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International Journal of Mental Health Nursing (2016) , – doi: 10.1111/inm.12260

O RIGINAL A RTICLE
Factors associated with psychotic relapse in
patients with schizophrenia in a Pakistani cohort
Irshad Ahmad,1 Muhammad Tahir Khalily,1 Brian Hallahan2 and Inayat Shah3
1
Department of Psychology, International Islamic University Islamabad, Islamabad,Pakistan, 2Department of
Psychiatry, National University of Ireland, Galway, Ireland, and 3Department of Psychology,University of
Malakand, Khyber Pakhtunkhwa, Pakistan

ABSTRACT: Despite a large body of research evaluating factors associated with the relapse of
psychosis in schizophrenia, no studies in Pakistan have been undertaken to date to identify any
such factors, including specific cultural factors pertinent to Pakistan. Semistructured interviews
and psychometric measures were undertaken with 60 patients diagnosed with schizophrenia (49
male and 11 female) and their caregivers at four psychiatric hospitals in the Peshawar region in
Pakistan. Factors significantly associated with psychotic relapse included treatment non-
adherence, comorbid active psychiatric illnesses, poor social support, and high expressed emotion
in living environments (P < 0.05). The attribution of symptoms to social and cultural values
(97%) and a poor knowledge of psychosis by family members (88%) was also prevalent. In
addition to many well-documented factors associated with psychotic relapse, beliefs in social and
cultural myths and values were found to be an important, and perhaps treatable, factor associated
with relapse of psychosis in Pakistan. The provision of evidence-based psychotherapeutic
interventions, such as behaviour and family therapy and cognitive behaviour therapy for
psychosis, could potentially ameliorate the relapse rate of psychosis in Pakistan.
KEY WORDS: culture, relapse of psychosis, schizophrenia.

achieve symptomatic remission (Falkai et al. 2005).

INTRODUCTION
Schizophrenia is a long-term and often disabling men-
tal illness affecting approximately 1% of the world’s
population, with no significant difference in prevalence
between countries or cultures (Insel 2010; Mueser &
McGurk 2004). In a majority of people, schizophrenia
is associated with functional impairment, including
poor occupational attainment (Marwaha et al. 2007).
However, with active intervention, most patients can
Correspondence: Irshad Ahmad, Department of Psychology, Fac-
ulty of Social Sciences, Room no. 207 A, Block-II, Sector H-10,
International Islamic University, Islamabad 44000, Pakistan. Email:
irshadahmad.sp@gmail.com
Irshad Ahmad, MSc, MS.
Muhammad Tahir Khalily, MSc, PMDCP, MPhil, PhD.
Brian Hallahan, MRC Psych, MS.
Inayat Shah, MSc, MS.
Accepted July 26 2016.
Unfortunately, psychotic relapse is common and is
associated with significant deleterious effects for the
individual and their family, including a worsening of
clinical symptoms, impaired functionality, a reduced
quality of life, and an increased financial burden for
the patient and potentially their family members or
carer (Awad & Voruganti 2008; Falkai et al. 2005; Kane
et al. 2007; Robinson et al. 2005)). Consequently,
understanding the factors associated with psychotic
relapse in schizophrenia and engaging in management
strategies to reduce the risk of such a relapse can be
beneficial.
Several factors have previously been associated with
psychotic relapse. The factors most commonly cited
include treatment non-adherence, comorbid depression
or psychoactive substance misuse, and stressful life
events (Kazadi et al. 2008; Moeller et al. 2006; Uc€ ßok

© 2016 Australian College of Mental Health Nurses Inc.

2 I. AHMAD ET AL.
et al. 2006). Additional factors associated with relapse
include limited insight into one’s illness, high expressed
emotion (EE) (high levels of criticism and emotional
over-involvement) and the attribution of mental illness
to social and cultural myths and values or religious
attributions (Butzlaff & Hooley 1998; Lauber & R€ossler
2007; Reddy et al. 2014; Sultan 2006; Zafar et al.
2008).
To date, in Pakistan, no study has examined factors
associated with psychotic relapse in individuals with
schizophrenia. Consequently, in the present study, we
wanted to ascertain factors associated with relapse in a
cohort of individuals with schizophrenia in Pakistan,
examine if these factors are similar to those noted in
other countries, and explore whether any specific fac-
tors pertaining to relapse of psychosis are present in
Pakistan that are not as prevalent in other countries or
regions.
METHODS
Participants
The sample consisted of 60 individuals with
schizophrenia, diagnosed by an experienced consultant
psychiatrist utilizing International Classification of Dis-
eases-10 operational criteria. All patients had previously
suffered at least one psychotic relapse. All participants
were actively engaged (inpatients) with the adult men-
tal health services (at the time of the study), and
attended one of four tertiary care mental health ser-
vices in the Peshawar region of Pakistan (Departments
of Psychiatry, Khyber Teaching Hospital, Hayatabad
Medical Complex, Lady Reading Hospital, and the Sar-
had Hospital for Psychiatric Diseases). All participants
had undergone recent review (at study entry) by their
consultant psychiatrist to confirm diagnosis and rule
out other potential diagnoses or factors that could
account for a psychotic relapse. Exclusion factors
included individuals <18 years or >65 years of age, the
presence of a psychotic illness other than schizophrenia
(i.e. schizoaffective disorder, bipolar disorder, or drug-
induced psychosis), or the presence of an intellectual
disability or dementia.
Basic clinical and demographic data were attained
for each study participant, including age, sex, socioeco-
nomic status, occupational status, and relationship sta-
tus, via clinical note reviews, patient interviews, and
discussions (where necessary) with the treating clinical
team. The Positive and Negative Syndrome Scale
(PANSS) was administered to all patients to assess
symptomatology by the first author (Kay et al. 1987).
The presence of symptoms on this 30-item scale was
rated from one (absent) to seven (extreme). The
PANSS and has well-documented good reliability
indices (a = 0.73–0.79) (Kay et al. 1987). A specifically-
designed clinical profile sheet was used for assessing
clinical and biopsychosocial factors. The responses
obtained were subsequently validated by examining
clinical records of the patient and from the collateral
history provided by their caregivers. These data,
including EE, understanding of one’s illness, medica-
tion non-adherence, psychosocial stressors, and family
knowledge and beliefs about illness and attribution,
were attained from these interviews. Interviews with
patients required 1–2 hours over one-to-two sessions.
Interviews with caregivers lasted approximately 90 min.
Additional information relating to these factors was
attained from clinical note reviews and discussions with
the treating clinical team.
Ethical approval was attained prior to the com-
mencement of this study from the Clinical Research
Ethics Committee, Department of Psychology, Interna-
tional Islamic University, Islamabad, Pakistan, with
individual approval obtained from the head of each of
the four tertiary care centres included in the study.
Individuals were identified by their treating team that
initially approached them in relation to study participa-
tion. After sufficient time was given for study consider-
ation (at least 1 week), patients were then approached
by the first author (IA), the study was explained to
them in more detail, and informed consent to partici-
pate was obtained by those who agreed to participate.
Six individuals declined to participate. All data were
anonymized and coded.
Data analysis
Statistical analysis was performed using the Statistical
Package for Social Sciences 22.0 for Windows (SPSS,
IBM, Armonk, NY, USA). For parametric data, the
independent sample t-test was utilized to compare
means between groups. Pearson correlation coefficient
was utilized to undertake correlational analysis between
scores on the PANSS and various clinical and social
factors associated with relapse.
RESULTS
The demographic characteristics of the 60 included
individuals who participated in the present study are
presented in Table 1. Eighty-two percent of the sample
© 2016 Australian College of Mental Health Nurses Inc.
FACTORS FOR RELAPSE IN SCHIZOPHRENIA 3

TABLE 1: Socio-demographic characteristics of patients (n = 60) TABLE 2: Clinical factors potentially associated with psychotic
relapse
Variables n (%) Mean (SD) Range
Variables n (%) Mean (SD) Range
Age 32.70 (8.34) 19–59
19–30 30 (50) PANSS score – 98.77 (12.12) 74–117
31–40 17 (28.3) Positive syndrome – 25.02 (5.08) 12–35
40+ 13 (21.7) Negative syndrome – 25.20 (4.25) 14–33
Gender General – 48.97 (7.63) 25–60
Male 49 (81.7) psychopathology
Female 11 (18.3) Age of onset (years)
Relationship status 19–25 44 (73.3) 23.42 (4.35) 19–33
Single 22 (36.7) 26–30 16 (26.7)
Married 38 (63.3) Duration of illness (years)
Socioeconomic status 1–5 14 (23.3) 8.83 (5.39) 1–23
$A<149.28 (<12 000 PKR Rs) 37 (61.7) 6–10 25 (41.7)
$A<248.81 (<20 000 PKR Rs) 23 (38.3) 11–15 15 (25)
Vocational status 15+ 6 (10)
Employed* 20 (33.3) Hospitalization history
Unemployed 40 (66.6) 2nd time 16 (26.7)
Education 3rd time 11(18.3)
None 14 (23.3) >3 times 33 (55)
Primary 19 (31.7) Comorbid psychiatric illnesses
Post-primary 16 (26.7) Major depressive 30 (41.1)
Secondary level 4 (6.7) episode
Third level 5 (8.3) Substance use 23 (33.8)
High level 2 (3.3) disorder
Generalized anxiety 13 (17.6)
The monthly minimum wage in Khyber Pakhtunkhwa Pakistan is disorder
$A<149.28 (<12 000 PKR Rs) (Paycheckpk, 2015). The literacy rate Obsessive compulsive 3 (4.4)
in Pakistan is 55% (Literacy Rate of Education in Pakistan, 2015). disorder
*Employment nature consisted of permanent, temporary and contract Comorbid medical conditions
workers. Metabolic disorders, including 6 (22.2)
hypertension
Liver disease, including 1 (3.7)
were male, and the mean age of the cohort was 32.7 hepatitis
Long-term pain, including 9 (33.3)
(standard deviation (SD): 8.3) years. Sixty-seven per-
osteoarthritis
cent of the sample was not engaged in active employ- Neurological conditions, 6 (22.2)
ment, 81% had not completed secondary school including migraine
education, and 62% had a monthly income below Epilepsy 5 (18.5)
$A150.45 (12 000 Pakistani rupees). Nobody from the
PANSS, Positive and Negative Syndrome Scale; SD, standard
cohort had been internally displaced from other deviation.
jurisdictions, such as Afghanistan.
Data pertaining to clinical factors are presented in
Table 2. The mean age of onset was 23.4 (SD: 4.4) psychiatric illnesses (95%), including depression
years, and the median of age of onset was 21 (range: (40%), substance abuse disorders (31%), and anxiety
19–41) years. Comorbid mental health (particularly disorders (18%) that were significantly associated with
depression (40.5%)), physical health (particularly pain psychotic relapse. Other non-pharmacological factors
conditions (20.3%)), and psychoactive substance misuse associated with not engaging with psychiatry when
(particularly cannabis (37.1%)) were common. PANSS symptoms emerged prior to psychotic relapse included
scores at study entry demonstrated significant the attribution of symptoms based on social and cul-
pathology. tural myths and values (97%) and a poor knowledge
Based on the responses obtained from patients on of the symptoms of psychosis from family members
the PANSS and semistructured interviews, we subse- (88%). In addition, high EE at home prepsychotic
quently examined patients’ clinical records and the relapse (based on interviews with both patients and
collateral history given by their caregivers to deter- family members) was evident in relation to 63% of
mine treatment non-adherence (95%) and comorbid patients (Table 3).

© 2016 Australian College of Mental Health Nurses Inc.

4 I. AHMAD ET AL.

TABLE 3: Psychosocial factors potentially associated with psychotic comorbid mental and physical illnesses, psychoactive
relapse substance misuse, high EE, and a poor understanding
Psychosocial factors n (%) of mental illnesses at home and the attribution of
symptoms based on social and cultural myths and
Treatment non-adherence
Yes 57 (95)
values.
No 3 (5) The most notable finding in the present study
Poor social support related to the practice of misattributing symptoms
Yes 23 (38.3) based on social and cultural myths and values. In Pak-
No 37 (61.7) istan (as in many other countries), the attribution of
High EE in home setting
psychiatric illness to magical influences, the presence
Yes 38 (61.3)
No 22 (36.7) of evil spirits, neglect of ritual obligations, or violations
Significant psychosocial stressor prerelapse of taboos is common (Ahmad & Rashid 2006). The
Yes 25 (41.7) attribution of psychotic symptoms to social and cultural
No 35 (58.3) myths and values were noted to reflect both patients
Poor family knowledge about illness
and family members’/carers’ views of symptoms.
Yes 7 (11.7)
No 53 (88.3) Indeed, there is a well-documented practice of ‘Taa-
Attribution of illness to social and cultural myths and values weez’ or ‘jinn’, which involves taking a patient with a
Yes 58 (96.7) mental illness to a local religious healer for treatment
No 2 (3.3) (Ahmad & Rashid 2006). The present study demon-
EE, expressed emotion. strated that a significant percentage of patients and
family relatives or carers attributed symptoms to social
and cultural myths and values rather than mental ill-
Higher PANSS scores were demonstrated in individ- ness, resulting in individuals having longer periods of
uals with high EE at home, attribution of symptoms untreated psychoses and consequent admissions to psy-
based on social and cultural myths and values, poor chiatric inpatient units. This finding replicates those
family knowledge of illness, lack of motivation, and lack from a number of studies in other jurisdictions, which
of insight (Table 4), with these factors also positively also demonstrated a significant association between
correlated with PANSS scores (Table 5). beliefs in social and cultural myths and values and psy-
chotic relapse (Zafar et al. 2008). Not surprisingly, and
DISCUSSION in keeping with the findings in the literature, poor
insight was present in most individuals who developed
To the best of our knowledge, the present study was a psychotic relapse (Amador et al. 1994; Reddy et al.
the first to examine clinical and social factors associated 2014)
with psychotic relapse in a cohort of patients with Treatment non-adherence prepsychotic relapse was
schizophrenia in Pakistan. Factors associated with psy- common in the present study (95%). While this finding
chotic relapse included treatment non-adherence, is consistent with international literature, treatment

TABLE 4: PANSS scores and variables associated with psychosocial stressors

Statistics
Psychosocial stress No psychosocial stress
Variables Mean (SD) Mean (SD) t (95% CI) P-value Cohen’s d

Family history of schizophrenia 100.00 (12.40) 93.70 (10.60) 1.97 ( 12.55, 0.09) 0.04 0.55
Poor social support 102.43 (11.28) 96.92 (13.84) 1.61 ( 12.38, 1.35) 0.11 0.44
High EE in home environment 101.74 (11.68) 94.36 (14.34) 2.17 ( 14.19, 0.55) 0.03 0.56
Attribution of illness to social and 99.64 (13.09) 85.50 (3.53) 1.51 ( 32.84, 4.56) 0.03 1.47
cultural myths and values
Stressful life events 97.04 (12.89) 99.51 (12.27) 0.75 ( 4.09, 9.05) 0.45 0.19
Poor family knowledge of illness 100.40 (11.44) 84.00 (11.06) 3.57 ( 25.57, 7.22) 0.001 1.46
Lack of motivation 104.55 (12.47) 95.45 (11.48) 2.81 ( 15.58, 2.62) 0.007 0.76
Lack of insight 100.69 (11.10) 91.87 (14.40) 2.47 ( 15.97, 1.67) 0.01 0.69

CI, confidence interval; EE, expressed emotion; PANSS, Positive and Negative Syndrome Scale; SD, standard deviation.

© 2016 Australian College of Mental Health Nurses Inc.

FACTORS FOR RELAPSE IN SCHIZOPHRENIA
TABLE 5: Correlations between PANSS and clinical or psychosocial factors
Clinical or psychosocial factors 1 2 3 4
1. PANSS 1
2. High EE in home settings 0.281* 1
3. Attribution of illness to social and 0.236* 0.051 1
cultural myths and values
4. Stressful life events 0.157 0.012 0.157
5. Poor social support 0.226* 0.458** 0.146
6. Poor family knowledge of illness 0.429** 0.154 0.222*
7. Treatment non-adherence 0.232* 0.224* 0.278*
8. Comorbid medical diseases 0.154 0.234* 0.246*
9. Comorbid psychiatric illnesses 0.278* 0.026 0.057
*
P < 0.05, P < 0.01. EE, expressed emotion; PANSS, Positive and Negative Syndrome Scale.
**
modalities to increase adherence rates are not currently
available in Pakistan, and thus it is likely in the short-
to-medium term that high rates of psychotic relapse
will continue (Morken et al. 2008). No patients in the
present study had access to any type of psychothera-
peutic interventions other than supportive psychother-
apy from staff members when admitted to psychiatric
inpatient units. An increasing evidence base demon-
strates lower relapse rates secondary to the provision of
various psychotherapeutic interventions, including cog-
nitive behaviour therapy for psychosis, family therapy,
or a combination of both (Aderhold & Gottwalz 2004;
Kuipers & Bebbington 2006; Pilling et al. 2002; Tarrier
et al. 1999). It is plausible that the introduction of such
psychotherapeutic interventions could lessen the need
for psychotropic medication, given concerns regarding
the significant adverse sequelae that psychotropic med-
ication have and that the risks of being on medication
can outweigh the benefits over time (Moncrieff 2006).
It is probable that an increase in the provision of
psychotherapeutic interventions could have a positive
effect on readmission and relapse rates long-term ill-
ness, particularly if such interventions could also
address patients and relatives’/carers’ views that symp-
toms are related to social and cultural myths and val-
ues. It has been shown that mental health nurses and
psychologists play a signficant role in the provision of
physical health care and in the delivery of appropriate
psychosocial and psychotheapuetic interventions to
patients and their relatives and carers (Bradshaw &
Pedley 2012; Gamble 1995). Such interventions include
psychoeducation and behaviour and family therapy to
patients with psychosis and their carer(s) and cognitive
behaviour therapy (Turkington et al. 2002, 2006). In
Pakistan, at present, there is a dearth of such resources
available in mental health services, and consequently
without greater numbers of mental health nurses and
© 2016 Australian College of Mental Health Nurses Inc.
5
5 6 7 8 9
1
0.041 1
0.325** 0.180 1
0.123 0.292* 0.054 1
0.179 0.125 0.326** 0.086 1
0.311** 0.091 0.180 0.371** 0.254* 1
psychologists employed, the provision of such interven-
tions will continue to be largely unavailable. For exam-
ple, for every 100 000 people, only 8.13 mental health
nurses (n = 13 643) are employed (predominantly in
inpatient mental health units), which is less than 40%
of the median rate of mental health nurses employed
in the European Union (WHO, Europe. 2014).
In addition, increased resources to manage comor-
bidities, including depression and psychoactive sub-
stance ingestion, might also be beneficial in reducing
relapse rates, given the high prevalence of these
comorbidities noted, a finding consistent with several
other studies (Buckley et al. 2009).
There are a number of limitations with the present
study. These include the fact that the results might not
be generalizable to the total population of Pakistan,
particularly as no private hospitals were included,
where resource provision is potentially greater. The
sample size is relatively small; however, this is the first
such study to be conducted in Pakistan and will serves
as a basis for larger studies to be conducted in multiple
centres. While family members and relatives were
interviewed in depth, further qualitative techniques,
including focus groups and qualitative analyses, were
not conducted, which should be the focus of future
studies. In addition, psychometric instruments for the
measurement of patients’ and families’ understanding
of patients’ illnesses, and for levels of EE, were not
undertaken, which would have been optimal.
CONCLUSION
While the present study replicated several known risk
factors for psychotic relapse in schizophrenia, such as
treatment non-adherence and psychoactive substance
misuse, one significant factor related to the attribution
of psychotic symptoms to social and cultural values,
6 I. AHMAD ET AL.
which resulted in a lack of treatment of psychotic
symptoms. Given the dearth of psychotherapeutic
interventions currently available in Pakistan for the
treatment of psychosis, the present study highlights the
urgent need for appropriate evidence-based psy-
chotherapeutic interventions, including cognitive beha-
viour therapy for psychosis and behaviour and family
therapy for patients (and their relatives and carers).
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© 2016 Australian College of Mental Health Nurses Inc.