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QUESTION: In patients with schizophrenia or schizoaffective disorder, does a programme for relapse prevention (PRP) consisting of antipsychotic medication and psychosocial treatment prevent relapse and readmission to hospital?
A community support programme at the University of Rochester, Rochester, New York, USA.
82 patients who were 19–60 years of age (mean age 30 y, 65% men), had a diagnosis of schizophrenia or schizoaffective disorder according to DSM-III-R criteria, and had an increased risk of relapse (≥1 hospital admission in the previous 3 years and ≥2 lifetime hospital admissions). Exclusion criteria were evidence of organic mental disorder or mental retardation, or severe drug or alcohol dependence that required inpatient treatment. Follow up was 86%.
Patients were allocated to PRP treatment (n=41) or usual care (n=41). All patients except 2 received standard doses of maintenance antipsychotic medication (equivalent to 300–1000 mg of chlorpromazine). PRP treatment consisted of education for patients and family members about relapse in schizophrenia and how to recognise prodromal symptoms and behaviour, active monitoring for prodromal symptoms, clinical intervention within 24–48 hours when prodromal episodes were detected, 1 hour weekly supportive group therapy (or 30–45 minutes of individual supportive therapy for patients who refused group treatment), and 90 minutes of multifamily psychoeducation groups biweekly for 6 months and monthly thereafter.
Main outcome measures
Relapse (score ≥5 on the positive scale of the Positive and Negative Syndrome Scale and score ≤30 on the Global Assessment Scale) and hospital readmission.
Fewer patients in the PRP group than in the usual care group relapsed (p=0.01) or were readmitted to hospital (p=0.03) by 18 months (table⇓).
A programme for relapse prevention that combined antipsychotic medication with psychosocial treatment reduced relapse and hospital readmission in patients with schizophrenia or schizoaffective disorder.
The prevention of relapse and readmission to hospital is a critical issue in community mental health practice. The study by Herz et al is the first experimental trial to compare outpatient relapse rates between clients receiving standard care and those receiving early intervention (PRP). The study sample is typical of schizophrenic clients seen in community mental health programmes, and patients were randomly assigned to a clearly described and replicable PRP group and a standard care group that provided considerably more visits than most outpatient services. This study confirms previous research on the importance of close monitoring of prodromal symptoms of relapse and prompt intervention to reduce relapse and readmission to hospital. It makes a major contribution to clinical practice in the description of a promising intervention model for relapse prevention.
Several clinical applications can be derived from this research. Firstly, training in detection of prodromal symptoms and the process of relapse is essential for early clinical intervention. The training PRP workers received was effective in improving early detection of prodromal symptoms. When symptoms of relapse were detected in the standard care group, 35% had already met the criteria for full relapse compared with 4% of the PRP clients. Secondly, the Early Signs Questionnaire-Brief Version (ESQ) can be used as an assessment tool for prodromal symptoms. Weekly use of the ESQ to monitor symptoms is recommended for the first year after discharge. Thirdly, the PRP protocol recommends early medical intervention with a 20% increase in medication at the onset of prodromal symptoms. Fourthly, the use of supportive group or individual counselling can be left to client choice or determined by agency resources. 59% of the PRP clients chose group treatment and 41% chose individual treatment. No difference in the relapse rate existed between these 2 groups. Fifthly, collaboration and continued contact with family members are critical. The multiple family psychoeducation groups helped family members to identify prodromal symptoms and provide support to their loved one. Only 1 of the PRP clients in the family groups relapsed, even though 50% of the clients had prodromal episodes. Sixthly, clients at greatest risk of relapse are characterised by non-compliance, denial of illness and need for treatment, and no contact with family. The PRP can be adapted easily to existing services in community mental health programmes to reduce emotional and economic costs of relapse and readmission to hospital.
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