# The nature of relapse in schizophrenia Emsley et al. BMC Psychiatry 2013, 13:50 http://www.biomedcentral.com/1471-244X/13/50 [[1471-244X-13-50.pdf]] Robin Emsley1*, Bonginkosi Chiliza1, Laila Asmal1 and Brian H Harvey2 --- - Relapse may carry biological risk. Each relapse worsen the level of functioning and takes longer to treat. (As observed also from clinical practice) - "relapse may carry a biological risk. It has been proposed that active psychosis reflects a period of disease progression insofar as patients may not return to their previous level of function and treatment refractoriness may emerge [3,4]" [[Multiple Factors contribute to increase risk of relapses]] Observations : 1. Relapse rates are very high after treatment discontinuation, even after a single episode of psychosis. 2. A longer treatment period prior to discontinuation does not reduce the risk of relapse. 3. Many patients relapse very soon after treatment discontinuation. 4. ==The transition from remission to relapse may be abrupt, with few early warning signs.== 5. Once illness recurrence occurs symptom severity rapidly returns to levels similar to the initial psychotic episode. 6. While most patients respond promptly to reintroduction of antipsychotic treatment after relapse, the response time is variable and frank treatment failure may emerge in a subset of patients. **How long does patients need to be on medication before discontinuation of medicine?** - No consensus on recommended duration - "Despite the fact that several studies have assessed the risk of relapse after discontinuation of antipsychotic medication, there is no consensus on the recommended duration of treatment. A recent systematic review of guidelines for maintenance treatment of schizophrenia found that, of 14 such guidelines, discontinuation of antipsychotic medication after a first-episode of schizophrenia was partially recommended after 1 to 2 years in six, not recommended in two, and not mentioned in six [28]." Time to relapse after treatment discontinuation - The interval between time of treatment discontinution and symptom recurrence is highly variable - "Three of the eight studies investigating relapse rates after treatment discontinuation (Table 1) reported mean times to relapse of 235 days [21], 323 days [27] and 207 days [10]. This could create the impression that patients remain well for a considerable period – perhaps months – before relapse. Onset of Relapse may be abrupt - No clear reliable way to predict relapse - Studies suggest that it may be difficult to identify many patients who are at risk of imminent relapse in clinical practice, and that early warning signs are relatively unreliable predictors of relapse [35-37]. ## **Duration varied. It could be 1 day, 1 - 3 days, or 1 week, 2 - 4 weeks, 4 weeks,** ^11ca94 - Herz and Mellville [38] assessed 145 patients with chronic schizophrenia and 80 family members. Approximately half of the patients and 68% of the family members indicated that the interval between the onset of noticeable symptoms and relapse was at least 1 week. - Between 8 and 15% of patients and families gave this interval as 1 to 3 days and 7 to 8% patients and 11% families indicated that it was less than 1 day. - Birchwood et al. [32] Breported that 75% of relatives of patients noticed changes from 2 to 4 weeks before relapse. - Henmi [39] retrospectively investigated 61 schizophrenic outpatients in remission, of whom 33 had relapses in the past 20 months. Non-specific (nonpsychotic) prodromal symptoms were identified 4 weeks prior to relapse in 64% - Norman and Malla [35] concluded that prodromal symptoms have only modest power as predictors of relapse. In a study investigating the predictive validity of self-reported early warning signs of relapse in a cohort of 60 remitted first-episode patients, the Early Signs Scale (ESS) achieved adequate sensitivity but poor specificity and positive predictive validity in predicting relapse or symptom exacerbations [41].