Early Recognition Method, relapse prevention in community mental health care: Evaluation of an intervention tailored to patients with schizophrenia or bipolar disorder

Research output: ThesisPh.D. thesis

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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 specialized treatment.
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 strategy.
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. 
Translated title of the contributionEarly Recognition Method, tilbagefalds forebyggelse i ambulant psykiatrisk behandling: Evaluering af en intervention tilpasset patienter med skizofreni eller bipolar lidelse
Original languageEnglish
Awarding Institution
  • University of Southern Denmark
  • Hounsgaard, Lise, Principal supervisor
  • Fluttert, Frans, Supervisor
  • Hansen, Jens Peter, Supervisor
Publication statusPublished - 11. May 2022


  • Relapse prevention
  • community mental health care
  • individual tailoring
  • nurse-patient collaboration
  • shared decision making
  • family involvement


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