Risk factors for relapse following treatment for first episode psychosis: A systematic review and meta-analysis of longitudinal studies

Centre for Youth Mental Health, The University of Melbourne, Australia
Schizophrenia Research (Impact Factor: 3.92). 06/2012; 139(1-3):116-28. DOI: 10.1016/j.schres.2012.05.007
Source: PubMed


Preventing relapse is an essential element of early intervention in psychosis, but relevant risk factors and precise relapse rates remain to be clarified. The aim of this study was to systematically compile and analyse risk factors for and rates of relapse in the early course of psychosis.
Systematic review and meta-analysis of English and non-English language, peer-reviewed, longitudinal studies, with a minimum 12-month follow-up and at least 80% of participants diagnosed with a first episode of psychosis (FEP) that reported risk factors for relapse.
Of 153 potentially relevant articles, 29 were included in the study. Pooled prevalence of relapse of positive symptoms was 28% (range=12-47%), 43% (35-54%), 54% (40-63%) at 1, 1.5-2, and 3 years follow-up, in that order. A total of 109 predictors were analysed, with 24 being assessed in at least 3 studies. Of those, 20 predictors could be extracted for meta-analysis. Medication non-adherence, persistent substance use disorder, carers' critical comments (but not overall expressed emotion) and poorer premorbid adjustment, increased the risk for relapse 4-fold, 3-fold, 2.3-fold and 2.2-fold, respectively.
Clinical variables and general demographic variables have little impact on relapse rates. Conversely, non-adherence with medication, persistent substance use disorder, carers' criticism and poorer premorbid adjustment significantly increase the risk for relapse in FEP. Future studies need to address the methodological limitations of the extant research (e.g. definition of relapse), focus on the identification of protective factors and evaluate theoretically derived models of relapse.

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    • "Despite general agreement on the need for continued, longterm treatment for relapse prevention, non-adherence to oral medication is a well-known problem that occurs regardless of the type of antipsychotic prescribed, first or second generation [33] [34] [35]. Partial and complete non-adherence are recognised as strong predictors of relapse in patients treated after their firstepisode [1] [36] [37]. The discontinuation rates of oral antipsychotics in chronic schizophrenia have been estimated to be as high as 74% after 18 months of therapy [38]. "
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    ABSTRACT: The use of long-acting injectable antipsychotics (LAIs) in schizophrenia is usually restricted to patients in long-term treatment, who prefer them to oral antipsychotics, and to patients with multiple relapses who have a history of non-adherence. However, preliminary evidence from patients in the early phases of the disease suggest that second generation LAIs may be superior to second generation oral medications with regard to the control of negative symptoms and psychosocial functioning. Moreover, several studies have found that psychiatrists are generally reluctant to prescribe LAI antipsychotics and under-estimate their acceptability by patients. Key elements to take into account when offering a LAI in the early course of schizophrenia should include their potential superiority in allowing early detection of non-adherence and in reducing the number of rehospitalisations and relapses. Copyright © 2014 Elsevier Masson SAS. All rights reserved. Published by Elsevier Masson SAS. All rights reserved.
    European Psychiatry 11/2014; 29S2:1409-1413. DOI:10.1016/S0924-9338(14)70001-X · 3.44 Impact Factor
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    • "High levels of carer burden have been found to be present in various chronic illnesses such as dementia [8-10], bipolar disorder [11] and psychosis [3]. Carer burden is particularly high during first episode psychosis (FEP) [5], and there is evidence to suggest that this is a predictor of poor long-term outcome for the patient [12]. However our understanding of this association is poor. "
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    ABSTRACT: Background Carer burden is high during First Episode Psychosis (FEP) and evidence suggests that this is a predictor of poor long-term outcome. However our understanding of factors associated with higher burden is poor. We propose that carers’ cultural backgrounds and health belief models will influence their perceived burden of care, over and above that explained by severity of illness. Methods Patients with FEP and their primary Carers were recruited from the Early Intervention Service. Patients and Carers completed a range of validated measures, self-report ethnicity and demographic information together with the Multidimensional Health Locus of Control and Caregiver Burden Inventory. Results Significant correlations were found between carer burden and health beliefs, which differed by ethnicity and gender. High physical burden was experienced by Black carers with an external locus of control; time restrictions and emotional burden correlated with an external locus of control in Asian carers. For White carers, external locus of control correlated with time dependence burden. In all ethnic groups female carers experienced more time dependency, physical and developmental burden. No significant correlations were found between patient measures of severity or duration of illness and carer burden. Conclusions The type of burden experienced by carers differed between gender and ethnicity and was related to their health belief models. Thus the explanation and understanding of illness appears to be more salient than simply a patient’s severity of illness when considering the development of carer burden. Interventions to tackle high carer burden, and thus expressed emotion to improve outcome in patients, may need increasing focus here.
    BMC Psychiatry 06/2014; 14(1):171. DOI:10.1186/1471-244X-14-171 · 2.21 Impact Factor
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    • "First, it has been argued that the components of EE are related to different variables and are best studied separately. Alvarez-Jimenez and colleagues (Alvarez-Jimenez et al., 2012 ; Álvarez-Jiménez et al., 2008 ) found that only criticism seemed to predict relapse , while emotional over- involvement was more strongly related to caregiver dis - tress . Second , the view of EE as a marker for a ' dysfunc tional family ' has been criticized ( Jansen et al. , 2013 ; Van Os , Marcelis , Germeys , Graven & Delespaul , 2001 ) , suggesting that especially over - involvement is a natural and understandable reaction to a crisis and is associated with caregivers who are involved in treatment and care . "
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    ABSTRACT: In first-episode psychosis, the family is considered an important part in the recovery process. This is often accompanied by significant distress, which is acknowledged in numerous studies. However, little is known about the psychological factors involved. One hundred and twenty-seven caregivers of persons with first-episode psychosis completed a series of questionnaires aimed at investigating the contribution of expressed emotion and metacognitions to caregiver distress. Linear mixed model analysis found that emotional over-involvement and metacognitions independently predicted caregiver distress. Mediation analysis using bootstrapping showed that emotional over-involvement could be seen as mediating the effect of metacognitions on distress. The current study is a first step towards understanding the role of metacognitions in caregiver distress, thus opening up for the possibility of using interventions from ‘contextual behaviour therapies’. Implications and future studies are discussed. Copyright
    Clinical Psychology & Psychotherapy 05/2014; DOI:10.1002/cpp.1907 · 1.66 Impact Factor
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