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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    • "In the 1950s and 1960s, researchers started examining the emotional atmosphere in families of individuals with schizophrenia, which led to the development of measures of expressed emotion (EE;Brown & Rutter, 1966). High levels of EE, defined as criticism, hostility, and emotional over-involvement, are a robust predictor of psychosis outcome and relapse (e.g.,Alvarez-Jimenez et al., 2012). Cross-culturally, lack of family warmth has been shown in some instances to be an even more potent predictor of relapse than criticism, hostility, or selfsacrificing behaviour (López et al., 2004). "
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    ABSTRACT: Family interventions for schizophrenia are recommended psychological interventions worldwide. The National Institute for Care and Clinical Excellence (UK) and the Royal Australian and New Zealand College of Psychiatrists recommend family interventions as a first-line treatment and “treatment essential,” respectively, at all stages of psychosis and with all aspects of care. However, the success of the integration of these interventions into routine clinical services has been problematic and remains a major challenge. We outline the national guidelines on family interventions for schizophrenia and review the evidence for this approach. Drawing on recent systematic reviews and through searching electronic databases for relevant articles, we review the barriers and facilitators associated with implementing family interventions into routine clinical services. National guidelines continue to recommend psychological interventions for schizophrenia, reflecting the evidence base to support the provision of this approach across the psychosis spectrum. Reported estimates of implementation rates remain low and vary between 0% and 53%. Barriers to implementing family interventions exist at the service user, clinician, and organisational level. Factors that facilitate implementation of family interventions have been reported to a lesser extent. Implementation of family interventions for schizophrenia remains poor and is below recommended levels, with wide variation of implementation rates reported. This reflects inequality in the provision of family interventions for schizophrenia. Barriers at the service user, clinician, and organisational level have influenced the implementation of family interventions. A research agenda for improving consistent implementation of family interventions for schizophrenia is discussed.
    Full-text · Article · Feb 2016 · Australian Psychologist
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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.
    Full-text · Article · Nov 2014 · European Psychiatry
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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.
    Full-text · Article · Jun 2014 · BMC Psychiatry
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