Relapse in schizophrenia: a review of the concept and its definitions

Psychoeducational interventions to promote adolescents' mental health literacy in schools: Identifying theory for the development of a complex intervention

TOPIC

The concept of mental health literacy (MHL) was defined as the knowledge and beliefs about mental disorders that help in their recognition, management, or prevention. The complexity of interventions to promote adolescents' MHL requires that they be investigated through a process of development, feasibility/piloting, evaluation, and implementation, according to Medical Research Council (MRC) Framework.

PURPOSE

This article aimed to identify the theory that supports the development of a psychoeducational intervention to promote adolescents' MHL in schools, possibly to be developed by mental health and psychiatric nurses.

SOURCES USED

Journal articles, books, reports, and regulations.

CONCLUSIONS

This theory allows us to design a psychoeducational intervention to promote adolescents' MHL in schools and supports the subsequent phases of the MRC Framework.

Definitions of relapse in trials comparing antipsychotic maintenance with discontinuation or reduction for schizophrenia spectrum disorders: A systematic review

INTRODUCTION

Avoidance of relapse is the main aim of long-term antipsychotic treatment in schizophrenia, yet how 'relapse' is defined in trials is not well-known.

METHODS

We conducted a systematic review of definitions of relapse in trials of continuous antipsychotic treatment compared with discontinuation, intermittent treatment or dose reduction for people with schizophrenia spectrum disorders. Trials were identified from previous Cochrane reviews and a new search. The quality of relapse definitions was rated in terms of reliability and clinical relevance and associations between quality of definitions and trial characteristics and outcome were explored.

RESULTS

We identified 82 reports of 81 trials which employed 54 different definitions of relapse. There were 33 definitions in the 35 trials published since 1990, with recent trials employing complex definitions often involving alternative criteria. Only ten primary definitions of relapse required the presence of psychotic symptoms in all cases, and only three specified this in combination with a measure of overall severity or functional decline. Only two definitions specified a duration longer than two days. Relapse definitions were rated as showing good reliability in 37 trials, but only seven showed good clinical relevance. Six trials with definitions that were both reliable and clinically relevant were slightly longer, but did not differ from remaining trials in other characteristics or overall or relative risk of relapse.

CONCLUSIONS

Antipsychotic trials define relapse in numerous different ways, and few definitions consistently reflect suggested indications of a clinically significant relapse.

Feasibility of using a smartphone app to assess early signs, basic symptoms and psychotic symptoms over six months: A preliminary report

BACKGROUND

Psychosis relapses are common, have profound adverse consequences for patients, and are costly to health services. 'Early signs' have been used to predict relapse, in the hope of prevention or mitigation, with moderate sensitivity and specificity. We investigated the feasibility and validity of adding 'basic symptoms' to conventional early signs and monitoring these using a smartphone app.

METHODS

Individuals (n = 18) experiencing a relapse within the past year were asked to use a smartphone app ('ExPRESS') weekly for six months to report early signs, basic symptoms and psychotic symptoms. Above-threshold increases in app-reported psychotic symptoms prompted a telephone interview (PANSS positive items) to assess relapse.

RESULTS

Participants completed 65% app assessments and 58% telephone interviews. App items showed high concurrent validity with researcher-rated psychotic symptoms and basic symptoms over six months. There was excellent agreement between telephone call and face-to-face assessed psychotic symptoms. The primary relapse definition, based on telephone assessment and casenotes, compared well with a casenote-only definition but had better specificity. Mixed-effects models provided preliminary evidence of concurrent and predictive validity: early signs and basic symptoms were associated with most app-assessed psychotic symptom variables the same week and with a number of psychotic symptoms variables three weeks later; adding basic symptoms to early signs improved model fit in most of these cases.

CONCLUSIONS

This is the first study to test a smartphone app for monitoring early signs and basic symptoms as putative relapse predictors. It demonstrates that weekly app-based monitoring is feasible, valid and acceptable over six months.

Risk factors for acute psychiatric readmission

A retrospective case note study explored readmissions to an acute psychiatric in-patient unit within six months of discharge. The study aimed to calculate a hospital readmission rate, to investigate the timing of readmissions, and to identify risk factors associated with readmission. The readmission rate was 27% with the majority of readmissions occurring within three months after discharge, suggesting the need for investigation of such early readmissions. The three factors found to predict readmission were: discharge against medical advice, number of previous admissions, and living alone or with family rather than in care. Implications for hospital service planning are considered.

Cognitive-Behavioural Family Interventions for Major Mental Disorders

Cognitive-behavioural family interventions for major mental disorder have undergone significant refinement over recent years. This paper reviews the current techniques for assessing mental disorder in the family. The initial task of the therapist is to undertake a comprehensive family assessment, including an assessment of their stress management. Specific information must be obtained about each family member's view of the presenting problems, interaction within the family system, and function in settings outside the family, as well as the family's effectiveness in problem solving and quality of life. Key goals of cognitive-behavioural family therapy are personal goal setting, education, and communication training that enhance the efficiency of family problem solving. The efficiency of cognitive-behavioural therapies in treating major mental disorders is also reviewed in relation to the family's ability to achieve specific goals in therapy and to modify the outcome of major mental illness. Particular attention is given to the strengths and weaknesses of the research, and to possible future research directions. Cognitive-behavioural family interventions are found to be effective in reducing clinical, social, and family morbidity.

Are there clinically useful predictors and early warning signs for pending relapse?

OBJECTIVE

Despite the availability of effective long-term treatment strategies in schizophrenia, relapse is still common. Relapse prevention is one of the major treatment objectives, because relapse represents burden and costs for patients, their environment, and society and seems to increase illness progression at the biological level. Valid predictors for relapse are urgently needed to enable more individualized recommendations and treatment decisions to be made.

METHODS

Mainly recent evidence regarding predictors and early warning signs of relapse in schizophrenia was reviewed. In addition, data from the first-episode (long-term) study (FES; Gaebel et al., 2007, 2011) performed within the German Research Network on Schizophrenia were analyzed.

RESULTS

On the basis of FES data, premorbid adjustment, residual symptoms and some side effects are significant predictors. Although a broad spectrum of potential parameters has been investigated in several other studies, only a few and rather general valid predictors were identified consistently. Data of the FES also indicated that predictive power could be enhanced by considering interacting conjunctions, as suggested by the Vulnerability-Stress-Coping model. Prospective studies, however, are rare. In addition, prodromal symptoms as course-related characteristics likewise investigated in the FES add substantially to early recognition of relapse and may serve as early warning signs, but prognosis nevertheless remains a challenge.

CONCLUSIONS

Comprehensive and well-designed studies are needed to identify and confirm valid predictors for relapse in schizophrenia. In this respect, broadly accepted and specifically defined criteria for relapse would greatly facilitate comparison of results across studies.

A systematic review of relapse measurement in randomized controlled trials of relapse prevention in first-episode psychosis

The prevention of relapse is an important treatment goal in first-episode psychosis. Randomized controlled trials (RCTs) provide the gold standard methodology for evaluating interventions for relapse prevention. Properly designed RCTs which include relapse as a treatment outcome should rigorously operationalize psychotic relapse. The aim of this systematic literature review was to evaluate according to six criteria the operationalization of relapse in RCTs of clinical innovations for the prevention of relapse in first-episode psychosis. Through a systematic literature search of relevant RCTs in first-episode psychosis patients, eight pharmacological and eight non-pharmacological trials, published between 1982 and 2009, were identified. Readmission to a psychiatric hospital was the most common definition of psychotic relapse. Five studies did not measure relapse using any standardized or validated observer-rated instruments. The majority of the studies did not specify a duration criterion for relapse. Only three studies satisfied six criteria for the adequate operationalization of relapse. These results raise concerns regarding the internal and external validity of these research findings. There is an urgent need for a standardized, universally adopted set of criteria for psychotic relapse with appropriate specification of measurement instruments for use in future RCTs.

Family and patient predictors of symptomatic status in schizophrenia

OBJECTIVE

To test an interactive hypothesis that, in schizophrenia, a combination of patients' and relatives' characteristics at 1-month postdischarge from hospital (Time 1 [T1]) better predicts the level of psychotic symptoms at follow-up (Time 2 [T2]), than do the characteristics of patients or relatives alone.

METHODS

Male patients (n = 38) with a diagnosis of schizophrenia, without substance abuse, and in contact with their families, were recruited at the time of hospital discharge. Patients' psychotic symptom levels were monitored every 2 weeks until follow-up, while family measures were administered at T1 and T2. The 4 predictor variables in the regression analysis were T1 symptom levels of the patient and 3 measures of family interaction (expressed emotion, family burden, and family functioning).

RESULTS

The model based on the family variable, family burden at T1, and the patient variable, patients' remitted levels of psychotic symptoms at T1, was found to significantly predict the level of psychotic symptoms at T2. These 2 T1 variables made independent and additive contributions to the level of psychotic symptoms at T2, predicting 19% of the variance. Neither expressed emotion nor family functioning at T1 added to the prediction.

CONCLUSION

This finding suggests a patient-family interactional component to symptomatic relapse in schizophrenia.

Définition de l’état aigu dans la schizophrénie : enquête réalisée auprès des psychiatres français

For schizophrenic disorders, the clinical conception of "acute state" is widely used in clinical settings to assess the effectiveness of therapeutic programs as well as epidemiological studies. Schizophrenic-specific symptomatology modification, need for hospitalization, significant change in care, disturbances in social behavior or suicide attempts were all used to define acute schizophrenic state. The decision to hospitalize is frequently used to define acute state but refers to multiple factors such as mood disorder, suicide attempts, drug abuse or social and environmental problems. Indeed, several and distinct definitions in a criteria basis form are available but no one has reached consensus. Because recognition of acute schizophrenic state remains based on the subjective clinician's advice, epidemiological and therapeutic studies fail in validity and reliability. The aim of the study was to evaluate how a population of French psychiatrists define criteria and therapeutic targets of acute schizophrenic state in their clinical practice. Psychiatrists filled out a self administered interview. At the time the interview was given, clinicians were notified that they were participating in a clinical consensus survey about schizophrenia. Six major indicators for acute state definition based on the literature data were proposed: general schizophrenic symptomatology modification (depression, anxiety, agitation, impulsivity/aggressiveness), specific schizophrenic symptomatology modification (positive symptoms, negative symptoms, disorganization), need for hospitalization, significant change in care, disturbance in social behavior and lastly, suicidal behavior. Minimal duration (1.2 or 4 weeks) of general and specific schizophrenic symptomatology modification required to define acute state were evaluated. The booklet included the 30 PANSS symptoms listed with their definitions. Among this symptom list, clinicians were instructed to select the ten criteria which they estimated best defined the acute state, followed by the ten most important target symptoms to be treated. Out of 2,369 questionnaires, 1,584 were collected on time (66.9%). Among the six majors indicators proposed to define acute state 75% of psychiatrists considered 1 to 3 criteria. Three were more frequently rated, including core schizophrenic symptomatology disturbance (68.4%), general schizophrenic symptomatology disturbance (68.0%) and suicidal behavior (64.9%). The other criteria were rated as follows: need for hospitalization (26.8%), significant change in care (18.3%), and disturbance in social behavior (29.1%). For 53.2% of psychiatrists the definition of acute state requires the presence of specific schizophrenic symptomatology for a minimal duration of one week. Two weeks with general symptomatology was required for 45.5% of psychiatrists to define acute state. Symptoms more often rated within the four first choices for acute state definition included delusions, conceptual disorganization, hallucinatory behavior and excitement. Except for grandiosity, all the PANSS positive subscale items were chosen to be included in the definition (delusions, conceptual disorganization, hallucinatory behavior, excitement, suspiciousness/persecution and hostility). Four items, including anxiety, depression, uncontrolled hostility, inner tension from the general psychopathology subscale were chosen as part of the ten most important criteria to define acute state. On the PANSS negative subscale (blunted affect, emotional withdrawal, poor relationships, passive apathetic withdrawal, difficulty in abstract thinking, lack of spontaneity/flow of conversation and stereotyped thinking), no item was rated to be included in the acute state definition. The highest rated symptoms among the four first choices for treatment included delusions, hallucinatory behavior, excitement and anxiety. The ten most important criteria for treatment were the same as for acute state definition with differences in frequency. Excited state, depression and suspiciousness/persecution were more rated for treatment than definition whereas delusion, hostility and conceptual disorganization were less rated as treatment target than definition criteria. In clinical practice, recognition of acute schizophrenic state is underscored by the association of specific schizophrenic symptomatology (positive symptoms, negative symptoms, disorganization) and general symptomatology (impulsivity/aggressiveness, anxiety, depression, agitation) of schizophrenia. For most clinicians, acute state definition requires specific symptom for a minimum of one week and other non-specific indicators such as suicidal behaviour have to be taken into account. With regard to PANSS criteria, most positive schizophrenic symptoms and some general schizophrenic symptoms are necessary for definition and designated as treatment priorities. Negative symptoms were not taken into account. Hallucinatory behavior is the first symptom rated in definition and is considered by psychiatrists as the absolute therapeutic priority. This survey could be a first step in the construction of an operational and consensual definition. This definition is strongly needed as a valid measurement in therapeutic and epidemiological outcome studies, which remain at least partly based on clinician subjective judgment.

A delphi approach to characterising "relapse" as used in UK clinical practice

BACKGROUND

'Relapse' is a common outcome indicator in intervention studies in schizophrenia. In community studies it is frequently equated with hospitalisation and in psychopharmacological studies with predetermined symptom scores. Its clinical meaning, however, remains undefined.

METHOD

Consensus on the defining features of 'relapse' in schizophrenia used by academic and clinical schizophrenia experts in the UK, was investigated using a four stage Delphi process. A two panel, four stage, Delphi based methodology was used to investigate the implicit meanings of 'relapse' in clinical practice. A multidisciplinary panel of twelve members each listed anonymously ten indicators of relapse. A second panel, of ten experienced psychiatrists, rated the 188 submitted indicators from essential-unimportant (1-5). This panel completed a one day workshop during the remaining Delphi rounds ending with a structured discussion of the results.

RESULTS

Very strong consensus was achieved on the relative importance of potential relapse indicators. There was complete agreement about some aspects of a definition of relapse (such as recurrence of positive symptoms) and a number of the complex issues underlying the concept were clearly articulated.

CONCLUSIONS

This four stage Delphi process achieved consensus on core features of relapse. The elucidation of the "softer" features at the threshold between normal fluctuations in functioning and the start of relapse require continuing investigations.

Reliability of an Italian standardized and expanded Brief Psychiatric Rating Scale (BPRS 4.0) in raters with high vs. low clinical experience

OBJECTIVE

The aims of this study were (i) to assess the inter-rater reliability of the latest Italian expanded 24-item version of the Brief Psychiatric Rating Scale, BPRS version 4.0 and (ii) to assess the feasibility of obtaining reliable BPRS 4.0 ratings by reliability training of clinically less experienced trainees (medical and rehabilitation students).

METHOD

A videotape-training procedure was used, and the inter-rater agreement scores of three different groups of raters, namely psychiatrists and psychologists (n=28), psychosocial rehabilitation students (n=27) and medical students (n=54) were calculated and compared.

RESULTS

The results indicated that both experienced raters (psychiatrists and psychologists) and inexperienced raters (medical and psychosocial rehabilitation students) were able to achieve high levels of inter-rater reliability.

CONCLUSION

Our results are of particular interest in view of the increasing need to draw upon professionals, other than psychiatrists and psychologists, for cost-effective and standardized evaluation of rehabilitation interventions.

Relapse criteria in schizophrenic disorders: different perspectives

Relapse and exacerbation of psychotic symptoms were investigated in a prospective study of 88 patients with recent-onset schizophrenia and related disorders. Relapse definitions were derived from expressed emotion and family intervention studies and based on the Brief Psychiatric Rating Scale (BPRS), the Present State Examination, and clinical judgment. Results indicate that research and clinical criteria represent different perspectives on relapse. Clinical criteria provide a validity check that can verify BPRS-rated changes in partially remitted patients.

The clinical relevance of an auditory attention task (PAT) in a longitudinal study of chronic schizophrenia, with placebo substitution for chlorpromazine

A new auditory attention task (PAT) is described. The test comprises four different subtest combinations (diotic/dichotic, slow/fast) each of 5 min duration. Omission and commission errors are combined by an index of errors (IE). The PAT was given fortnightly to 20 chronic schizophrenic inpatients for more than one year. Independent psychiatrists rated the patients according to the Brief Psychiatric Rating Scale and a Global Rating Scale. All measures yielded significant test-retest reliabilities. The patients were stabilized on individualized doses of chlorpromazine (CPZ) and randomized to two groups. Placebo was substituted for CPZ during 10 weeks, according to a double-blind cross-over design. Significant deterioration under placebo was detected by all three methods, but the PAT was the most sensitive to change. The PAT mean score (M IE) was correlated with both rating scales. Unlike the rating scales, it also correctly ordered the twenty patients along a dimension which measured the severity of illness and 'predicted' hospital discharge.

Psychosocial factors, arousal and schizophrenic relapse. The psychophysiological data

This annotation describes psychophysiological research that has examined the hypothesis that autonomic hyperarousal is a possible mediating factor between schizophrenic relapse and psychosocial influences such as expressed emotion (EE) and life events. We review several studies that have measured psychophysiological activity in schizophrenic patients while in the presence of their relatives. The findings from this area of research are compared with those of other psychophysiological studies of schizophrenia which have employed more traditional laboratory tasks such as the electrodermal response-habituation paradigm. Finally, some conclusions are drawn regarding the clinical implications of psychophysiological research, and areas for future investigation are suggested.

Patterns of outcome in schizophrenia in Hong Kong

A total of 153 schizophrenic subjects were included for outcome assessment in different aspects of their life functions. The same group of subjects was followed-up 1 year later to assess the consistency of their outcome pattern. A factor analysis on the outcome measures was conducted, and 5 independent factors were noted. Outcome on symptomatic control was most favourable but less consistent over time. Psychosocial deficits, on the other hand, were more enduring and noted in a significant proportion of the subjects.

The effect of research on readmission to a psychiatric hospital

The effects on outcome of research into the course of psychiatric illness are controversial. This study examines a cohort of research patients involved in an outcome study in which the research and clinical teams were kept separate. While research intervention of this nature would not be expected to influence outcome, the research cohort had fewer readmissions than non-research controls. This occurred despite the presence of factors which would be expected to be associated with a contrary result. It is stressed that the confounding effects of research need to be taken into account when designing follow-up studies and evaluating outcome results.

Counselling the relatives of the long-term adult mentally ill. II. A low-cost supportive model

A psychosocial intervention is described geared to the needs of carers of the long-term mentally ill, which is feasible for a busy clinical team to implement: relatives were not selected for the group by patient diagnosis or motivation and little extra staff input was required. An interactive education session at home was followed by a monthly relatives group which aimed to reduce components of expressed emotion (EE) and to alleviate burden. The group facilitators adopted a directive but non-judgemental style, and constructive coping efforts were encouraged. The intervention was effective at reducing EE and improving family relationships. The study offers a realistic model of how to offer support to people providing long-term care for the severely mentally ill.

A contribution to rehospitalization of schizophrenics

A statistical investigation of rehospitalization was carried out retrospectively on 148 schizophrenics who had been repeatedly admitted to our university clinic during a time span of 24 years. The length of rehospitalizations as well as that of intervals were investigated in addition to the rehospitalization rate. These results were discussed chiefly in relation to sex and to the marital state. Finally, the relationship between relapses and rehospitalizations was surveyed on the patients who had been observed for more than 10 years.

The impact of individual and family treatment on the affective climate of families of schizophrenics

Measures of parental affective style were compared for families of schizophrenics participating in a controlled treatment study which contrasted individual and family-based therapeutic programmes. The total number of critical statements and non-critical, intrusive remarks was significantly lower after three months for parents of schizophrenics participating in family therapy, compared to those whose offspring received only individual therapy. An increased risk for relapse was associated with an increase in the number of critical and/or intrusive remarks for patients in individual treatment. A significant increase in non-emotional, problem-solving statements was observed in parents who received family therapy, compared with those who did not. The results suggest that a behaviourally-oriented, problem-solving family approach may have reduced the risk of relapse in the first nine months after discharge from hospital by teaching families concrete ways of solving problems and concomitantly reducing the amount of negative emotional relating between family members.