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Meta-Analysis
. 2013 Feb 28;2013(2):CD005147.
doi: 10.1002/14651858.CD005147.pub2.

Training to recognise the early signs of recurrence in schizophrenia

Richard Morriss  1 , Indira Vinjamuri, Mohammad Amir Faizal, Catherine A Bolton, James P McCarthy
Affiliations
Meta-Analysis

Training to recognise the early signs of recurrence in schizophrenia

Richard Morriss et al. Cochrane Database Syst Rev. .

Abstract

Background: Schizophrenia has a lifetime prevalence of less than one per cent. Studies have indicated that early symptoms that are idiosyncratic to the person with schizophrenia (early warning signs) often precede acute psychotic relapse. Early warning signs interventions propose that learning to detect and manage early warning signs of impending relapse might prevent or delay acute psychotic relapse.

Objectives: To compare the effectiveness of early warning signs interventions plus treatment as usual involving and not involving a psychological therapy on time to relapse, hospitalisation, functioning, negative and positive symptomatology.

Search methods: Search databases included the Cochrane Schizophrenia Group Trials Register (July 2007 and May 2012) which is based on regular searches of BIOSIS, CENTRAL, CINAHL, EMBASE, MEDLINE and PsycINFO. References of all identified studies were reviewed for inclusion. We inspected the UK National Research Registe and contacted relevant pharmaceutical companies and authors of trials for additional information.

Selection criteria: We included all randomised clinical trials (RCTs) comparing early warning signs interventions plus treatment as usual to treatment as usual for people with schizophrenia or other non-affective psychosis

Data collection and analysis: We assessed included studies for quality and extracted data. If more than 50% of participants were lost to follow-up, the study was excluded. For binary outcomes, we calculated standard estimates of risk ratio (RR) and the corresponding 95% confidence intervals (CI), for continuous outcomes, we calculated mean differences (MD) with standard errors estimated, and for time to event outcomes we calculated Cox proportional hazards ratios (HRs) and associated 95 % CI. We assessed risk of bias for included studies and assessed overall study quality using the GRADE approach.

Main results: Thirty-two RCTs and two cluster-RCTs that randomised 3554 people satisfied criteria for inclusion. Only one study examined the effects of early warning signs interventions without additional psychological interventions, and many of the outcomes for this review were not reported or poorly-reported. Significantly fewer people relapsed with early warning signs interventions than with usual care (23% versus 43%; RR 0.53, 95% CI 0.36 to 0.79; 15 RCTs, 1502 participants; very low quality evidence). Time to relapse did not significantly differ between intervention groups (6 RCTs, 550 participants; very low quality evidence). Risk of re-hospitalisation was significantly lower with early warning signs interventions compared to usual care (19% versus 39%; RR 0.48, 95% CI 0.35 to 0.66; 15 RCTS, 1457 participants; very low quality evidence). Time to re-hospitalisation did not significantly differ between intervention groups (6 RCTs; 1149 participants; very low quality evidence). Participants' satisfaction with care and economic costs were inconclusive because of a lack of evidence.

Authors' conclusions: This review indicates that early warning signs interventions may have a positive effect on the proportions of people re-hospitalised and on rates of relapse, but not on time to recurrence. However, the overall quality of the evidence was very low, indicating that we do not know if early warning signs interventions will have similar effects outside trials and that it is very likely that further research will alter these estimates. Moreover, the early warning signs interventions were used along side other psychological interventions, and we do not know if they would be effective on their own. They may be cost-effective due to reduced hospitalisation and relapse rates, but before mental health services consider routinely providing psychological interventions involving the early recognition and prompt management of early warning signs to adults with schizophrenia, further research is required to provide evidence of high or moderate quality regarding the efficacy of early warning signs interventions added to usual care without additional psychological interventions, or to clarify the kinds of additional psychological interventions that might aid its efficacy. Future RCTs should be adequately-powered, and designed to minimise the risk of bias and be transparently reported. They should also systematically evaluate resource costs and resource use, alongside efficacy outcomes and other outcomes that are important to people with serious mental illness and their carers.

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Conflict of interest statement

None known.

Figures

1
1
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 1 Relapse: 1. Relapse.
1.2
1.2. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 2 Relapse: 2. Time to first relapse.
1.3
1.3. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 3 Service use: 1a. Re‐hospitalisation.
1.4
1.4. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 4 Service use: 1b. Re‐hospitalisation (5‐7 year follow‐up).
1.5
1.5. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 5 Service use: 2. Time to re‐hospitalisation.
1.6
1.6. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 6 Mental state: general 1a. Average score (BPRS, high = bad).
1.7
1.7. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 7 Mental state: general 1b. Average score (PANSS, high = bad).
1.8
1.8. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 8 Mental state: general 1c. Average score (KGV, high = bad).
1.9
1.9. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 9 Mental state: specific 2. Average score in positive symptoms (various scales).
1.10
1.10. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 10 Mental state: specific 3. Average score in negative symptoms (various scales).
1.11
1.11. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 11 Social functioning: 1a. Not employed.
1.12
1.12. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 12 Social functioning: 2a. Average scores (various scales).
1.13
1.13. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 13 Social functioning: 2b. Average scores (various scales).
1.14
1.14. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 14 Quality of life: Average scores (various scales).
1.15
1.15. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 15 Satisfaction with care: 1a. Average endpoint scores (various scales).
1.16
1.16. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 16 Satisfaction with care: 1b. Average change scores (various scales).
1.17
1.17. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 17 Adverse events: 1. Lost to follow‐up.
1.18
1.18. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 18 Adverse events: 2. Death.
1.19
1.19. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 19 Knowledge: 1a. Average scores (various scales).
1.20
1.20. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 20 Knowledge: 1b. Average scores (various scales).
1.21
1.21. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 21 Knowledge: 1c. Average scores (various scales).
1.22
1.22. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 22 Burden of care: 1. Average scores (FBIS, high = bad).
1.23
1.23. Analysis
Comparison 1 EARLY WARNING SIGNS TRAINING + TAU versus TREATMENT AS USUAL (TAU), Outcome 23 Medication compliance: Not compliant to medication.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD005147

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Munroe‐Blum 1993 {published data only}
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杜芳 2010 {published data only}
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王莉 2010 {published data only}
    1. 王莉. Self‐care education on self‐care ability of patients with schizophrenia rehabilitation and quality of life [Google Translate] [自我护理教育对康复精神分裂症患者自理能力和生活质量的影响]. Chinese Journal of Coal Industry Medicine 2010;2:282‐4.
许玉芳 2008 {published data only}
    1. 许玉芳, 蒋菊芳, 吴晓梅, 张紫娟, 唐红, 方春霞, et al. Title only available in Chinese characters. Medical Journal of Chinese People's Health China and China Medicine 2008;20(5):471‐3.
许玉芳 2008a {published data only}
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References to ongoing studies

Farhall 2001 {published data only}
    1. Farhall J. Trialling CBT for psychosis in ordinary mental health services. Australian New Zealand Clinical Trials Registry 2001.
Jones 2012 {published data only}
    1. Jones P. Cts: Cognitive training for schizophrenia. http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=11571 2012.
NCT00046085 {published data only}
    1. NCT00046085. Online family support and education for schizophrenia. http://www.clinicaltrials.gov 2002.
NCT00069433 {published data only}
    1. NCT00069433. Skills training for schizophrenia: enhancing outcomes. http://www.clinicaltrials.gov 2003.
NCT00169052 {published data only}
    1. NCT00169052. Rehabilitation and health care for elderly with SMI. http://www.clinicaltrials.gov 2005.
NCT00435721 {published data only}
    1. NCT00435721. The families coping with mental illness program. http://www.clinicaltrials.gov 2007.
NCT00515671 {published data only}
    1. NCT00515671. IMR for veterans with SMI. http://www.clinicaltrials.gov 2007.

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