How to manage the first episode of schizophrenia. Authors did not take account of systemically collected information.

Editor—Frangou and Byrne review recent descriptive work on how to manage the first episode of schizophrenia but omit to note that some of the treatment issues discussed have been systematically investigated.1 The authors are apparently unaware that the efficacy of drug treatment and its correlates was examined in a controlled clinical trial following first episodes of psychosis conducted at the Medical Research Council Centre at Northwick Park.2 This study established that by two years following discharge after the first episode, 46% of patients taking active drug treatment had relapsed compared with 62% taking placebo.3 Response to treatment was not predicted by the features of the illness—a point of practical importance. An important determinant of relapse was the duration of illness before the start of neuroleptic treatment, a finding that has been well established in the literature subsequently. Of those who had experienced symptoms for one year before admission, only 18% given active treatment were relapse free at two years and all the patients given placebo had relapsed. The meaning of this finding—whether long duration of illness before admission is a correlate of poor outcome or whether early treatment prevents deterioration—remains obscure. Other findings in this study are relevant to Frangou and Byrne's recommendations regarding family therapy.4 Some forms of such therapy have been suggested to reduce expressed emotion in relatives and thereby to reduce the probability of relapse. In this study, when preadmission duration of illness and neuroleptic treatment were taken into account, the variables of expressed emotion were not related to outcome or to response to treatment. This suggested that such features might be a correlate of severity of illness rather than a precipitant or predictor of relapse. Frangou works at the Institute of Psychiatry in London. When systematically collected information from a controlled trial is available I am disappointed to find that it has had little impact on recommendations regarding management from a leading academic institute.