Monday, June 3, 2013

Risk factors for psychotic relapse

Alvarez-Jimenez et al. have done a good meta-analysis looking at risk factors for relapse of psychotic symptoms, published in Schizophrenia Research (2012;139-116-128).

The authors conclude that there are four major factors associated with increased risk of relapse in schizophrenia and other psychotic disorders:

1) non-compliance with meds (increases risk x4)
2) substance use (increases risk x3)
3) criticism from caregivers (increases risk x2.3) -- conversely better social support is associated with reduced risk of relapse
4) poorer premorbid adjustment (increased risk x2.2)

Interestingly, the authors conclude that factors such as diagnosis, length of illness, length of untreated symptoms, demographic variables, and cognitive function, are not associated with relapse risk.

Clearly, these findings add to the recommendations for helping patients who have had psychotic symptoms, and their families:
1) medication compliance is extremely important!
2) substance use must be avoided!
3) caregivers must work hard to avoid hostile or critical comments towards the patient

One question I have about these findings, however, is how causative some of these factors are.  It could be argued that an individual who is already more likely to relapse may be more likely to be non-compliant with medication, be more likely to engage in substance use, and may be more likely to behave in a way which elicits more criticism from other people.  The existence of these "risk factors" may indicate that the underlying disorder was more severe.  So, some or all of these risk factors may simply be non-causal associations.

In order to more definitively show that risk factors #1-#3 are causative (and therefore controllable or reversable), we would have to show evidence that externally improving medication compliance in a previously non-compliant person would clearly reduce relapse rate.  And we would need to show that a change in caregiver environment would produce a change in subsequent relapse rate. 

There is some such evidence, but I think it would be good to see a careful meta-analysis looking at risk-factor management in reducing relapse rate. 

Another thought I have about these findings is that the recommendations are appropriate not just for people who have had psychotic symptoms, but for all psychiatric conditions, and even for all members of the whole population!  That is, avoidance of substance abuse and having good social support with minimal hostility and criticism is probably good and protective for everybody's mental and physical health!   But we would have to look further at the research to see if this thought of mine has been proven. 


Anonymous said...

Your last paragraph is quite cute.

I wanted to comment on your interpretation of the results. As an alternative you suggest that there is something inherently different about the people who relapse, don't take meds, don't have good social relationships and use other drugs. This could very well be. But perhaps it might not just be the individual and their problem

For causation to be inferred, three conditions must be met.
1)An association (or correlation) between the variables. (ie if medication compliance decreases relapse increases.)
2)Establishment of temporal order
(ie: medication compliance decreases before there is a relapse)
3) Elimination of confounding variables.

The third criteria is not met (with certainty)

How about the possibility that there are a lack of good solutions to handle psychosis?

It could be that the patients were not on the right meds or that the side effects were too awful. This caused them to go off their meds and or possibly use drugs because their illness was not managed correctly or appropriately. This could be the fault of professionals, the patient, their illness, their family, or our lack of understanding of psychosis and it's treatment.

Yes-- the factor seem more correlational than causal.

IN addition:

You have to look at the assumptions that are implied in this work.

1) Psychotic relapse can be avoided if you stay on your medication.

2) Each patient was on the right medication.

3)The illness experienced by each person is non changing/ non evolving. (I think mental illness over time changes, adapts, and evolves much like viruses)

There are obviously more...

I don't know if we can trust these assumptions.

GK said...

Thanks for the comment!

It's certainly a common experience in psychiatry to see people in the midst of a psychotic relapse who had either stopped or reduced their medications (sometimes following medical advice), and whose symptoms then resolve after a few weeks of restarting medications.

But the reasons for stopping the medication in the first place could be different in different people. For some, it could simply be that the medication is unpleasant in terms of side effects or tolerability. For others, there could be a lack of insight that medications are helpful or needed, especially between episodes. In others, the medication did not work adequately, and the relapse began despite full medication doses. Subsequent noncompliance with medication would then have occurred only after the relapse had started.

It's interesting to consider the possibility of changeability over time, in which different strategies including different doses or varieties of medication might be best at different times. Right now we don't have a clear method--other than trial and error--to test this.

Psychose said...

Interesting and valuable writing. Thanks also for the comments on this article. I loved to read about risk increase in psychotic disorders. How can psychotherapy prevent to fall back in a psychosis? Of course, meds are most important but is counseling not also a predictor for improvement?