Liam Davenport

April 06, 2017

FLORENCE, Italy — Medication nonadherence is the primary predictor of an initial relapse after first-episode psychosis (FEP), say Spanish researchers, who found that other factors predicted subsequent relapses.

The findings showed that second and subsequent relapses were associated with nonmodifiable factors, such as age at onset, a schizophrenia diagnosis, and a low level of positive symptomatology.

"This subgroup of patients could have greater predisposition to relapse related with the severity of the disease itself," the investigators, led by Marcos Gomez Revuelta, MD, Hospital Universitario de Álava-Sede Santiago, Vitoria-Gasteiz, Spain, note.

The findings were presented here at the European Psychiatric Association (EPA) 2017 Congress.

Major Disease Burden

Nuria Núñez Morales, MD, also from Hospital Universitario de Álava-Sede Santiago, who presented the findings on behalf of Dr Revuelta, noted that positive symptoms in FEP "are just the tip of the iceberg" in terms of disease burden.

She said relapse following FEP is associated with hospitalization, treatment resistance, brain tissue loss, suicide, violence, social stigma, and economic and familial burden, as well as loss of clinical, social, and vocational recovery.

Although previous studies have shown that a first relapse is linked to nonadherence to medication, persistent substance use disorder, and poor premorbid adjustment, little is known about the factors affecting subsequent relapse.

To examine the predictive factors of first and subsequent relapse, the team examined data on 393 antipsychotic-naive FEP patients who had taken part in a prospective, randomized, flexible-dose, open-label drug study between 2001 and 2011. The patients were allocated to receive one of six antipsychotics.

Of those patients, 341 achieved clinical remission and were considered to be at risk for relapse. As part of the trial, they were assessed at baseline, 6 weeks, and again at 12 and 36 months.

During the 3-year follow-up, 166 (48.68%) patients experienced at least one relapse. Fifty-six patients (33.73%) experienced a second relapse. A total of 15 patients (26.79%) had three relapses, six patients experienced four relapses (9.20%), and a single patient had five relapses.

Cox regression analysis revealed that the main predictor of first relapse was poor adherence to medication (ExpB: 2.979; P < .001). Predictors of a second relapse were diagnosis (ExpB: 1.975; P = .074), age at onset, (ExpB: 1.078; P = .003), and a low level of positive symptomatology (ExpB: 0.863; P = .03).

Dr Núñez Morales concluded that nonadherence to medication "was the main relevant predictor for clinical relapses after a first episode of psychosis." She said that "only nonmodifiable factors, such as diagnosis and age of onset, increased the risk" for further relapses.

Need for Better Patient Relations

However, session chair Armida Mucci, MD, PhD, Department of Psychiatry, University of Naples SUN, in Italy, took issue with this notion and said that age of onset is a modifiable risk factor, noting it can be modified by identifying high-risk patients early on and enrolling them in prevention programs.

Speaking to Medscape Medical News after the session, Dr Mucci said that the rate of medication nonadherence in psychiatry is extremely high. She believes that the key to solving this problem lies in better physician-patient relationships, which she described as the "number one factor in the dropout rate.

"We should strive to have better relationships with our patients, we should consult with them more, and we should really work on adherence via the relationship," she said.

Dr Mucci noted that the problem of nonadherence is not confined to psychiatry. "All the chronic diseases are plagued by this," she said. She added that it is largely due to the fact that patients do not like to take medications for a lifetime.

"But if they trust their doctor and they have not only the pills but perhaps a warm relationship with their doctor, this helps a lot, both in medicine and in psychiatry," she said.

No funding for the study and no relevant financial relationships have been disclosed.

European Psychiatric Association (EPA) 2017 Congress. Abstract O079, presented April, 3, 2017.

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