Programme for relapse prevention was effective for patients with schizophrenia or schizoaffective disorder
Herz MI, Lamberti JS, Mintz J, et al. A program for relapse prevention in schizophrenia: a controlled study.Arch Gen
Psychiatry 2000 Mar;57:277-83
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?
Design
Randomised (allocation concealment), blinded (out.
come assessor), controlled trial with 18 months of
follow up.
Setting
A community support programme at the University of
Rochester, Rochester, New York, USA.
Patients
82 patients who were 19.60 years of age (mean age 30,
65% men), had a diagnosis of schizophrenia or schizo.
affective 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%.
Intervention
Patients were allocated to PRP treatment (n = 41) or
usual care (n = 41). All patients except two received
standard doses of maintenance antipsychotic medi.
cation (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 in.
tervention 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.
Main results
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).
Conclusion
A programme for relapse prevention that combined
antipsychotic medication with psychosocial treatment
reduced relapse and hospital readmission in patients
with schizophrenia or schizoaffective disorder.
COMMENTARY
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 out.
patient 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 pre.
vious 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 two groups. Fifthly, collaboration and continued con.
tact 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 one 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 char.
acterised 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.
William Bradshaw, University of Minnesota Saint Paul, Minnesota, USA
studentBMJ 2001;09:1-42 February ISSN 0966-6494
