This thesis develops knowledge about tailored relapse prevention for adult patients with schizophrenia or bipolar disorder in outpatient settings, by applying the strategy Early Recognition
Method (ERM). Knowledge is developed regarding implementing ERM in community mental health care settings, how it impacts relapse and patient-perceived treatment needs, in addition to patients’ perceptions of their needs for and benefits from collaboration with their caregiver.
The study focuses on patient-caregiver collaboration in an individualized and systematic treatment approach that is applied in the usual community care treatment setting. It is a multi-centre study that evaluates the implemented intervention with regard to number of readmissions, as well as patient experience and satisfaction. A combination of qualitative and quantitative data constitutes the empirical foundation of the thesis.
BackgroundThe objective is to enhance stability in patients with severe mental illness, and thereby reduce the
need for rehospitalization and enforced hospitalization.
Mental illnesses, such as schizophrenia or bipolar disorder, has a prevalence of 1-1.5%. They are
characterized by a cyclical pattern of relapse and remission, and constitute a burden to patients,
families and society in general. The prognosis depends on a number of individual factors, and is
generally aggravated in cases of childhood onset.
Over the recent decades, there has been a change in the conceptual approach to severe mental illness,
towards a more individualized treatment, involving the patients in a process of shared decisionmaking and involvement of family or social relations for support. However, the continued use of
coercive measures in mental health care is an area of controversy, and, according to WHO constitutes
violation of human rights. Enforced treatment is shown to adversely affect the therapeutic relationship
and treatment adherence. WHO urges the international society to participate in promoting mental
wellbeing and human rights.
In spite of the objective of the Danish Department of State on Health and Prevention to reduce the use
of coercive measures, the numbers are increasing, indicating an ongoing unresolved challenge in the
treatment of patients with mental illness. According to the Danish Health Authority report from 2019,
23.8% of discharged patients were readmitted within 30 days; of these, 11% were readmitted within a
week. One percent of patients with severe mental illness has numerous contacts of various character,
and accounts for about 20 % of cumulative treatment costs. These patients are characterized by limited illness insight, difficulty in establishing a therapeutic relationship and they have a need for
In 2020, a programme was launched in the Region of Southern Denmark to meet the increasing need
for admission, emphasizing preventive treatment in community mental health care, including
coherence in treatment across sectors.
AimThe aim of this Ph.D. study was to create an overview of the elements in current non-pharmacological
relapse prevention interventions applied in outpatient settings, targeting patients with schizophrenia
or bipolar disorder, and to generate evidence-based knowledge on how implementing the ERM
strategy in community mental health care impacts relapse and rehospitalization. The target group was
patients with schizophrenia or bipolar disorder. Moreover, the impact of implementing the ERM
strategy was explored in the areas of patient-perceived benefit of treatment in terms of illness insight,
illness management and the experience of control over own life.
The study was guided by the following research questions:
• What is the current state-of-the-art non-pharmacological relapse prevention tailored to
patients with schizophrenia or bipolar disorder in outpatient settings? (Study 1)
• What is the relationship between ERM and respectively, relapse and readmission? (Study 2)
• How is patient involvement in ERM related to illness insight, management and control over
own life? (Study 3 and 4)
Methods The study employs a range of scientific methods to develop knowledge. The overview of existing
knowledge on relapse prevention was created by a systematic literature review. In addition, a
qualitative and a quantitative study was conducted. The qualitative study was theoretically and
methodological guided by the phenomenological hermeneutic theory of interpretation of Paul Ricoeur,
and the quantitative study applied a statistical analysis for knowledge generation. The PhD study
consists of four sub studies:
1. A systematic literature review, including 25 articles, presenting various non-pharmacological
relapse prevention interventions tailored adult patients with schizophrenia or bipolar
disorder. The process was guided by Cochrane guidelines for systematic literature review. The
analysis applied was a content analysis inspired by Krippendorff (2004), and the results were
reported according to PRISMA guidelines for reporting.
2. A quantitative study with a longitudinal naturalistic design and a staggered baseline for
inclusion. The analysis was a linear regression comparing number and duration of contacts to psychiatric wards during respectively, treatment as usual and intervention periods. The data
source was patient records.
3. A methodological paper presenting how transcribed interviews and field observations fixed as
text, can be combined into a coherent text and subsequently be analysed and interpreted by
the Ricoeur-inspired approach to text analysis. Moreover, it is argued that combining field
observations with interviews provides rich and in-depth data.
4. A qualitative study was undertaken, based on 26 in-depth semi-structured patient interviews
before and after participating in the relapse prevention intervention, based on the ERM
strategy. The interviews were analysed according to Ricoeur’s theory of critical interpretation.
Results This thesis presents evidence-based knowledge to enhance the understanding of relapse and relapse
prevention in adult patients with schizophrenia or bipolar disorder, who are affiliated with community
mental health care.
The systematic literature review provided evidence-based knowledge on the state-of-the-art nonpharmacological relapse prevention elements, showing a distinction in treatment need and effect
between the two diagnostic groups, in addition to an apparent gap in knowledge regarding patientperceived treatment need.
The quantitative study showed that participating in an intervention applying the ERM strategy
reduced number and duration of relapse (spending one night or more at a psychiatric ward) for both
diagnostic group, when the historic and intervention period were compared. For patients with bipolar
disorder, the reduction was statistically significant, both in terms of number and duration. For patients
with schizophrenia, there was a significant postponement of relapse during the intervention.
The qualitative study based on the semi-structured interviews revealed two major themes: “Patient
care”, describing how dialogue and collaboration increases illness-insight and control. The other
theme “Insight and experience” describes the impact of illness on personality and self-image, and how
illness insight empowers and entails self-confidence. Participating in the intervention enhanced illness
insight and management, and the acknowledgement of own need for support.
Conclusion he aim of this Ph.D. study was to provide knowledge about relapse prevention in community mental
health care, targeting patients with schizophrenia or bipolar disorder, by implementing the ERM
The study provided new knowledge about the application of the ERM strategy, a strategy that has not
previously been applied in community mental health care settings. The strategy proved uncomplicated
to adapt and implement in community settings. The study provided new knowledge about tailored
relapse prevention targeting patients with schizophrenia or bipolar disorder, and it addressed the gap in knowledge concerning patient perceived treatment needs, for this particular group of patients. In
addition, it illuminated the patient perceived challenges associated with living with SMI.
Future implications For clinical practice: The results of this PhD study presents several implications for practice. They
provide knowledge for stakeholders planning relapse prevention intervention for patients with
schizophrenia or bipolar disorder, for optimal tailoring of interventions and enhancing treatment
outcome. In addition, a systematic approach to patients’ symptoms, as in ERM strategy, enhances the
individual patient’s knowledge of own symptoms and treatment needs. Addressing the individual
needs, and establishing coherence in treatment across sectors and settings, is likely to reduce relapse.
For education: Dissemination of the new knowledge about implementing the systematic and
individualized treatment approach of ERM to staff in community settings, could in turn initiate
introduction of the ERM strategy to patients during the phase of hospital discharge. This might add to
establishing coherence in treatment across sectors, as would communication between sectors and the
involvement of a family member.
For research: In the light of the results of this study, research in the area of enhanced tailoring of the
approach of the ERM strategy, to target patients with schizophrenia and enhance treatment outcome,
is recommended. In addition, researching the applicability of the ERM strategy on other diagnostic
groups, such as patients with misuse/abuse or depression; or other age groups, such as young adults
would be relevant. Moreover, investigating the impact of implementing the ERM strategy in housing
facilities for patients with mental illness is relevant, and may prove a tool for establishing a
collaborative relationship between patients and staff.
For policymakers, the results of this study offer a variety of possible future implications, all presenting
the potential to enhance the service in the area of mental health care.