International Journal of Mental Health Nursing (2004) 13, 107–116 FEATURE ARTICLE Recognition of early warning signs in patients with schizophrenia: A review of the literature Berno van Meijel, 1,2 Mark van der Gaag, 3 René Kahn Sylvain 4 and Maria H.F. Grypdonck 5 1 Department of Nursing Science, University Medical Center Utrecht, Utrecht, 2 INHOLLAND University, Diemen, 3 Parnassia Psychiatric Institute, The Hague, 4 Department of Neuro-Sciences, University Medical Center Utrecht, and 5 Department of Nursing Science, University Medical Center Utrecht, Utrecht, The Netherlands ABSTRACT: This article reviews and discusses the literature on the recognition of the early warning signs of psychosis. The assumption is that nurses, in the everyday exercise of their profession, can contribute to the prevention of psychotic relapse in schizophrenic patients by the early recognition of warning signs. First, the process of psychotic relapse and the factors that influence it are described. Then research on the early signs of psychosis is discussed. This article questions the most common early signs, when they occur, and who can recognize them. Then the predictive value of the early signs is considered: how well can psychotic relapse be predicted with these early signs? Finally, the research on the effects of early recognition and early intervention is discussed, primarily with respect to the question of whether psychotic relapses can actually be prevented by making use of preventive intervention strategies. The conclusion is that the preliminary results are hopeful and invite further research on such matters as the application of this intervention strategy within nursing practice. KEY WORDS: early warning signs, nursing, prevention, relapse, schizophrenia. INTRODUCTION Schizophrenia is a serious psychiatric disorder with a lifetime prevalence of approximately 0.8% (Buchanan & Carpenter 2000). The occurrence of psychotic relapse is characteristic of schizophrenia. Symptoms occur such as delusions, hallucinations, thought incoherency, and seri- ously chaotic behaviour. Adequate medication therapy significantly reduces the risk of a psychotic relapse (Ayuso-Gutierrez & Rio Vega 1997). As a supplement, psychosocial intervention is of great importance for favourably influencing the disorder. Supportive assist- ance of the patient and the patient’s family (with atten- tion to information and education, therapy compliance, problem solution, and stress reduction), deserves a prom- inent place in care programs for schizophrenic patients. In addition, a number of skill and rehabilitation training programs have proven to be effective, such as those directed to symptom and medication management, work, and living (Buchanan & Carpenter 2000; Bustillo et al. 2000; Marder et al. 1996; Wallace et al. 1992; Wirshing et al. 1991). Much research has been done in recent years on the effects of medication and psychosocial interventions with the occurrence of psychotic relapses being the measure of outcome. Comparison of these studies on this measure of outcome is complicated by divergent operationaliza- tions of psychotic relapse, differing research populations, and different treatment conditions (see, inter alia, Ayuso- Gutierrez & Rio Vega 1997; Crow et al. 1986; Gilbert et al. 1995; Kissling 1992; Liberman & Kopelowicz 1995; Linszen et al. 1996; Viguera et al. 1997). Nevertheless, a pattern does emerge. Upon discontinuation of medica- tion or with placebo treatment, very high relapse rates of between 60% and 75% after 1 year were found. Under favourable treatment conditions in which an optimal medication regime is offered (with intensive supervision of medication use) and intensive psychosocial assistance is given, relapse rates were around 20%. Under regular treatment conditions, the relapse rate is estimated at Correspondence: B. van Meijel, Department of Nursing Science, University Medical Center Utrecht, PO Box 85060, 3508 AB Utrecht, The Netherlands. Email: B.K.G.vanMeijel@med.uu.nl B. van Meijel, RN, PhD. M. van der Gaag, PhD. R. S. Kahn, PhD. M. H. F. Grypdonck, PhD. Accepted May 2004.