The association between relapse and the outcome of schizophrenia and recurrent psychotic disorders

Schizophrenia follows a relapsing–remitting pattern in a significant proportion of people. Reference Jørgensen, Bøg and Kabra1 Periods of relapse of psychotic illness are strongly linked to severe negative impacts on day-to-day functioning, social relationships and general health. Reference Tessier, Roger, Gregoire, Desnavailles and Misdrahi2 The mechanisms underlying relapse of psychotic illness remain unclear, but established risk factors include periods of external stress, sleep disturbance, drug abuse and discontinuation of maintenance antipsychotic treatment. Reference Rivelli, Fitzpatrick and Nelson3 There is considerable concern that the more frequent, severe and longer-lasting the periods of psychotic relapse, the less likely that the person will return to their baseline functioning. Reference Emsley, Chiliza, Asmal and Harvey4 However, despite considerable evidence that maintenance antipsychotic treatment reduces relapses, a significant proportion of people with a psychotic illness do not adhere to treatment with antipsychotic medication. The article by Moncrieff et al reports no significant differences in social functioning, symptom scores or quality of life outcomes after 24 months in patients with schizophrenia who had a relapse of their illness versus those who did not. However, the authors did find a detrimental impact of relapse on participants’ employment status. Their data comprise secondary analysis of a randomised controlled trial assessing the impact of antipsychotic medication dose reduction versus maintenance treatment on social functioning. Reference Moncrieff5 This original study found that antipsychotic medication dose reduction was associated with an increased number of relapses of greater severity and several other adverse outcomes, but findings did not support the a priori hypothesis of significant improvement in social functioning or neurocognition. All the participants who relapsed in this primary antipsychotic reduction study were included in the secondary analysis of the publication. Here, we place these findings in a wider context, examining issues with antipsychotic discontinuation: the impact of relapse on brain physiology, the generalisability of the participant sample recruited into the primary study and, finally, the potential impact on clinical practice.