An Intervention Study to Prevent Relapse in Patients With Schizophrenia

Caregivers' experiences and perspectives of factors associated with relapse in Iranian people living with schizophrenia: A qualitative study

BACKGROUND

Relapse in People Living with Schizophrenia (PLS) has several reasons and recognizing these can increase the effectiveness of treatment interventions. Formal and informal caregivers are an informed source to reduce relapse in PLS.

AIM

This study explores the caregivers' perspective in Iran on the factors affecting relapse in PLS.

METHOD

A total of 28 caregivers (16 formal caregivers and 12 informal caregivers) of PLS were enrolled in our qualitative study. A content analysis was conducted using individual and group, semi-structured in-depth interviews with informal and formal caregivers of PLS. This study was conducted in a hospital, three universities, and a non-governmental organization in Tehran, Iran.

RESULTS

The majority (69%) of the participants were females. About half of the informal caregivers were over 60 years old and about 40% of the formal caregivers were in the age range of 30 to 40 years. The average number of years of work for informal caregivers was 17.6 years and the average of work experience among the formal caregivers was 14.1 years. Seven key dual themes were identified from data: 'awareness-stigma', 'social support-social exclusion', 'treatment adherence-treatment discontinuation', 'holistic approach - one-dimensional approach', 'supported employment-social dysfunction', 'emotional management in family - family with high emotional expression', and 'access to treatment-treatment gap'.

CONCLUSION

The results of this research can help practitioners and policymakers to enable evidence-based practices to reduce relapse in PLS by emphasizing and acting on factors identified in our analyses.

Acceptability of Texting 4 Relapse Prevention, Text Messaging-Based Relapse Prevention Program for People With Schizophrenia and Schizoaffective Disorder

ABSTRACT

We report process outcomes of the pilot randomized controlled trial of Texting 4 Relapse Prevention (T4RP), a text messaging-based relapse prevention program for people with schizophrenia or schizoaffective disorder (SAD). Forty people were randomized to either the intervention or treatment as usual control group at a 2:1 ratio. Process indicators were collected at 6 months post enrollment.Over 90% of patients agreed or strongly agreed that the text messages were easy to understand, easy to answer, positive, and helped them feel supported. Patient acceptability was positively associated with recovery (β = 0.29, p = <0.001) and patient-provider communication scores (β = 1.04, p < 0.001), and negatively associated with symptoms of the disorder (β = -0.27, p = 0.07). Acceptability was similar by diagnosis (β, SAD diagnosis = 0.40, p = 0.90) and age (β = 0.05, p = 0.67). Findings suggest that a text messaging intervention aimed at preventing relapse is feasible and perceived as beneficial in individuals with schizophrenia and SAD. Future research might include a targeted study of T4RP within the context of hospital discharge when people with schizophrenia/SAD are at highest risk of relapse.

Relapse prevention in ambulant mental health care tailored to patients with schizophrenia or bipolar disorder

WHAT IS ALREADY KNOWN ON THE SUBJECT?: Understanding the need for psychoeducation and management strategies in relapse prevention, for individuals with schizophrenia or bipolar disorder. Interventions for individuals with severe mental illness, especially schizophrenia, often requires support from family or social network to successfully improve mental stability in the life of the mentally ill. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: To our knowledge, no previous review has provided an overview of state of the art intervention elements currently used in ambulant mental health care interventions and how these elements are combined in interventions tailored to individuals with schizophrenia or bipolar disorder. Moreover, this systematic review indicates the effect of the different intervention elements. This review reveals an apparent gab in knowledge regarding patient perceptions of and need for individualized relapse prevention interventions. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The review is a relevant tool for stakeholders and practitioners in community mental health service when planning future interventions. Considering the specific needs for intervention complexity of the target group is likely to improve not only treatment outcome, but also patient satisfaction and treatment adherence. ABSTRACT: Introduction In recent years, there has been a development in ambulant mental health care towards a more preventive approach, resulting in relapse prevention interventions. Interventions may be patient tailored, to a greater or lesser extent, in relation to the treatment elements included. Aim To create an overview of non-pharmacological intervention elements described in relapse prevention interventions for patients with schizophrenia or bipolar disorder based on a systematic review. Method Six scientific databases were systematically searched. The search strategy, identification and selection of literature complied with the PRISMA statement. Results Of 7.429 studies screened, 25 were included for analysis. Six treatment elements were identified: Pharmacological treatment, personalized action plan, patient education, patient skills, treatment adherence and family involvement. Discussion The varying degree of complexity of the interventions indicates that patients with bipolar disorder and schizophrenia have, respectively, different treatment needs. Patients with schizophrenia seem to benefit more from interventions that include support from social network or family than patients with bipolar disorder. More qualitative studies clarifying the patient's perspective on tailored relapse prevention are indicated. Implications for practice Optimally tailoring relapse prevention for patients with schizophrenia and bipolar disorder will improve treatment outcome, and probably also treatment satisfaction and adherence.

Developing Texting for Relapse Prevention: A Scalable mHealth Program for People With Schizophrenia and Schizoaffective Disorder

Symptom relapse in people with schizophrenia and schizoaffective disorder is common and has a negative impact on the course of illness. Here, we describe the development of Texting for Relapse Prevention, a scalable, cost-effective text messaging relapse prevention program that queries patients' "early warning signs" daily. Results of development focus groups and content advisory teams with 25 patients and 19 providers suggest that patients were enthusiastic about the program and thought that receiving daily messages about their symptoms would help them feel supported. Providers also were positive about the idea but worried that the program might interfere with patient-provider communication if patients thought that the messages were coming from providers. Patients found the content positive and actionable. The program was improved to address this feedback. This iterative development process that included multiple stakeholders ensured that the program is feasible and acceptable to both patients and providers.

Factors affecting mental health nurses working with clients with first-episode psychosis: A qualitative study

WHAT IS KNOWN ABOUT THE SUBJECT?: First-episode psychosis (FEP) usually occurs in adolescence, a time of great change and upheaval and the effect on the sufferer and their family can be immense The nurse's role is to alleviate this suffering, aid recovery and minimize the risk of relapse. They manage this onerous task ideally through the therapeutic relationship, and use the skills of assessment and risk identification in order to maximize patient outcomes. WHAT DOES THE STUDY ADD TO EXISTING KNOWLEDGE?: The study adds knowledge about the challenges that mental health nurses experience specifically in the presentation of first-episode psychosis The findings of this study reinforce the idea that pathways to care need to be clearly identified with a community-wide educational led experience This study illuminates the fact that additional training and formalized clinical supervision are necessary for mental health nurses to improve quality of care and reduce stress levels, both of which lead to better clinical outcomes. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental Health nurses should engage with additional training, formalized clinical supervision and avail of peer support in order to improve confidence, skills and quality of care. Dialogue among mental healthcare colleagues is important not only about caring for people presenting with a first-episode psychosis but in relation to the wider community and family. This demonstrates the need for family-centred care within the mental health profession. There should be more recognition of the social impact on the individual during untreated psychosis with regard to isolation and withdrawal as well as factors which also affect help-seeking behaviours.

ABSTRACT

Introduction Although there is much research on mental health nurses working with individuals presenting with psychosis, there is a lack of knowledge about the factors that impact the experience of nurses in the presentation specifically of first-time psychosis. Aim This study aimed to explore the factors that impact on the experience of mental health nurses working with individuals and their families who present with a first-time psychosis. Method This qualitative study was conducted through individual semi-structured interviews with eight mental health nurses recruited from community mental health settings with a minimum of 2 years post-qualification experience. Data were then subjected to a thematic content analysis. Results This study identified the importance of therapeutic engagement, as well as the need to have clear pathways to care and building capacity through clinical supervision and training when working with this population. Implications for practice Mental Health nurses should engage with additional training, formalized clinical supervision and avail of peer support in order to improve confidence, skills and quality of care, leading to better therapeutic engagement. Pathways to care should be embedded within the wider community to ensure ease of access for individuals and their families. There should be more recognition of the social impact on the individual during untreated psychosis with regard to isolation and withdrawal as well as factors which also affect help-seeking behaviours.

[Effects of a Relapse Prevention Program on Insight, Empowerment and Treatment Adherence in Patients with Schizophrenia]

PURPOSE

The purpose of this study was to develop a relapse prevention program (RPP) and examine the effects of the RPP on insight, empowerment, and treatment adherence in patients with schizophrenia.

METHODS

A non-equivalent control group pretest-posttest design was used. Participants were 54 inpatients who had a diagnosis of schizophrenia (experimental group: 26, control group: 28). The study was carried out from February 7, 2012 to February 6, 2013. Over a 10-day period prior to discharge each participant in the experimental group received three one-hour sessions of RPP a one-to-one patient-nurse interaction. Data were collected using Assess Unawareness of Mental Disorder (SUMD), Empowerment Scale, and Insight and Treatment Attitude Questionnaire (ITAQ) and analyzed using PASW 18.0 with chi-square test, independent t-test, Mann-Whitney U test, and ANCOVA.

RESULTS

The experimental group had a significant increase in insight and treatment adherence compared to the control group. However, there was no significant difference in empowerment between the two groups.

CONCLUSION

Findings indicate that the RPP for patients with schizophrenia was effective in improving insight and treatment adherence. A longitudinal study is needed to confirm the persistence of these effects of RPP in patients with schizophrenia.

Reminiscence work with older people: the development of a historical reminiscence tool

AIMS AND OBJECTIVES

(i) To explore how reminiscence workers in older people's care define their work and (ii) to describe the development of a historical reminiscence tool containing historical developments from the older person's passage through life, intended to support reminiscence work.

BACKGROUND

Reminiscence work refers to the recall of past occurrences in a client's life with the intention of enhancing well-being, social skills and self-image.

DESIGN

The design of the historical reminiscence tool was informed by the model of intervention design developed by van Meijel et al. starting with problem definition followed by the accumulation of building blocks for the intervention, the design of the intervention and, lastly, a validation of the intervention.

METHOD

Two studies were designed to develop the historical reminiscence tool. Study 1 was a focus group interview, conducted in 2008, aimed at generating knowledge about current practice and to develop the historical reminiscence tool. Eighteen women who identified themselves as reminiscence workers participated in three focus groups. Study 2 was a telephone survey, conducted in 2012 by the first author, serving the purpose of validation. The results provided information about the use of such a historical reminiscence tool.

RESULTS

Participants understood reminiscence work primarily as meaningful activity, working with personal experience and honouring the individual's memories and life story. The historical reminiscence tool containing information about important historical events and everyday life in the period 1925-1955 was welcomed by the participants. They provided numerous suggestions for improvement of the draft.

CONCLUSION

Reminiscence work in Iceland is of the social or meaningful activity type rather than a therapy. A historical reminiscence tool containing pertinent historical information was considered helpful in strengthening reminiscence workers' knowledge of the social and historical background of their clients and person-centred care.

IMPLICATION FOR PRACTICE

Reminiscence tools, such as books or electronic sources containing historical information pertaining to aging individuals, can enhance the care of older people.

A review on schizophrenia and relapse--a quest for user-friendly psychopharmacotherapy

OBJECTIVE

Schizophrenia in general is notoriously associated with relapses rendering the illness progressive to worse outcomes, a concept of which is compatible with neurotoxicity. Therefore, relapse prevention is of utmost clinical relevance.

METHODS

In this review, we aim to put relapse into clinical context in the realm of natural history of, or heterogeneity in, schizophrenia and summarize risk factors of relapse. We discuss how to effectively 'define' relapse in schizophrenia and recent meta-analytic studies on this topic to highlight the importance of continuous antipsychotic treatment.

RESULTS

The following issues emerged: 'How low maintenance antipsychotic dosage could be?’, 'How extended dosing could be?’, 'Who could be successfully withdrawn from antipsychotics?’ and 'How relapse could be defined in the first place?’ The question in particular is how better to deliver antipsychotics at the lowest possible, whereby dose and dosing interval are relevant. While ongoing antipsychotic treatment is the rule, recent works are pointing to a possibility of lower dosage in the maintenance phase of the illness.

CONCLUSIONS

Bearing in mind that suboptimal adherence and withdrawal from antipsychotics are an established and unequivocal risk factor for relapse, further investigations are certainly needed to explore user-friendly manner of psychopharmacotherapy to prevent relapse in schizophrenia.

Training to recognise the early signs of recurrence in schizophrenia

BACKGROUND

Schizophrenia has a lifetime prevalence of less than one per cent. Studies have indicated that early symptoms that are idiosyncratic to the person with schizophrenia (early warning signs) often precede acute psychotic relapse. Early warning signs interventions propose that learning to detect and manage early warning signs of impending relapse might prevent or delay acute psychotic relapse.

OBJECTIVES

To compare the effectiveness of early warning signs interventions plus treatment as usual involving and not involving a psychological therapy on time to relapse, hospitalisation, functioning, negative and positive symptomatology.

SEARCH METHODS

Search databases included the Cochrane Schizophrenia Group Trials Register (July 2007 and May 2012) which is based on regular searches of BIOSIS, CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO. References of all identified studies were reviewed for inclusion. We inspected the UK National Research Registe and contacted relevant pharmaceutical companies and authors of trials for additional information.

SELECTION CRITERIA

We included all randomised clinical trials (RCTs) comparing early warning signs interventions plus treatment as usual to treatment as usual for people with schizophrenia or other non-affective psychosis

DATA COLLECTION AND ANALYSIS

We assessed included studies for quality and extracted data. If more than 50% of participants were lost to follow-up, the study was excluded. For binary outcomes, we calculated standard estimates of risk ratio (RR) and the corresponding 95% confidence intervals (CI), for continuous outcomes, we calculated mean differences (MD) with standard errors estimated, and for time to event outcomes we calculated Cox proportional hazards ratios (HRs) and associated 95 % CI. We assessed risk of bias for included studies and assessed overall study quality using the GRADE approach.

MAIN RESULTS

Thirty-two RCTs and two cluster-RCTs that randomised 3554 people satisfied criteria for inclusion. Only one study examined the effects of early warning signs interventions without additional psychological interventions, and many of the outcomes for this review were not reported or poorly-reported. Significantly fewer people relapsed with early warning signs interventions than with usual care (23% versus 43%; RR 0.53, 95% CI 0.36 to 0.79; 15 RCTs, 1502 participants; very low quality evidence). Time to relapse did not significantly differ between intervention groups (6 RCTs, 550 participants; very low quality evidence). Risk of re-hospitalisation was significantly lower with early warning signs interventions compared to usual care (19% versus 39%; RR 0.48, 95% CI 0.35 to 0.66; 15 RCTS, 1457 participants; very low quality evidence). Time to re-hospitalisation did not significantly differ between intervention groups (6 RCTs; 1149 participants; very low quality evidence). Participants' satisfaction with care and economic costs were inconclusive because of a lack of evidence.

AUTHORS' CONCLUSIONS

This review indicates that early warning signs interventions may have a positive effect on the proportions of people re-hospitalised and on rates of relapse, but not on time to recurrence. However, the overall quality of the evidence was very low, indicating that we do not know if early warning signs interventions will have similar effects outside trials and that it is very likely that further research will alter these estimates. Moreover, the early warning signs interventions were used along side other psychological interventions, and we do not know if they would be effective on their own. They may be cost-effective due to reduced hospitalisation and relapse rates, but before mental health services consider routinely providing psychological interventions involving the early recognition and prompt management of early warning signs to adults with schizophrenia, further research is required to provide evidence of high or moderate quality regarding the efficacy of early warning signs interventions added to usual care without additional psychological interventions, or to clarify the kinds of additional psychological interventions that might aid its efficacy. Future RCTs should be adequately-powered, and designed to minimise the risk of bias and be transparently reported. They should also systematically evaluate resource costs and resource use, alongside efficacy outcomes and other outcomes that are important to people with serious mental illness and their carers.

Perceptions of relapse risks following first-episode psychosis and attitudes towards maintenance medication: a comparison between nursing and social work professionals

AIM

Existing clinical guidelines have not yet identified an optimal duration of maintenance antipsychotic drug treatment for stable, remitted first-episode psychosis patients. This study compares the perception of relapse risk and attitudes towards maintenance medication among professionals in nursing and social work fields who have direct clinical experience with first-episode psychosis patients. We explore a perception model that identifies the decision-making factors in the clinical dilemma between relapse and maintenance.

METHODS

A specially designed survey addressing perceptions of relapse risk and optimal duration of maintenance treatment was conducted among 63 experienced health-care professionals (30 nurses and 33 social workers) in the field of early psychosis in Hong Kong.

RESULTS

Two clinically relevant themes were identified that affected professionals' judgment on the optimal duration of maintenance treatment in stable, remitted first-episode psychosis patients: (i) the remission period; and (ii) professionals' perceptions of relapse risk involved in medication discontinuation. The remission period was a significant predictor of the perceived relapse risk. Compared with social workers, mental health nurses perceived a higher relapse risk for patients before Bonferroni adjustment.

CONCLUSIONS

The three key clinical components discussed--remission period, perceived relapse risk and perceived optimal duration of maintenance treatment--are interconnected, collectively influencing health-care professionals' attitudes towards relapse and maintenance for patients. Our study identified differences between the perceptions of nursing and social work professionals, indicating a need for communication and discussion among professional groups in order to arrive at a coherent, efficacious team consensus.

Antipsychotic medication for early episode schizophrenia

BACKGROUND

Long-term treatment with antipsychotic medications in early episode schizophrenia spectrum disorders is common, but both short and long-term effects on the illness are unclear. There have been numerous suggestions that people with early episodes of schizophrenia appear to respond differently than those with multiple prior episodes. The number of episodes may moderate response to drug treatment.

OBJECTIVES

To assess the effects of antipsychotic medication treatment on people with early episode schizophrenia spectrum disorders.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group register (July 2007) as well as references of included studies. We contacted authors of studies for further data.

SELECTION CRITERIA

Studies with a majority of first and second episode schizophrenia spectrum disorders comparing initial antipsychotic medication treatment with placebo, milieu, or psychosocial treatment.

DATA COLLECTION AND ANALYSIS

Working independently, we critically appraised records from 681studies, of which five studies met inclusion criteria. John Rathbone from the Schizophrenia Group supported us with the data extraction. We calculated risk ratios (RR) and their 95% confidence intervals (CI) where possible. For continuous data, we calculated mean difference (MD). We calculated numbers needed to treat/harm (NNT/NNH) where appropriate.

MAIN RESULTS

Five studies with a combined N = 998 met inclusion criteria. Four studies (N = 724) provided leaving the study early data and results suggested that individuals treated with a typical antipsychotic medication are less likely to leave the study early than those treated with placebo (Chlorpromazine: 3 RCTs N = 353, RR 0.4 CI 0.3 to 0.5, NNT 3.2, Fluphenaxine: 1 RCT N = 240, RR 0.5 CI 0.3 to 0.8, NNT 5; Thioridazine: 1 RCT N = 236, RR 0.44 CI 0.3 to 0.7, NNT 4.3, Trifulperazine: 1 RCT N = 94, RR 0.96 CI 0.3 to 3.6). Two studies (Cole 1964; May 1976) contributed data to assessment of side effects and present a general pattern of more frequent side effects among individuals treated with typical antipsychotic medications compared to placebo. Rappaport 1978 suggested a higher rehospitalisation rate for those receiving chlorpromazine compared to placebo (N = 80, RR 2.29 CI 1.3 to 4.0, NNH 2.9). However, a higher attrition in the placebo group is likely to have introduced a survivor bias into this comparison, as this difference becomes non-significant in a sensitivity analysis on intent-to-treat participants (N = 127, RR 1.69 CI 0.9 to 3.0). One study (May 1976) contributes data to a comparison of trifluoperazine to psychotherapy on long-term health in favour of the trifluoperazine group (N = 92, MD 5.8 CI 1.6 to 0.0); however, data from this study are also likely to contain biases due to selection and attrition. One study (Mosher 1995) contributes data to a comparison of typical antipsychotic medication to psychosocial treatment on six-week outcome measures of global psychopathology (N = 89, MD 0.01 CI -0.6 to 0.6) and global improvement (N = 89, MD -0.03 CI -0.5 to 0.4), indicating no between-group differences. On the whole, there is very little useable data in the few studies meeting inclusion criteria.

AUTHORS' CONCLUSIONS

With only a few studies meeting inclusion criteria, and with limited useable data in these studies, it is not possible to arrive at definitive conclusions. The preliminary pattern of evidence suggests that people with early episode schizophrenia treated with typical antipsychotic medications are less likely to leave the study early, but more likely to experience medication-related side effects. Data are too sparse to assess the effects of antipsychotic medication on outcomes in early episode schizophrenia.

Mental health nursing and first episode psychosis

The purpose of this literature review is to identify mental health nursing's contribution to the care and treatment of patients with a first episode of psychosis; A systematic literature review was undertaken, with 27 articles selected for study. Five domains were identified: development of therapeutic relation, relapse prevention, enhancement of social functioning, stimulation of medication adherence, and support of family members. The level of evidence of mental health nursing's contribution to the care and treatment of those undergoing their first episode of psychosis was low. Our review suggests that mental health nurses should reflect upon their own daily practices within the five domains.

Relapse prevention in serious and enduring mental illness: a pilot study

The purpose of the research was to ascertain whether coping knowledge and relapse outcomes are enhanced after 12 months following a programme of community-based relapse prevention (RP). Relapse to mental illness has high societal costs and this programme aims to lessen the likelihood of relapse by equipping service users with greater coping mechanisms by employing a quasi-experimental design with some controls. Participants are recruited from a day hospital in London. There are two groups: (1) experimental group (n = 10) and (2) control group (n = 10). The experimental group is given an 8-week RP programme, and the control group receives routine care. Both groups are then followed up at 1, 2 and 12 months. The research hypothesis was participants undergoing a programme of RP will have greater 12-month knowledge and superior relapse outcomes. The 52-week follow-up rates are 80% for experimental group and 70% for control group. There are no differences in the two groups in terms of relapse outcomes. Knowledge between baseline and 52 weeks is improved in the experimental group though most of the changes are observed during the first 12 weeks. We conclude that an 8-week RP programme resulted in improved knowledge but not relapse outcomes at 52 weeks. A randomized controlled trial should now be conducted to assess whether these results are replicated.