomized control trials (RCT) done with other
tive level.
major mental disorders with the caregivers including the spouses of
persons with mental illness proved the efficacy of psychoeducation in
enhancing overall family functioning, decrease in perceived role strain, Financial disclosure
reduced expressed emotions and development of positive attitude to-
wards the affected member (Chadda, 2014; Chien, 2008; Navidian This study has not been supported by any of the external funding
et al., 2012; Setty et al., 2016). Similarly in the current study adoption sources as this study had been carried out as a part of partial fulfillment
of husband inclusive approach in terms of addressing their concerns of MPhil programme of the researcher.
and providing information about their role in the management along
with illness-specific details of their spouse using an informative and
supportive model in a flexible and innovative passion, in limited Declaration of Competing Interest
number of sessions would have served as a best method to address their
concerns bound with male identity and parenting role expectations and This study has no potential conflict of interest to disclose.

4
V. Anchan and N. Janardhana
Acknowledgements
Extending the heartfelt gratitude to all the multidisciplinary team
members of Mother Baby Unit, NIMHANS, Bengaluru for their support
to carry out this study and also all the participants who took part in the
study without them this study would have been impossible.
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