Psychological Medicine, 1996, 26, 333-342. Copyright © 1996 Cambridge University Press Treatment, expressed emotion and relapse in recent onset schizophrenic disorders D. L1NSZEN, 1 P. DINGEMANS, J. W. VAN DER DOES, A. NUGTER, P. SCHOLTE, R. LENIOR AND M. J. GOLDSTEIN From the Academic Medical Centre, University of Amsterdam, Department of Psychiatry, Amsterdam and Department of Psychiatry, Leiden University, Leiden, The Netherlands; and Department of Psychology, University of California, Los Angeles, USA SYNOPSIS The effect of in-patient and individual orientated psychosocial intervention (IPI) and in-patient and individual and family orientated intervention (IPFI) across levels of expressed emotion (EE) on relapse was compared in a group of patients with recent onset schizophrenic disorders. Patients were randomly assigned to an individual orientated psychosocial intervention programme or to an identical psychosocial programme plus a behavioural family intervention. Seventy-six patients were studied during a 12 month out-patient treatment period after an in-patient treatment programme in which parents followed a psychoeducational programme. Overall relapse rates during the out-patient interventions were low (16%). Adding family intervention to the psychosocial intervention did not affect the relapse rate. Patients in low EE families relapsed slightly more often during the psychosocial plus family intervention. In-patient treatment with psychoeducation for parents, followed by an out-patient psychosocial intervention programme, has a favourable impact on relapse. Additional family intervention may increase stress in low EE families, thus affecting relapse in their children. INTRODUCTION Psychoeducational family intervention pro- grammes have been evaluated in controlled clinical trials in the United States and Great Britain as components of the in-patient (Glick et al. 1990) or post-hospitalization treatment of schizophrenic patients. Studies evaluated whether this intervention had additive effect of maintenance antipsychotic drugs. Maintenance pharmacotherapy alone was tested against the combined treatment condition, which included family intervention (Goldstein et al. 1978; Leff el al. 1982; Tarrier et al. 1988), social skills training (Hogarty et al. 1986) and individual supportive therapy (Falloon et al. 1982). All studies found a significant effect of family intervention in relapse prevention over a year. These studies used a select sample of schizo- phrenic patients, namely those from families ' Address for correspondence: Dr Don H. Linszcn, Academic Medical Centre. University of Amsterdam, Department of Psy- chiatry. Tafclbergwcg 25. 1105 BC, Amsterdam, The Netherlands. rated as high in expressed emotion (high EE), who are at a significantly higher risk for relapse than those from low EE families (Kavanagh, 1992). No studies but one have evaluated as yet the impact of combined drug and family treatment with a full sample of schizophrenic patients. Since the present study was completed, another study has been reported (Randolph et al. 1994) with a more chronic sample that also stratified patients according to relatives' EE status. In our study, patients came from high and low EE family constellations, as determined prior to the out-patient phase of the study. One purpose of the present study was to assign patients and families, in a stratified and random- ized design, after the in-patient treatment period to a patient orientated psychosocial intervention programme (IPI) or to the same psychosocial intervention combined with a family inter- vention programme (IPFI). We hypothesized that the addition of family intervention to the in-patient psychosocial intervention (IPFI) would be more effective with patients from high compared with those from low EE families. 333