Training to recognise the early signs of recurrence in schizophrenia.

The lifetime prevalence of schizophrenia is just less than 1% with onset usually occurring during adolescence or early adulthood. People with schizophrenia have an increased risk of suicide and physical illness, as well as impaired occupational and social functioning. A large proportion experience a cyclical pattern of illness, with periods of acute psychotic episodes followed by stable periods of full or partial remission, although these are often accompanied by the presence of residual symptoms.

This Cochrane Review from February 2013 examines whether one particular aspect of psychological treatment for schizophrenia – training in the detection of early signs of relapse – might help people with schizophrenia and those who care for them to work towards a better outcome. The intention was to try to separate the effects of this training from other psychological interventions, but only one of the included studies examined this. All the studies looked at the effects of training provided to people with schizophrenia.

In total, 34 randomised trials were available for the review. These had been reported in 41 publications and included more than 3500 participants. There was a certain symmetry to these studies, with 11 from North America, 11 from Europe and 11 from the East Asia. The remaining study was from Australia. The primary outcomes for the review were relapse and rehospitalisation. The authors conducted analyses of whether or not people experienced one of these events and, where possible, they also looked at the time to the event. Almost all the trials randomised participants individually, but two of the studies used a cluster approach.

Some of the included studies concentrated on early warning signs as the primary intervention, while others had this as part of a wider programme. There were also variations in how the interventions were implemented, what they focused on and who delivered the therapy. For example, the practitioners in some trials were psychologists, while doctors or nurses were involved in other trials. A further complication was that the definition of ‘relapse’ varied across studies, ranging from the onset of symptoms to admission to hospital. Coupled with this considerable heterogeneity, when the authors assessed the quality of the evidence, they judged that it was ‘very low’.

With these cautions in mind, the review found that significantly fewer people relapsed with early warning signs interventions than with usual care (23% versus 43%; risk ratio [RR]: 0.53, 95% confidence interval [CI}: 0.36 to 0.79), based on data from 1502 participants in 15 trials. The risk of re-hospitalisation was also significantly lower with early warning signs interventions compared to usual care (19% versus 39%; RR: 0.48, 95% CI: 0.35 to 0.66), in 15 trials with 1457 participants. Six trials (550 participants) could be included in the analysis of time to relapse, and this was found to be not significantly different between the intervention groups, and there was also no significant difference in time to re-hospitalisation (6 trials, 1149 participants). The findings for participants’ satisfaction with care and economic costs were inconclusive because of a lack of evidence.

The review concludes that early warning signs interventions may have a positive effect on the proportions of people who relapse and who are re-hospitalised, but that the overall quality of the evidence makes it unclear whether the interventions would have similar effects outside trials and suggests that further research is very likely to alter the current estimates. There is also doubt about whether the early warning signs interventions would be effective on their own, given that they were used alongside other psychological interventions in the trials.

The authors note that the interventions might be cost-effective due to reduced hospitalisation and relapse rates, but highlight the importance of further research, of high or moderate quality, before mental health services should routinely provide psychological interventions involving the early recognition and prompt management of early warning signs to adults with schizophrenia. They emphasise the need for future randomised trials to be adequately-powered, designed in ways that will minimise the risk of bias and reported in ways that enhance transparency. They also stress that these studies should evaluate resource costs and resource use, alongside efficacy outcomes and other outcomes that are important to people with serious mental illness and their carers.

Soure: Cochrane Library