No abstract

A study is reported of a controlled trial of social intervention in the families of schizophrenic patients at high risk of relapse. The patients were selected for being in high contact with high Expressed Emotion relatives. All patients were maintained on neuroleptic drugs. One half of the 24 families were randomly assigned to routine out-patient care, while the other half received a package of social interventions. This comprised a programme of education about schizophrenia, a group for the relatives, and family sessions for relatives and patients. The relapse rate in the control group was 50 per cent compared with nine per cent in the experimental group (P = 0.04). The stated aims of the therapeutic interventions were achieved in 73 per cent of experimental families. In these families, no patient relapsed. The results provide evidence for the causal role of relatives' expressed emotion (EE) in schizophrenic relapse, as well as for the therapeutic effectiveness of social intervention combined with drug treatment.

The two-year follow-up results are reported of a trial of social intervention in families of schizophrenic patients in high social contact with high-expressed emotion (EE) relatives. For those patients who remained on antipsychotic medication throughout the two years, the social intervention significantly reduced the relapse rate. In those experimental families where relatives' EE and/or face-to-face contact was lowered, the relapse rate was 14% compared with 78% for control patients on regular medication (P = 0.02).

SYNOPSIS Data from two studies, one naturalistic and the other a controlled trial, were analysed to clarify the relationships between independent life events, Expressed Emotion of a key relative, maintenance neuroleptics and the relapse of schizophrenia. It was found that patients in the community who are unprotected by medication are vulnerable either to acute stress in the form of life events or to chronic stress in the form of living with a high Expressed Emotion relative. Patients on regular medication are protected against one or other stress, but are very likely to relapse if the two forms of stress occur together. A model of schizophrenic susceptibility to environmental stress is constructed to incorporate these observations.

Measurements of skin conductance response frequencies (SCRf) were obtained from 30 acutely ill schizophrenic patients during a standardised videotaped interview, conducted with the patient's key relative present. Significant differences in SCRf's were demonstrated between patients whose relatives had high and low Expressed Emotion (EE) respectively. Patients at high risk of relapse were allocated either to a control or an experimental group, the latter being offered a number of social interventions in order to reduce the relative's EE and/or contact with the patient. Follow-up measurements were obtained on 19 patients nine months after discharge. Although social intervention was highly successful in reducing relapse rates, its effects did not appear to be directly mediated via SCRf, which was found to be independently related to relapse.

Measurements of spontaneous fluctuations in skin conductance in 20 acutely ill schizophrenic patients were made in a video-tape studio. Recordings were made initially with the patient talking to an interviewer, then during a video-taped interview conducted with the patient's key relative. The Expressed Emotion (EE) of the patient's key relative had been measured previously. Significant differences in the type of spontaneous fluctuation activity between patients who had low EE and high EE relatives were demonstrated when the relative was present, but not when the relative was absent. The findings were not related to phenothiazine medication.

The measure expressed emotion (EE) is an established indicator of characteristics in the relatives of schizophrenic patients which predict relapse. Despite this, little is known of its construct validity except that schizophrenic patients are less calm in the presence of high EE than low EE relatives. There is also tentative evidence that schizophrenic patients show heightened avoidance responses to aversive social stimuli. It was therefore hypothesized that acutely ill schizophrenic patients would show social behaviours characteristic of avoidance in interaction with high but not low EE relatives. This hypothesis was not confirmed as no patient difference was found, but there were differences in the behaviour of high and low EE relatives. High EE relatives spend more interview time talking and less in looking at the patients. Low EE relatives were more prepared to be silent. This is consistent with the general tendency of high EE relatives to be socially intrusive and low EE relatives to be supportive to schizophrenic patients.

The implementation of market reforms has transformed the National Health Service (NHS) from a single national healthcare provider to a complex conglomeration of national and private organisations providing healthcare under the umbrella of the NHS brand. Private and state-run organisations compete to provide services to increasingly knowledgeable and entrepreneurial healthcare consumers. As a result, the NHS has become more and more business-like and is subject to the same consumer drivers that can be identified elsewhere in society. Healthcare consumers are not typical 'customers', however, since most consume NHS services out of necessity and the state funds the care they receive. Yet it is this 'necessity' of consumption that makes contracts to provide services on behalf of the NHS such a valuable commercial opportunity for private providers. This paper examines how consumer culture has influenced attitudes towards health and dying and is contributing to the creeping commodification of healthcare consumers themselves.