What Needs To Follow Early Intervention? Predictors Of Relapse & Functional Recovery Following First-Episode Psychosis

The following is a summary of Kam SM, Singh SP, Upthegrove R. What needs to follow early intervention? Predictors of relapse and functional recovery following first-episode psychosis. Early Interv Psychiatry. 2013 (doi: 10.1111/eip.12099), which was developed independently of the article authors.

• Predictors of poor outcome in schizophrenia are under-researched in patients who have received early intervention, in whom risk of relapse has been ameliorated or may be different from other patients.
• Some of the known predictors of poor outcome include long duration of untreated psychosis, repeated relapse, male gender and a younger age of onset.
• While a clear association between experience of fewer psychotic symptoms in the first 2 years of illness with better outcomes 5 years later has been observed, service pathways, relapse and functional recovery after EIS have rarely been reported.

• The aim of this study was to investigate service input, factors predicting post-discharge relapse and functional outcome in patients following completion of early intervention for FEP.

• Quantitative data from case-note review were obtained between the beginning of 2005 and 2009 from 163 patients aged 16–35 years at admission who had completed care within the EIS department of a Birmingham Mental Health Facility (United Kingdom) and had a clinical diagnosis of FEP (as defined by the International Classification of Diseases, 10^th Revision, Clinical Modification [ICD-10]). The endpoint of the study follow-up was December 2011.
  • Patients who were assessed but not enrolled by the service, discharged without completing care with the service and those who were discharged without a diagnosis of psychosis were excluded from the study.
• Predefined criteria for data discussion included age at admission, ethnicity, gender, children, marital status at follow-up, NEET status at admission, discharge and endpoint.
• Patients in whom multiple unattended appointments resulted in discharge from service or no further appointments were offered, were classified as ‘lost to follow-up’.
• Significant relapse and relapses occurring while with the EIS were classified as a home-treatment episode, informal mental health admission to hospital, compulsory admission under the Mental Health Act (2007), or forensic mental health service involvement.
• Kaplan-Meier survival analysis and Cox proportional hazards regression analyses were performed for time to post-discharge relapse. A hierarchical logistic regression was also conducted to determine predictors of endpoint NEET status.

• In the 163 patients included in this study that were followed-up for a median of 3.6 years post-discharge:
  • The mean EIS admission age was 22.4 years (standard deviation=3.8).
  • The median duration of care with the EIS was 3.8 years.
  • Diagnoses largely belonged within the ‘schizophrenia, schizotypal and delusional disorders’ subcategory (n=135, 83%).
  • Following discharge from EIS, the majority of patients remained with psychiatric services, community mental health teams (n=102, 63%) or assertive outreach (n=11, 7%).
    • Twenty-one of 44 (48%) patients discharged immediately to primary care were later re-referred to psychiatric services.
• Relapse:
  • Sixty-seven (41.1%) patients experienced at least one post-discharge relapse.
    • For 46% (n=31) of these patients, this was their first ever relapse.
  • The majority of episodes (n=182), both with and after EIS, were treated by home-treatment (n=94; 52%).
  • The majority of relapses occurred during the first year (n=39; 23%).
  • A positive skew was observed for the distribution of yearly relapse rates, such that the median time to post-discharge relapse was 3.8 years (standard error=0.7; 95% confidence interval [CI]=2.38–5.17).
    • However, further analysis did not reveal a significant difference between patients who were followed up for 3 or > 3 years (P = 0.2).
  • The only significant factor predicting time to relapse was the ‘number of relapses whilst with the EIS’ (P = 0.021).
    • For hazard of post-discharge relapse, an increase of one pre-discharge relapse was associated with a factor increase of 1.21 (95% CI=1.04–1.39).
• Vocational recovery:
  • Compared to EIS discharge, a significantly higher proportion were NEET at study end (73% vs 60%; odds ratio=1.76 [95% CI=1.04–2.97]; P=.034).
  • The likelihood of being NEET increased for those in the black and minority ethnic group (P = 0.036), participants with substance misuse (P = 0.003) and in patients experiencing a relapse (P = 0.024). Increase in the number of relapses also increased the likelihood of NEET status.

• This study focused on the post-EIS follow-up period and reported that most relapses occurred within the first year of discharge from Birmingham EIS. Additionally, occupational functioning was reported to decrease post-discharge. The number of relapses occurring while with the EIS was the only significant predictor identified for time-to-relapse after discharge from EIS.
• Prevention of relapse after FEP remains a key clinical goal as the basis for symptomatic and functional remission, and vulnerability to further relapse.