Assessing early signs of relapse in psychosis: Review and future directions

Abstract

Relapse of psychosis is common and has profound adverse consequences. Early signs interventions assume that timely prediction of relapse allows preventative action to reduce the chance of full relapse. The utility of early signs in this context is critically reviewed. Cohort studies suggest that early signs (e.g. anxiety, insomnia) appear in the few weeks before relapse and have modest predictive validity (sensitivity 10%-80%, median 61%; specificity 38%-100%, median 81%), indicating that accuracy of relapse prediction needs improvement. Trials using early signs to target interventions show that targeted antipsychotic medication is less effective than adequately dosed maintenance medication but relapse rates are lower than when intervention is delayed until relapse. The relative value of more complex interventions including psycho-education and relapse prevention strategies is not yet clearly established because there are few trials, some with important design limitations. Basic symptoms are subtle, subjective, qualitative changes in experience claimed to precede psychosis. One retrospective cohort study and studies of "at risk mental states'" transition to psychosis indicate some predictive validity. We suggest that basic symptoms are potentially valuable additions to the range of early signs and deserve further investigation in the effort to enhance the predictive validity of the early signs syndrome.

Qualitative investigation of targets for and barriers to interventions to prevent psychosis relapse

“…increased medication, increased support, stress reduction). Such interventions show promise but could be further improved [5]. Qualitative methods are suited to exploring how an intervention works and potential barriers to its effective implementation [6], complementing quantitative approaches [5] that necessarily impose a preconceived structure on such experiences and may overlook unexpected, important findings.…”

Psychological approaches to understanding and promoting recovery in psychosis and bipolar disorder: a mixed-methods approach

“…However, at the 15-month follow-up, the majority of participants remained stable regardless of treatment group. Given that this is a group with typically high rates of relapse, 198 it is possible that by choosing their own treatment, people received the level of support they needed and this was sufficient to keep them stable over a significant period of time; however, it is also likely that people remained stable owing to the benefits associated with participation in a clinical trial. 199 Attendance rates in the high-support group were particularly poor and this may be owing to a number of issues.…”

SleepSight

“…Therapeutic treatments often require an initial phase of dose adjustment to take effect and may result in a loss of drug efficacy, requiring dose readjustment with disease progression (Eisner, 2013). Around 80% of those treated for a first episode of psychosis relapse within five years (Robinson et al, 1999).…”

“…Early signs of relapse in SchizophreniaMost relapse prevention strategies rely on self or observer-rated early warning signs (EWS) such as anxiety, dysphoria, and poor concentration that manifest prior to relapse (Eisner et al 2013). However, sensitivity and specificity have been modest, and are limited by infrequent assessment and loss of insight.…”