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

Key Messages

Data regarding predictors of post-discharge relapse and factors affecting longer term functioning in patients who have received early intervention in first-episode psychosis (FEP) are sparse.
The authors reported that most patients who are likely to relapse, typically do so within the first year after discharge from early intervention service (EIS).
The results of this study suggest that post-discharge, in the first year in particular, there may need to be a higher emphasis on early post-discharge monitoring, and services should be designed …

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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, 10th 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.