Someone with schizophrenia can be frightened by the prospect that they may relapse but relapse prevention is not a spectator sport. If someone becomes noncompliant and stops taking their medication relapse can be quite sudden, even if it is not immediate. Even if someone takes their medication as prescribed they can still relapse but the process seems to be a little slower. I have noticed that someone with schizophrenia who is willing and able to realize they have the illness usually has plenty of warning of an impending relapse as long as they are taking their medication. Although they have to understand the form the illness takes in them they can recognize emerging symptoms. One has to separate one's illness from one's identity and manage the biology of the illness. Everyone has their own unique early warning signs of relapse. For me it is a dramatic increase in ideas of reference. Someone is communicating to me through messages that only I can understand. Tibetans start controlling my dreams, observing and judging me. I start to have trouble falling asleep at night because my mind is agitated.
My psychiatrist suggested I take 5mg of Stellazine when symptoms became obvious and take a good look at what stresses and responsibilities were demanding too much from me. Stellazine tends to knock me out and I start sleeping better right away. After a week the emergent symptoms have always faded. For me, an extended period of isolation, the stress of increased responsibility, or the loss of a friend, can all make positive symptoms become much more real. They never completely disappeared in the first place but most of the time they are in the distant background. When they come to the foreground they can be very seductive or just overpowering.
Case managers are very familiar with this occasional need for extra medication by the individual with schizophrenia. Often they notice a deterioration and try to prevent a rehospitalization by getting this PRN medication to the individual in time. Ideally though you want to empower the individual to manage the biology of their illness in the same way someone with diabetes manages their illness. Without insight, other people have to, with and without cooperation from the individual. Without control of the biology of the illness people end up in hospital, in jail or homeless on the street. They have a deteriorating course that is a tragic and expensive loss to the individual, their families and society.
In the research that's been done the two most important factors that reduce relapse rates are medication, and family education. People stop taking their medication when they are feeling better not wanting to believe they have schizophrenia and they relapse. Family members are often the main care givers, but I'm not sure why family education is so effective in preventing relapse. It clearly is though in a number of different studies.
There are some other considerations to consider in preventing relapse. A major one is substance abuse. Someone on medication for schizophrenia should refrain from any alcohol or illegal drugs. It is just asking for trouble. Some psychiatrists believe that an individual who is drinking or taking drugs can continue to take their medication. Some don't. I think it probably depends on how heavily the individual is drinking or taking drugs. The treatment strategy becomes one of harm reduction, reducing the amount of drinking and substance abuse.
One also has to look at the "structure" people are living in. When I was in hospital I felt safe and started eating three meals a day again. I had a comfortable bed and a regular routine. My positive symptoms faded a lot as I sobered up in that environment without actually taking any medication. I feel better having a nice place to live and money to spend. Having something to do that's meaningful, and being able to accomplish something, all contribute to a sense of well being, and I think, fewer symptoms of schizophrenia.
I chatted with a psychiatrist once who works in a prison part time. He was telling me about people coming into the prison quite psychotic who would refuse medication. They would improve without medication, he thought, because of the routine and structure of the prison environment. The psychiatrist was frustrated because the individuals would then say they didn't need medication because they were better. Other people can deteriorate a lot in prison, get beat up often by other inmates, and have to be put in solitary for their own protection. Getting them out of there can be a real problem. I'm not recommending prison for it's structure just relaying what one psychiatrist has observed.
In schizophrenia the positive symptoms which can lead to a psychosis and rehospitalization tend to fade in males after they turn 40. The opposite is true for women. They tend to have a milder schizophrenia for the first ten years until they enter menopause. Women probably get some relapse protection from the level of estrogen in their blood. Their symptoms can actually vary with the stage of their menstrual cycle, and they might not need medication during a pregnancy because their estrogen levels are so high. After delivery of the baby though, their estrogen levels drop and they are at considerable risk of a relapse. With the medications and treatment strategies they have today most positive symptoms can be controled in most people, provided people take their medication faithfully, as prescribed.
I asked a psychiatrist once how he achieves compliance, and he said he involves everyone the individual loves and trusts to give the same message about the need to take medication. This kind of "swarming" in combination with the low side effect profile of the atypicals means noncompliance tends to be much less of a problem. Insight is usually best with a good response to medication because the individual realizes that what they experienced was very strange. The benefits to an individual in taking medication are an increased quality of life and a decreased probability of relapse. If that is not their experience they should be asking for something at a dose which will mean an improvement in the quality of their life.
Relapse is a very destructive event to an individual over the long
term. (See Early intervention for more information.)
theoretical outcomes
theoretical outcomes
The response to medication tends to decrease
with each relapse and the individual becomes more and more disabled,
requiring more and more support. With each relapse people lose some of their abilities to take care of themselves and enjoy their life. Insight becomes more difficult and compliance
becomes a determining issue that leads to more relapses.
My psychiatrist scared me when I first started on medication. He told me if I didn't take it there was a 90% chance I would relapse and be rehospitalized within a year. It took two or three years before I was convinced I had schizophrenia, and I was willing to take the medication only because it didn't seem to have any effect. Each year the quality of my life has improved a little on medication, particularly on the atypical Olanzapine. I was always able to prevent a relapse and/or rehospitalization, and now rarely experience warning symptoms. I hope everyone else finds that kind of relief from schizophrenia.