Relapse risk assessment in early phase psychosis: the search for a reliable and valid tool.

Abstract

A significant advance in the field of mental health during the past 2 decades has been the recognition that early and optimal, phase-specific treatment of mental illness results in better clinical and functional outcome.1-4 A framework for SEI services for psychosis, focused on the critical period of the first 5 years following the onset of illness,5 and comprised of pharmacological and psychosocial interventions,6-9 has been shown to have superior effectiveness in comparison with routine care.10-12 Importantly, relatively high rates of symptomatic remission rates in response to early intervention and treatment have been reported.13 However, there is considerable variation in remission rates (24% to 82%), which may be attributed to variation in the criteria used for remission (for example, inclusion of remission of negative symptoms),14 duration of follow-up period,15 aspects of the multi-component treatments used,16 and possible pharmacological treatment options17 (for example, oral, compared with long-acting injectable) used.While remission of symptoms is an important early goal of treatment, the principal objective of treatment of early phase of psychosis should be to promote full recovery. Recently, there has been a more optimistic outlook on recovery generated from SEI services, as it is assumed that patients in the early phase are likely to have retained greater motivation and skills to engage in a process that could lead to full recovery in all dimensions.18, 19 Although recovery is defined on multiple dimensions,20-23 remission of symptoms still remains an important part of the road to recovery, whether guided by clinical, functional,14 or a patient's subjective perspective.23 However, one clinical barrier toward remission, and thus recovery, is the high rate of relapse and the lack of an assessment tool for identification of risk of relapse at this early phase of illness.Relapse in Early Phase PsychosisWhile remission rates are high and recovery is more tangible in early phase psychosis, a sobering statistic that clinicians, patients, and their families face is the relatively high rate of relapse during the first 5 years following initial treatment. In fact, in regular care, 80% of patients with a diagnosis of a first episode of schizophrenia have been reported to experience relapse, often multiple, within 5 years of treatment or remission from their index episode.24,25 Rates of relapse in SEI services are lower than that reported in regular care,26,27 but still remain a substantial barrier to recovery. These lower rates (20% to 30% during 2 years) may be, at least partly, associated with the better medication adherence rates27 achieved in these programs through better engagement in the multiple components of treatment provided. The significantly high risk of relapse, even with enhanced treatment offered in SEI services, exposes our lack of capacity to predict relapse with any degree of confidence. A reliable prediction of risk for relapse would ensure early intervention and thereby reduce the associated negative effects of relapse and improve overall outcomes.Why Is Relapse of Psychosis an Important Concern for Clinicians?Relapse in early phase psychosis can have significant consequences for patients and their families. The most obvious consequence of relapse is its relation to functional outcome through interruption of sustained remission. Indeed, length of remission of both positive and negative symptoms has recently been shown to be by far the most significant predictor of functional outcome (employment, school, and social relationships) at 1 and 2 years follow-up of patients with early phase psychosis.28 In the latter study, conducted on a large sample of patients with early phase psychosis in an SEI service, length of remission of negative symptoms contributed most to functional outcome at 1 year, while length of positive symptom remission played an even more significant role at 2 years. …