Integrated Review:  Relapse and Re-hospitalization of Schizoaffective Patients

Integrated Review:  Relapse and Re-hospitalization of Schizoaffective Patients

Relapse and Re-hospitalization of Schizoaffective Patients 

Researchers conducting studies on mental disorders in most organizations discovered that relapses and re-hospitalization was a common occurrence in patients who stop taking antipsychotic medication. Chien, Mui, Gray, & Cheung (2016) state that “While current guidelines for schizophrenia care recommend antipsychotic medication to be essential for long-term maintenance treatment, nonadherence to this medication is found to be a predictor factor for re-hospitalization and relapse.” Although other factors can attribute to increased relapses and re-hospitalization among such patients, suspension of antipsychotic medication is the most common cause across the world. Although studies on other factors that may lead to relapses are underway, this paper presents results from studies on the effect of antipsychotic drugs cessation on patients with mental illness. Mental illnesses affect patients and their extended families and, therefore, psychotherapy impacts on the patients alongside their family members on some occasions. Results indicate that for schizophrenia patients, suspension of medication results in relapse and hospitalization long after treatment. This purpose of this paper is to identify if antipsychotic medication together with psychotherapy promotes better medication compliance. It also investigates if the interventions to reduce risks of relapse and re-hospitalization compared to antipsychotic drugs use only.

Literature Search Methods

This section highlights the methods used to gather information about the study issue since there are many approaches to collecting data. Literature reviews always require systematic search methods to streamline the research process and confine the search parameters to the required scope of the study. This study incorporated several search methods during the literature review process to ensure that the information collected was relevant to the clinical problem and reflect current concerns in modern society. The search methods are examined and discussed in two main areas of content, which are sampling strategies and the inclusion and exclusion criteria adopted.

Sampling Strategies

This section highlights how the research materials were chosen. The literature reviewed in this study consisted of published journal articles collected from the PubMed database, which is a reliable source of published peer-reviewed journal articles. The types of studies focused on in the research are interventions for schizophrenia and causes for relapse and re-hospitalization of patients with this illness. PICO elements included in the study were the problems causing regression and re-hospitalization of adults with schizophrenia and the intervention suggestions to increase the adherence to antipsychotic medication. The report then provides a comparison of the effectiveness of antipsychotic medication against therapeutic methods. The study also limited the literature to articles published between 2015 and 2020 to ensure the incorporation of the latest evidence-based interventions.

The PICO question for the study was: “in adults, can antipsychotic medication together with psychotherapy promote better medication compliance to reduce risks of relapse and re-hospitalization compared to antipsychotic medications use only.” The review of the articles, therefore, enabled use of current data. The key terms used in search of items in the PubMed database were “adherence to antipsychotic medication and psychotherapy.” Other vital search terms included “interventions for relapse in the use of antipsychotic medications compared to psychotherapy”. These results provided the most critical information essential in the formulation of intervention measures. The terms used in the search helped in the streamlining of the research, and by combining these terms with the other strategies, the search became more specific and concise.

Inclusion/Exclusion Criteria

This section explains that criteria used in selecting literature sources and materials to utilize the most relevant ones for the study. The criteria used in evaluating research articles for the review limited the search topics to schizophrenia, adherence to antipsychotic medication compared to psychotherapy and interventions to the problem of suspension of the medication mid-treatment. This criterion helps in the utilization of comprehensive and detailed research studies on the clinical issue and the responses. The PubMed database was used as the primary source of literature because it contains relevant peer-reviewed research studies, which are essential for the literature review. The search parameters were also narrowed to include only articles between 2015 and 2020, which provide current information.

Literature Review Findings

General findings

This paper presents results and inferences based on the review of various literature concerning the relationship and intervention of relapses in the treatment of schizophrenic patients using antipsychotics. Systematic reviews indicate that adherence to oral medication by patients with schizophrenic spectrum disorder is often low with average rates of between 30% and 50% (Chien, Mui, Gray, & Cheung, 2016). The study explored the factors that lead to the suspension of antipsychotic medication by patients with mental illness and the resulting re-hospitalization. The focus of the paper was on the effectiveness of antipsychotic medication in reducing these cases of cessation of treatment compared to psychotherapy and other emerging treatment methods. This method of treatment is compared to the therapeutic techniques used in earlier intervention methods. In this section, the general findings from a variety of academic and scientific sources are presented to illustrate the problem facing patients with schizophrenia concerning adherence to medication and the methods of intervention available as of the writing of this paper. The primary advantage of the use of antipsychotic medications in the treatment of schizophrenia is that the drugs provide the patients with the option to treat and manage the illness outside mental health facilities.  Psychotherapy, on the other hand, requires the patient and the physician to meet physically.

Antipsychotic medications are the primary treatment for mental illness and therefore play a significant role in preventing and minimizing relapses and, consequently, re-hospitalization (Tareke., Tesfaye, Amare, Belete, & Abate, 2018). Concepts concerning the clinical problem are highlighted to explain the topic from a local and global perspective. These concepts help in providing information that creates awareness about the effects of the suspension of antipsychotic drugs in schizophrenic patients. Reversions and re-hospitalization rates of schizophrenic patients after the withdrawal of antipsychotic medications increase significantly when the disorder is not well managed. The speed at which patients relapse vary depending on the type of medication. The cost of re-hospitalization and the suffering that accompanies it poses severe challenges for the patient and their families. The effects of schizophrenia vary in severity ranging from problems forming interpersonal relationships, self-care challenges and difficulty in finding and maintaining stable working conditions. It is, therefore, prudent that patients observe their medication guidelines to avoid relapsing by taking regular dosages and attending psychotherapy sessions as prescribed by the primary care physician.

The quality of care provided to patients with mental illness affects the recovery process significantly. Post-treatment interactions between physician and patients during follow-up treatments and checkups may influence the chances of the patient relapsing. In most cases, nurses discontinue the administration of antipsychotic medication systematically after one year of a patient being symptoms free (Harrow & Jobe, 2013). Research indicated that patients who discontinue the antipsychotic medication without following the nurses’ direction end up relapsing or worsening their condition, leading to re-hospitalization. This problem, therefore, impacts everyone involved, including the nurses, the patient and the individuals responsible for caring for the patient outside the medical institution. The entire nursing profession is impacted negatively by the frequent relapse by patients taking antipsychotic drugs, and cases of re-hospitalization cast significant doubt on the effectiveness of the medication.

Most researchers recognize and support the use of antipsychotic medication as the standard treatment for mental disorders. The current standards of care in the treatment of mental disorders such as schizophrenia rely on the use of antipsychotic drugs supported by other therapeutic methods and emerging technologies. As a result, most medical institutions treating mental illnesses often rely on these antipsychotic drugs almost entirely. Mental illnesses, however, vary significantly. This variation often leads to a lack of effective medication for curing psychological problems. Most antipsychotic drugs function as inhibitors to the risks that accompany mental illnesses such as the limitation of physical impairments and the reduction of the chances of relapse and re-hospitalization. A cure that can treat mental illnesses definitively is not currently available. Researchers are working on creating treatments for mental illnesses with an improved understanding of the inner workings of the brain in recent years.  Health organizations, therefore, need to find a solution to tackle the medical giant of mental illness. (Morken, Widen & Grawe, 2008). It is essential, therefore to find a permanent solution to the relapse and re-hospitalization of mental health patients due to antipsychotic medication discontinuation

According to most researchers, the risk of relapse and subsequent re-hospitalization is highest during the first five years of diagnosis. The impact of cessation of treatment during this period is severe as statistics from these studies indicate that withdrawal of the medication is associated with worsening symptoms and slow adjustment to medication prescriptions (Tareke et al., 2018). In a project study, discontinuation after the use of medication within the first six months resulted in 25% to 55% of the patients reverting and being re-hospitalized (Harrow & Jobe, 2013). This paper presents reports from the study area, which is a local health facility dealing with mental health illness. The reports suggest that withdrawal of medication among schizophrenia patients heightens the risks of reversions and consequently re-hospitalization within six to ten months of discontinued medicines for the treatment of schizophrenia.

Relapse and re-hospitalization among schizophrenic patients, however, could also occur due to other factors related to treatment and the physicians. Ignorance of the dangers of discontinuation of medication is one of the significant factors that contribute to this problem. This ignorance or lack of awareness has been part of the leading causes of relapse and re-hospitalization of patients with schizophrenia in most countries around the globe.  Another contributing factor is experience with the medication, where patients had adverse side effects (Harrow & Jobe, 2013). Social and family support is also another factor. Patients lacking stable social structures and support, such as family ties or a caring community withdraw from antipsychotic medication for various reasons that may be related to work or personal relationships. Researchers note that love and support are often necessary conditions in the recovery of schizophrenic patients, and lack of these conditions may lead to prolonged illness and relapse from medication. Lastly is the therapeutic relationship between a patient and a physician (Harrow & Jobe, 2013). The relationship between a physician and their patient plays a very significant role in recovery, and schizophrenic patients, who require stable treatment environments often benefit from good relationships with their caregivers.

Mitigation and prevention of relapse and re-hospitalization of schizophrenic patients due to suspension of medication often comes with challenges and hindrances that patients and doctors have to face. An example of these hindrances is the wide variety of antipsychotic medicines available to the patients at affordable prices. Schizophrenic patients faced with this wide array of drugs tend to shift from one type of medication to another, causing more harm than good in most cases. As a consequence of this random change in medication, most patients often relapse in their mental health leading to re-hospitalization and commencement of treatment again. Another barrier hindering the mitigation of the relapse problem among schizophrenic patients is the shortage of particular antipsychotic drugs. Physicians often prescribe antipsychotic medication that fits the diagnosis of the patient, but in some cases, the medicine may not be readily available. The patient has no choice but to take substandard medication that may not treat their illness effectively leading to re-hospitalization. This problem is common in regions where antipsychotic medication is not readily available, especially in rural areas. Results indicate that patients who experience a shortage of antipsychotic medication experience relapse and re-hospitalization due to a lack of treatment (Morken, Widen, & Grawe, 2008). Studies into the prevention of relapse and re-hospitalization of these patients are therefore necessary to alleviate the pain of patients in these marginalized areas.

Why Are the Above Interventions Perceived Ineffective?

As stated above, psychotherapy treatments often miss the cause of the illness and provide general relief to patients in the short term. Patients with schizophrenia, therefore, have to visit the physicians over prolonged periods to ensure that the antipsychotic medication. Chemical interventions using antipsychotic drugs, on the other hand, are faster and provide noticeable results in short periods. Cases of relapse and re-hospitalization reduce when antipsychotic drugs effectively mitigate the harmful effects of the illness. This paper advocates for the use of antipsychotic medication because of this degree of certainty that they provide as treatments. Cured patients rarely relapse after finishing the dose as prescribed by the physician, reducing the problems associated with re-hospitalization of patients.

Schizophrenic patients often lack options in the way of treatment methods and have to rely on antipsychotic medication as the first option. This limitation makes it difficult for these patients to explore other avenues of treatment, locking them in a situation where they have to rely on one channel of therapy. Studies always indicate that lack of options, especially in the medical field, leads to poor outcomes due to the reliance on one treatment method for varied types of illnesses. Schizophrenia affects different patients in different ways, and antipsychotic medications which serve as inhibitors for the harmful effects of mental disorder may often fail in some particular cases. Most local medical institutions use antipsychotic medication as the standard method of treatment for schizophrenia. These medications should be taken over extended periods, and regular checkups are mandated to ensure that the drugs are useful in the procedure. Limited use of antipsychotic medicines or suspension of the medication mid-dosage often results in adverse outcomes such as relapse and progression of the symptoms in some cases. Addressing the problem of medication nonadherence resulting in reversion and re-hospitalization among patients with mental illness and poorer patient outcomes is, therefore, a critical part in the treatment of schizophrenia. Some of the adverse consequences of the discontinuation of medication by schizophrenia patients include violence, suicidal tendencies, and functional impairments. These outcomes may result in permanent symptoms persistence, relapse, re-hospitalization, and premature mortality (Morken, Widen & Grawe, 2008). Results indicate that the rates of medication discontinuity, which lead to declines among patients with schizophrenia, are between 20% and 50% depending on the clinical settings and the medication approach (Harrow, & Jobe, 2013). These statistics reflect a significant problem in the treatment of the mental illness since almost half of the patients tend to discontinue the medication leading to relapses.

The severity of the impacts and challenges resulting from patient discontinuation of medication without direct instructions from the primary physician is evident in most communities with schizophrenic patients. Doctors and nurses often fail to notice changes in patient medication due to various factors, but empirical results indicate that 53% of patients with schizophrenia become non-adherent to medicine. The patients suffer worse symptoms, relapses and re-hospitalization as a consequence of this cessation of treatment. In the most severe cases, patients may die from actions resulting from erratic behaviour during psychotic episodes resulting from this discontinuation of the medication. Studies indicate that people with schizophrenia have a 40% to 60% greater chance of dying prematurely (Wildgust, Hodgson & Beary, 2010). More than 40% of the deaths are due to suicide and accidental deaths among patients with schizophrenia (Wildgust, Hodgson & Beary, 2010). Mitigation of this problem may help reduce these statistics and improve the recovery rate of patients adhering to the prescriptions by the physicians. Medical conditions with high mortality rates often receive preference from researchers. Given the high mortality rate of the discontinuation of medication and its related effects, more studies into the mitigation of this issue are necessary.

The cost of treatment for mental illnesses is often substantial on the patient, their family and the community. Relapses and re-hospitalization because of medication discontinuation among patients with schizophrenia increase this cost and the utilization of healthcare resources. Reports indicate that re-hospitalization costs alone due to nonadherence to medication are more than $1.5 billion in the United States annually (Wildgust, Hodgson & Beary, 2010). Mental disorders such as schizophrenia carry a significant economic burden, especially in instances of relapse, re-hospitalization, and unplanned adjustment of medication prescription (Dilla, Ciudad, and Alvarez, 2013). Addressing the issue will help in saving costs that would otherwise be spent on healthcare services. Usually, the antipsychotic medication forms the basis of treatment for mental disorders. It reduces psychotic symptoms and other risks associated with mental illness. In general, results indicate that adherence to antipsychotic medication improves patient outcomes and reduces the financial burden associated with relapse and re-hospitalization.

Chosen Intervention

For this study, the population under investigation was not age, race or gender-specific. The review focused on relapse and re-hospitalization of patients with schizophrenia following the suspension of antipsychotic medication. The intervention proposed is the use of antipsychotic drugs accompanied by regular psychotherapy sessions to ensure that patients and physicians keep track of changes in factors that could cause a relapse. The integration of psychosocial interventions in the treatment of schizophrenia is necessary for mitigating relapses and re-hospitalization (She at al., 2017). The study aimed to identify whether a combination of antipsychotic drugs and psychotherapy could reduce cases of relapse and re-hospitalization compared to the drugs alone. Results and inferences from the literature reviewed indicated that psychotherapy was an essential tool in ensuring adherence of schizophrenic patients to antipsychotic medications. The sessions also provide physicians with insights into the factors that cause relapse in most patients, helping them formulate better measures to mitigate the problem. This section will discuss the studies investigated on a case-by-case basis, noting the patient demographics, suggested interventions, and how they compare with others.

Chien, Mui, Gray and Cheung (2016) conducted a randomized control trial with 134 schizophrenic patients to investigate nonadherence to medication in patients with schizophrenia. The study was interview-based with a repeated-measures control group and an intention to treat bias and was conducted between 2012 and 2015. All the patients were examined by a psychiatrist to determine their mental capability to follow the directions of the trial for 18 months until the next follow up interview. The test took place in Hong Kong. The 134 patients aged between 18 and 64 years were chosen randomly from two healthcare facilities using random computer-generated numbers. The intervention assignments assigned to each patient were concealed to the clinic, assessors and researchers until all data entry procedures were complete (Chien, Mui, Gray, & Cheung, 2016). All the patients portrayed symptoms of one form of schizophrenic spectrum disorder or another. The criteria used for inclusion to the study included the ability to speak Chinese, patient within three years with the schizophrenic disorder, and a history of nonadherence to medication (Chien, Mui, Gray, & Cheung, 2016).

The trial was conducted based on the adherence therapy (AT) guidelines in addition to the regular treatment provided in the medical facilities. Since the test was control-based, only 67 of the 134 patients received the AT in six 2-hour therapy sessions for two weeks (Chien, Mui, Gray, & Cheung, 2016). The rest of the group served as the control to ensure accurate outcomes and inferences from the trial. The therapy was conducted by a qualified community psychiatric nurse and involved cognitive, motivational, insight-inducing and behavioural training (Chien, Mui, Gray, & Cheung, 2016). This technique was effective for patients with addictive personalities and those with negative and ambivalent attitudes towards psychiatric intervention.

The outcomes of the trial indicated little statistical differences in the two groups (Chien, Mui, Gray, & Cheung, 2016). The researchers also noted that the patients in the trial showed little statistical difference with the patients outside the study.  The group that received regular psychiatric treatment, however, showed improved understanding of the illness, reduction in the severity of the symptoms and reduced re-hospitalization durations (Chien, Mui, Gray, & Cheung, 2016). This improvement was attributed to the differences in interactions between these patients and psychiatric specialists. The adherence to antipsychotic medication also improved over time in the patients who received psychotherapy compared to the patients in the control group (Chien, Mui, Gray, & Cheung, 2016). This study illustrated the need for regular psychotherapy, in addition to antipsychotic medication, in the improvement of adherence to medication among patients with schizophrenia.

Yeisen et al. (2017) also conducted a study to investigate the attitudes and subjective experiences of patients with psychotic episodes within the first two years of treatment.  This study was aimed at investigating the factors that affect adherence to antipsychotic medication in these patients based on their attitudes and experiences. A thematic analytic approach was used during this study, generating interpretative elements from the dialogue between patients and researchers (Yeisen et al., 2017). This study was conducted in Norway, and most of the inclusion criteria used in the admission of the patients were published elsewhere. The participants in the trial, however, had to fulfil the following conditions to meet the minimum requirements for participation: live in a catchment area, aged between 15 and 65 years, and be actively psychotic as measured by a Positive and Negative Syndrome Scale (Yeisen et al., 2017). The study included 20 participants chosen based on the stability of the experiment (Yeisen et al., 2017). All the participants needed to be active users of antipsychotic medication

The study revealed that adherence to antipsychotic medication suffered from poor communication and lack of sufficient information from nurses and physicians (Yeisen et al., 2017). The researchers note that the adherence issue is a complex problem facing schizophrenic patients and requires multiple approaches to provide all the necessary information. The participants in the study indicated that poor physician-patient relationships led to inadequate communication about the medication (Yeisen et al., 2017). This lack of sufficient information on the need to adhere to dosages often resulted in patients suspending treatment after the acute phase of the psychosis had passed. The participants also noted that most instructions for the medication were provided during the acute stage of psychosis leading to miscommunication or memory lapses after a particular duration (Yeisen et al., 2017). All these challenges illuminated the need for psychotherapy alongside the antipsychotic medication to avoid suspension of drugs and relapse of patients into psychosis.

Begemann et al. (2020) conducted a study to investigate whether functional and symptomatic patients recovering from schizophrenia improved after gradually reducing their antipsychotic medication dosages 3 to 6 months after remission. The study also investigated the effects of the continuation of medication by similar patients for one year after remission. The test conducted was a single-blinded randomized test on the extension and discontinuation of treatment of patients with schizophrenia in remission (Begemann et al., 2020). The study included 512 participants with different symptoms of schizophrenic spectrum disorder and within 3-6 months of remission (Begemann et al., 2020). All participants were also required to be between 16 and 65 years (Begemann et al., 2020). These patients were chosen at random from inpatient and outpatient settings in the Netherlands.

The study was aimed at investigating the effects of continuation versus the discontinuation of medication after remission (Begemann et al., 2020). The researchers noted that most studies conducted before their trial indicated that discontinuation of treatment after remission from schizophrenic disorders often led to relapse and re-hospitalization (Begemann et al., 2020). As of the writing of this paper, this trial was still ongoing. Indications from previous studies pointed to the continuation of treatment as the best option for patients even after remission. The authors indicate that relapse is often associated with resistance to medication (Begemann et al., 2020). Although this trial does not reflect on the importance of psychotherapy in these cases, previous studies have made it clear that antipsychotic medication without therapy often fails to address the problem of relapses and re-hospitalization among schizophrenic patients. Researchers agree that remission may be well defined in clinical terms, but recovery from schizophrenia involves the regaining of all social and functional capabilities affected by the illness (Brugnoli et al., 2020). Psychotherapy is, therefore, a critical tool during the recovery process to determine the success of the drugs in treating the disorder.

Discussion

Limitations

The limitations experienced during the study included a lack of formal and scientific studies that address the correlation between the factors that lead to cessation of treatment and the specific impact they have on the patients. Physicians treat most schizophrenic patients only using antipsychotics. Nonadherence also arises from other causes such as depression and anxiety, which may or may not be related to the illness. These external factors may affect the adherence of the patients to the prescribed medication significantly. The report, therefore, leaves the door open for treatments that seem to ease the patients’ pain to avoid locking out solutions that may help researchers in future studies into the issue.

Conclusion of Findings

The inferences made from the scholarly articles made it clear that none of the two methods can be used as standalone measures in the treatment, despite the PICO question. The study sought to show that antipsychotic drugs coupled with psychotherapy, would reduce cases of relapse and re-hospitalization in schizophrenic patients compared to antipsychotic drugs alone.  In cases where the patients faced challenges during the treatment, physicians had the opportunity to collect more information and re-adjust the medication based on the outcome of the psychotherapy sessions. Most studies investigated noted that patients taking antipsychotic medications alone suffered from frequent relapses. Some statistics showed that almost half of the patients taking these drugs without psychotherapy often relapsed within the first five years. However, researchers indicated that therapeutic interventions alongside some chemical interventions produced the best results.

Potential Practice Change

Based on the challenges described above, it was clear that there is insufficient research into the correlation between factors that cause nonadherence to drugs and lack of psychotherapy. Although chemical interventions provide the best results in the short term, most researchers recommended therapeutic interventions for prolonged cases. The paper, therefore, suggests that mental institutions should create treatment regimens that incorporate antipsychotic medication with regular psychotherapy sessions to reduce instances of relapse and re-hospitalization in schizophrenic patients.

Conclusion

This report was aimed at investigating whether antipsychotic drugs alongside psychotherapy could be more effective in preventing relapses and re-hospitalization of patients with schizophrenia compared to the drugs alone. Most of the studies reviewed during the investigation revealed that most patients with schizophrenic spectrum disorders often relapse after discontinuation of the medication. This condition often leads to re-hospitalization costing the patients and their families extra cash. Re-hospitalization also increases the burden on the community since patients with mental illness often rely on the support of family and friends in their recovery process. Most of the studies reviewed indicated that antipsychotic drugs alone are effective in treating mental illnesses, but psychotherapy is necessary to understand factors that cause relapse and prevent re-hospitalization. This report, therefore, recommends regular psychotherapy sessions, in addition to the antipsychotic drugs to promote awareness for the need to adhere to the prescriptions. Patients in remission are also encouraged to take the medicine and discontinue them gradually while taking regular therapy sessions to avoid re-hospitalization.

References

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