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Perspectives of patients, carers and mental health staff on early warning signs of relapse in psychosis: a qualitative investigation

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posted on 2022-04-28, 00:17 authored by Stephanie Allan, Simon Bradstreet, Hamish J McLeod, John Gleeson, John FarhallJohn Farhall, Maria Lambrou, Andrea Clark, Andrew Gumley, John Ainsworth, Sandra Bucci, Shon Lewis, Mathew Machin, Alison Yung, Mario AlvarezJiminez, Sue Cotton, Reeva Lederman, Max Birchwood, Swaran Singh, Ancrew Thompson, Andrew Briggs, Chris Williams, Paul French, Graeme MacLennan, Cathy Mihalopolous, John Norrie, Matthias Schwannauer, Frank Reilly, Lesley Smith, Suresh Sundram

Background: Relapse prevention strategies based on monitoring of early warning signs (EWS) are advocated for the management of psychosis. However, there has been a lack of research exploring how staff, carers and patients make sense of the utility of EWS, or how these are implemented in context. 

Aims: To develop a multiperspective theory of how EWS are understood and used, which is grounded in the experiences of mental health staff, carers and patients. 

Method: Twenty-five focus groups were held across Glasgow and Melbourne (EMPOWER Trial, ISRCTN: 99559262). Participants comprised 88 mental health staff, 21 patients and 40 carers from UK and Australia (total n = 149). Data were analysed using constructivist grounded theory. 

Results: All participants appeared to recognise EWS and acknowledged the importance of responding to EWS to support relapse prevention. However, recognition of and acting on EWS were constructed in a context of uncertainty, which appeared linked to risk appraisals that were dependent on distinct stakeholder roles and experiences. Within current relapse management, a process of weighted decision-making (where one factor was seen as more important than others) described how stakeholders weighed up the risks and consequences of relapse alongside the risks and consequences of intervention and help-seeking. Conclusions: Mental health staff, carers and patients speak about using EWS within a weighted decision-making process, which is acted out in the context of relationships that exist in current relapse management, rather than an objective response to specific signs and symptoms.


This study was supported by NHS Research Scotland, through the Chief Scientist Office and the Scottish Mental Health Research Network. This project was funded in the UK by the National Institute for Health Research Health Technology Assessment Programme (project number 13/154/04) and in Australia by the National Heath Medical Research Council (APP1095879). It will be published in full in the Health Technology Assessment. The Health Services Research Unit is funded by the Chief Scientist Office of the Scottish Government Health Directorate. S.A. was funded by the Cremore Research Fellowship. The views and opinions expressed are those of the authors and do not necessarily reflect those of the Health Technology Assessment programme, National Institute for Health Research, the National Health Service, the Department of Health, NorthWestern Mental Health Services, the Cremore Research Fund or the National Health Medical Research Council.


Publication Date



BJPsych Open





Article Number





Cambridge University Press



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© The Author(s) 2019. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.