Background to the Study
Relapses, which include symptom exacerbations and a deterioration in functioning that often requires re-hospitalization, can be very distressing and demoralizing for persons with severe mental illness such as schizophrenia. Gazzaniga, Heatherton & Halpern (2010) asserted that Schizophrenia, which literally means “splitting of the mind,” refers to a split between thought and emotion. It is a chronic psychotic disorder, characterized by alterations in thoughts, perceptions, actions sense of self or consciousness, and interpersonal relationships. The disorder is characterized not only by its florid and extraordinary positive symptoms, but also negative and disorganisation symptoms; all of which affect almost all aspects of mental function in emotion, language, motor, as well as perception and reasoning. Clinical observation has suggested that schizophrenia has a great variety of courses and outcome with the majority of patients experiencing one or multiple relapses during the course of the illness. Boyd (2005) described schizophrenia as a common and serious neurobiological illness that affects 1in100 people world-wide. This is in line with the American Psychiatric Association (APA, 2000) approximation that one out of every 100 people in the world suffers from schizophrenia during his or her lifetime.
The first episode of this illness is characterized by frank psychotic symptoms of hallucinations and delusions, and the effect is usually long-lasting and always severe. This severe mental disorder that manifests a complex syndrome inevitably has a devastating effect on the lives of not only the patients, but also their family members; with both patients and their families suffering from poor care and social ostracism because of wide-spread ignorance about the disorder.
Barlow and Durand (2005) observed that, despite important advances in treatment, complete recovery from schizophrenia is rare because of the characteristic multiple relapses. In addition to the emotional costs, the financial drain is considerable. For example, the American Psychiatric Association (1994) estimated the annual cost of schizophrenia in the United States to exceed $65 billion when factors such as family care giving, lost wages, and treatment are considered. When managed and treated with antipsychotic medications in combination of psychotherapy and other psycho-social interventions, the condition of patients with this disorder tends to remain stable. Sometimes, in spite of all these therapeutic interventions, some patients still relapse. Because of the severity and devastating effects of this illness, research on its causes, course, treatment, and factors influencing relapse its relapse deserve attention. Investigation into the factors influencing schizophrenic relapse will facilitate prompt and early identification, treatment and prevention of the disorder by mental health team, more so the mental health and psychiatric nurses who, through the application of the Nursing Process, play diversified roles in the care of the mentally ill and their families. According to Suzuki, Yasumura, Fukao (2003) in Kazadi, Moosa, and Jeenah ( 2008), relapse rates vary from 50% to 92 %, and are similar in developed and developing countries despite the former having well established mental health services. Hogarty, and Ulrich (1998) as cited in Janet, Sarah, Osborne et al. (2011), estimated the risk of relapse for a person with schizophrenia to be 35 % per month. Relapse may result in re-hospitalizations, treatment resistance, cognitive impairment owing to progressive structural brain damage, personal distress, incarceration, and interference with rehabilitation efforts (Kazadi, et al., 2008). It can interfere with independent living, work, and community adjustment; thus making minimizing relapse a common treatment goal in patients with schizophrenia.
Risk factors for relapse in schizophrenia, as identified by Hogarty and Ulrich. (2006), include poor adherence to medications, severe residual psychopathology, poor insight, substance misuse, poor interpersonal relationships, and expressed emotion (EE). Barlow and Durand (2005) observed that, despite important advances in the treatment of schizophrenia, complete recovery is rare. This chronic disorder is characterised by one or multiple relapses. In addition to the emotional costs, the financial drain is considerable. For example, the American Psychiatric Association (2004) estimated the annual cost of schizophrenia in the United States to exceed $65 billion when factors such as family care giving, lost wages, and treatment are considered. When managed and treated with antipsychotic medications in combination of psychotherapy and other psychosocial interventions, the condition of patients with this disorder tends to remain stable. Sometimes, in spite of all these therapeutic interventions, some patients with schizophrenia relapse.
Relapse of schizophrenia can be reduced through the use of a multi-faceted, integrating, biological and psychosocial approaches in the treatment.
Successful treatment for people with schizophrenia rarely includes complete recovery. Prevention of relapse in mental disorders is crucial not only because symptoms are detrimental to quality of life but also because the occurrence of relapse increases chances for future relapses; and also economic burden on health care systems because of its associated morbidity and readmissions to hospital. Prevention of relapses could have significant therapeutic and social economic implications (Kazadi et al. (2008). The only available research literature on relapse in schizophrenia was that conducted by Kazadi et al. (2008) in South Africa, and Adellah, (2012). In Nigeria, there are a dearth of data on the factors influencing relapse in schizophrenia. This study is intended to bridge this gap.
Statement of the Problem
Despite the best efforts of biological approach in the management of mental illness, relapse is still unacceptably high in most psychiatric disorders especially in schizophrenia. In a 2- year- study, Hogarty et al. (2008) observed that for individuals regularly and reliably taking oral or depot antipsychotic medications, an average of 40% – 50% of relapses was estimated. Suzuki, Yasumura, Fukao and Otani (2003) in Adellah (2012) observed that the most common outcome of schizophrenia is a declining course with one or multiple relapses in 50-92% of cases. The number of increasing patients with schizophrenia relapse in most mental health and psychiatric institutions is alarming. This is particularly true of the Federal Neuropsychiatric Hospital, Enugu in Enugu State, Nigeria with the risk of relapse in schizophrenia having been estimated at 3.5% (Chinawa, 2012).
Although the Health facility has a good multidisciplinary psychiatric mental health team to give adequate bio-psychosocial approach to the management and treatment of schizophrenia and the management is highly committed to seeing that patients who attend the institution receive quality mental health services but, in spite of all these efforts, relapse rates are still unacceptably high. Could it then be that there are some unidentified factors that have been perpetuating schizophrenic relapse in the hospital? This question motivated the researcher to undertake this study. Multiple relapses characterise the course of illness in most patients with schizophrenia, yet the factors responsible for these relapses have not been extensively explored.
Purpose of the Study
The purpose of this study was to review the case notes of schizophrenic relapsed patients and the factors that influence relapse among the patients with schizophrenia hospitalized and discharged at the Federal Neuropsychiatric Hospital, Enugu between January,2005 and December, 2014.
Specific objectives were to:
- ascertain the annual prevalence of schizophrenic relapse among the patients with schizophrenia at the Federal Neuropsychiatric Hospital, Enugu between January, 2005 and December, 2014.
- find out the method of management/treatment of patients with schizophrenia relapse in the hospital during the period under study.
3.identify the factors influencing relapse/s among patients with schizophrenia at the Federal Neuropsychiatric Hospital, Enugu between January, 2005 and December, 2014.
These objectives will be achieved by answering the following research questions:
- What is the prevalence of schizophrenic relapse among patients with schizophrenia hospitalized, re-hospitalized and treated at the Federal Neuropsychiatric hospital, Enugu between January, 2005 and December, 2014?
- What was the treatment approach for schizophrenia relapse adopted by the Federal Neuropsychiatric Hospital, Enugu during the study period?
- What are the factors influencing relapse in schizophrenia among patients hospitalized and re-hospitalized at the Federal neuropsychiatric hospital Enugu between January, 2005 and December, 2014?
Hypothesis 1: There will be no statistical significance between the factors influencing relapse and schizophrenia at the Federal neuropsychiatric hospital, Enugu within the study period.
Hypothesis 2.There will be no statistical significance between treatment/management of schizophrenia and schizophrenic relapse at the Federal neuropsychiatric hospital, Enugu within the period of study.
Significance of the Study
The findings of this study will ascertain the prevalence of relapse in schizophrenia among patients treated at the Federal Neuropsychiatric Hospital, Enugu. This will thus help the hospital management in planning effective treatment and management of patients with schizophrenia so as to lessen the economic burden of relapse on the health care system.
Furthermore, the findings of this study will contribute to the body of knowledge in the field of psychiatry and mental health especially in Psychiatric, and Mental Health Nursing. The study will also serve as a baseline information for further studies especially on relapse in schizophrenia as well as research on any of those factors that would be identified as influencing schizophrenic relapse in the health facility.
The knowledge of the factors influencing schizophrenia relapse discovered from this study will help psychiatric and mental health care providers to improve the standard of mental health care and interventions in the prevention and care of both inpatients and out patients with schizophrenia in psychiatric and mental health care settings. The study will also enable mental health care providers to identify innovations for caring for patients with schizophrenia thereby reducing relapse and lessening the burden of relapse on health care system. It will also have the potential to help influence health care policies in improving mental health and reducing the burden of relapse on patients with schizophrenia, their families and the community as a whole.
Scope of the Study
This research study was delimited to the prevalence and Factors Influencing Relapse/s among patients with schizophrenia hospitalized, treated, discharged and re-hospitalized for re-emergence or aggravation of psychotic symptoms (relapse/s) at the Federal Neuropsychiatric Hospital, Enugu between January, 2005 and December, 2014.
The study only involved a review of the hospital admission and discharge registers in the wards and review of the patients’ hospital case files in the institution’s Medical Records Department for collection of the relevant data (socio-demographic data, factors influencing schizophrenic relapse and the treatment approach for schizophrenia, and relapse of schizophrenia.
Operational Definition of Terms
For the purpose of this study schizophrenia refers to a psychotic disorder as diagnosed by a psychiatrist and according to the criteria for the Diagnostic and Statistical Manual of Mental disorder fourth edition text revision (DSM- IV- TR) which requires the presence of severe symptoms for at least one month and the presence of some symptoms for at least six months.
Positive symptoms: two or more of the following present for at least a one- month- period: delusions, hallucinations, disorganized speech grossly disorganized or catatonic behaviour.
- Social/ occupational functioning: significant impairment in work, academic performance, interpersonal relationships, and/ or self-care
- Duration: continuous signs of the disturbance for at least six months ; at least one month of this period must include symptoms that meet criterion A above (APA, 2000).
Relapse in schizophrenia is defined here as patients with schizophrenia who have been hospitalized and treated and re-hospitalized for re-emergence or aggravation of psychotic symptoms, at least six months following the initial diagnosis, hospitalization for the disorder.
Factors Influencing Relapse in Schizophrenia
For the purpose of this research means those circumstances and or conditions etc. that have triggered acute psychotic symptoms in the patients who had been initially diagnosed as having schizophrenia and having been hospitalized six months following the initial hospitalization and discharge. The factors include:
comorbid mental disorder e.g., depression, anxiety disorder, bipolar disorder, mania etc. Substance abuse/misuse, e.g., cannabis, marijuana, cocaine, Indian hemp, alcohol abuse, poor medication compliance, medical /surgical conditions such as, malaria, asthma, pneumonia, surgical operation etc., lack of insight, ignorance and so on, non-comprehensive/integrative treatment approach for schizophrenia relapse, stressful life events, expressed emotions and so on.
Comprehensive/Integrative Management/treatment approach. This includes combining antipsychotic medications such as chlorpromazines, olanzapines, clozapines etc., with psychotherapy, other psychosocial services and community mental health services in the treatment of schizophrenia and schizophrenia relapses.
Community Mental Health Services. This includes rehabilitation services, milieu therapy, half- way home, shop front, assertive community, milieu therapy for continuity of treatment within the client’s/patient’s community.
Prevalence in this study refers to the number of cases of schizophrenic relapses identified among schizophrenic patients treated at the Federal Neuropsychiatric hospital, Enugu between 1st January, 2005 and 31st December, 2014.