Expressed emotion and psychoeducational intervention for relatives of patients with schizophrenia: a randomized controlled study in Japan

Abstract

The benefit of single-family treatment (SFT) in addition to short educational sessions (SES) consisting of multiple-family treatment was investigated. The study design was a randomized controlled study. Subjects were 30 patients suffering from schizophrenia with at least one of their family members showing high expressed emotion (EE) in the Camberwell Family Interview. After the SES, the patients were randomly allocated to two groups: those who received routine individual outpatient treatment and those who received additional SFT and routine treatment. The two groups were followed for 9 months after discharge, and the relapse risks were compared. The relapse risk was lower in the SES+SFT group than in the SES group (23.1% vs. 35.3%). However, the difference was not significant. When high-EE families were classified into those with many critical comments (high-CC) or a high score of emotional overinvolvement (high-EOI), the relapse risk was 0% in the patients living with a high-CC family not only in the SES+SFT group but also in SES group. In the patients living with a high-EOI family, the relapse risk was lower in the SES+SFT group than in the SES group (42.9% vs. 60.0%). These findings suggest that high-EE families should receive at least SES, and additional SFT should be given to families with specific needs.

Introduction

Psychoeducational approaches to patients with schizophrenia and their families have developed partly based on studies on expressed emotion (EE) of the family (Brown et al., 1972, Vaughn and Leff, 1976, Leff and Vaughn, 1985). High-EE status in the family has been shown to be a risk factor for relapses of schizophrenia (Bebbington and Kuipers, 1994), and this has been supported in Japanese sample (Tanaka et al., 1995, Mino et al., 1997, Mino et al., 1998). Since 1982, studies on family intervention using EE as a target have shown the effects of psychoeducational family intervention for preventing relapses (Falloon et al., 1982, Leff et al., 1982, Tarrier et al., 1988, Tarrier et al., 1989). Psychoeducational approaches to the family vary among investigators; there are approaches on a multiple-family basis (McFarlane et al., 1995) or a single-family basis (Leff et al., 1982, Leff et al., 1985) or those involving social skills and training (Falloon et al., 1982, Falloon et al., 1985, Hogarty et al., 1986, Hogarty et al., 1991). To improve the methods of approaching the family, comparison of the relapse risk among different family intervention methods is necessary. Leff et al. (1982) performed psychoeducational single-family therapy (SFT) or relatives group therapy after two education sessions and found no significant differences in the results. However, McFarlane et al. (1995), who did not evaluate EE, reported that psychoeducational multiple-family treatment was more effective than SFT for prolonging remission, and attributed this difference between their study and the study of Leff et al. (1982) to the facts that a program for patients was performed and psychoeducation was given by the physician in charge in their study. Linszen et al. (1998) compared the relapse risk between two groups who underwent or did not undergo additional behavioral family intervention of 18 sessions after psychoeducation given separately to patients and their families during hospitalization, and found no effects of adding family intervention on the relapse risk. Discussion is difficult since one or two sessions for the family were performed during hospitalization of the patients in their study. However, strong support of the patient alone was associated with a decrease in the relapse risk, which differed from previous studies on EE.

To find a more efficient form of family education, we compared a short education sessions (SES) group with a SES+SFT group in high-EE households, using the randomized controlled trial method.