BackgroundMultiple relapses characterise the course of illness in most patients with schizophrenia, yet the nature of these episodes has not been extensively researched and clinicians may not always be aware of important implications.MethodsWe critically review selected literature regarding the nature and underlying neurobiology of relapse.ResultsRelapse rates are very high when treatment is discontinued, even after a single psychotic episode; a longer treatment period prior to discontinuation does not reduce the risk of relapse; many patients relapse soon after treatment reduction and discontinuation; transition from remission to relapse may be abrupt and with few or no early warning signs; once illness recurrence occurs symptoms rapidly return to levels similar to the initial psychotic episode; while most patients respond promptly to re-introduction of antipsychotic treatment after relapse, the response time is variable and notably, treatment failure appears to emerge in about 1 in 6 patients. These observations are consistent with contemporary thinking on the dopamine hypothesis, including the aberrant salience hypothesis.ConclusionsGiven the difficulties in identifying those at risk of relapse, the ineffectiveness of rescue medications in preventing full-blown psychotic recurrence and the potentially serious consequences, adherence and other factors predisposing to relapse should be a major focus of attention in managing schizophrenia. The place of antipsychotic treatment discontinuation in clinical practice and in placebo-controlled clinical trials needs to be carefully reconsidered.

The RSWG remission criteria are easy to apply and define an achievable and desirable treatment goal. Measures of social and occupational functional outcome, quality of life and cognitive status need to be further developed and standardized before remission and recovery criteria can be more broadly defined.

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These findings are cross sectional and do not infer causality. Nonetheless, they indicate that associations between one type of childhood adversity (i.e. neglect) and social cognition are present and are not illness-specific.

The available evidence does suggest that long-acting injectable antipsychotics can be used safely and effectively in early stages of the illness, and that they may be associated with better outcomes than with oral medications. However, this is largely supported by evidence from naturalistic cohort studies and a small number of controlled trials of risperidone long-acting injection. Evidence for olanzapine and paliperidone long-acting injectables in particular is limited.

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