IntroductionA Literature review is an analysis of published resources on a chosen

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IntroductionA Literature review is an analysis of published resources on a chosen topic and the purpose is to recognise variables and document the findings in those sources (Aveyard, 2014). The chosen topic is Schizophrenia: factors that increase relapse in the community. Schizophrenia is a long-term mental disorder, complex in its aetiology and presentation, having a broad range of consequences for the individuals, their family and society (Tsuang et al., 2011). The disorder presents differently in every individual and its characteristics manifest as a disconnection between thought, emotion and behaviour. Individuals may present a wide range of disruptions such as inappropriate actions, thoughts and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and the inability to process the world around them (Tsuang et al., 2011). Schizophrenia is a serious illness, potentially debilitating and often misunderstood by the public causing a great deal of stigma to those with a diagnosis (Burton and Davidson, 2012). Schizophrenia is a complex illness and one of the central tenets of its epidemiology is it seems to occur equally the world over, only when studying closer is a slight difference seen between developed and developing countries (Murray et al., 2003, p.3). Thornicroft and Essock (2012) write that people with Schizophrenia experience long term difficulties irrespective of where they live in the world. The World Health Organisation (2018) reports that the disorder affects more than 21 million people in the world, it also clearly states that the condition is treatable although 50% of those with the condition are not obtaining the most appropriate care. Schizophrenia is rarely treated without medication, it is difficult to implement any rehabilitation therapy without drug treatment (Patel et al., 2014), despite drug treatment relapse is not always prevented. BLAH, BLAH, BLAH and BLAH, to name a few, state relapse as a continuing problem in patients with schizophrenia. In searching the literature and in pre-reading I have found a high saturation of papers, articles and books all looking at relapse and writing that relapse is a part of the illness, Thornicroft and Essock (2012) state that the condition is associated with relapsing symptoms. For this literature review I will be looking at factors that increase relapse in patients adult aged, based in the community, who have a diagnosis of schizophrenia. In a placement during nurse training an individual patient piqued my interest, they were relapsing from medication on a regular basis and on reading the patients background to gain understanding I noted several factors that impacted on the management and recovery for them. The main treatment process for this patient was mainly focussed around medication and management of such. Very little input was made from patient or professional regarding changes to promote a better recovery to an optimal level for the longevity of the disorder. Crisis plans were in place and relapse triggers noted within however, once a person was at the perceived level of management for the individual, services ‘backed off’. The patient’s General Practitioner (GP) continued prescribing medication, screening any physical health needs although not much was done to screen for potential triggers of relapse or to monitor aspects of concern with the individual’s mental health unless they presented at a level of obvious risk.This review will be looking at the topic from the nurses’ point of view and areas of how they can focus on improving their approach in supporting patients to be pro-active in self-monitoring triggers and signs before they are at the point of requiring inpatient services. The search was conducted using the electronic databases AMED, CINAL Complete, MEDLINE, MEDLINE Complete, PSYCH info and PSYCH Articles. Keywords used in the search were Schizophrenia, medication, relapse, community, factors, increase and risk and this was further broken into synonyms of those keywords to enhance the search and pick up different language terms used in the range of literature. A variety of resources were utilised; articles, journals, books, guidelines as well as online resources and the University library. The following themes emerged from the literature: non-adherence to prescribed medication, substance abuse, lack of insight/cognitive function, lack of social support and side effects. This review of the literature will be done under those themes.Literature selected for review has a timeframe of 2008 to 2018, this is mainly due the change in NICE guidance in 2009 (NICE, 2014 and, 2014). Amendments were made in 2014 to better include physical health issues and other mental health conditions that relate or arise in or separate to the condition that impact its progression, patients’ life style choices, medication involved and other factors (NICE, 2014 and, 2014). The National Institute for Health and Care Excellence (2014) guidance was changed to include factors…… ……. Current nurse delivery in mental health service needs to continue addressing factors and supporting those with factors that affect them in the hope of lowering the level of relapse in those with the disorder.The search was limited to adults who were in the community and whom had a diagnosis of schizophrenia. Literature around children or adolescents was excluded primary, due to them to be still developing mentally and physically and secondly, due to them being a population of patients that will have the protective and support factors that will affect relapse in a more diverse and possibly complex manner. The search and literature chosen was not limited to the United Kingdom, the prevalence of schizophrenia and factors that increase relapse were not of significant difference geographically, in fact the condition is thought to be ……Once the search criteria had been entered, papers were assessed for relevance to the topic based on content and nature of discussions within. Critical Appraisal Skills Programme (CASP, 2013) tools were used to build a CASP supported matrix (Appendix 1) and then a further thematic synthesis matrix utilised to find recurrent themes to support the topic (Appendix 3)The selected articles were subject to an exclusion and inclusion criteria to ensure that the literature chosen was relevant to the chosen topic being reviewed (Appendix 2).Chapter one will discuss the meaning of relapse and how it can impact a person with Schizophrenia. It will also look into the literature on how factors increase relapse for those in the community setting. Community within this review is understood as living independently and engaged in services in some way, physical through General Practitioner (GP) and/or mental health services of any kind.Viewing the approaches towards patients with Schizophrenia in the community setting in my role and experience as a student nurse, followed by information viewed from individual clinical notes, I can see practice and approach can be improved. I can see how patients’ choice and decisions can have better outcomes for individuals when nurses utilise all the possible interventions and services to hand and that patients empowered are more likely to engage with professionals and services. The uniqueness of the condition to each person requires a Person-Centred Approach as with all health care interventions however, I feel patients with Schizophrenia need emphasis on patient responsibility to engage with services and to self monitor their mental health to prevent relapse. .Chapter OneThis chapter will discuss the definition of relapse and how relapse impacts people with Schizophrenia. It will also discuss how factors increase relapse in the community setting and look at the systems and guidelines in place to support prevention of such. WHAT ABOUT THE LNK BETWEEN CONDITION AND RELAPSE??Relapse is described in literature from many different angles. Collins dictionary online (2018) states relapse as; to slip back into a former state or condition or to become ill again after apparent recovery. This implies the status of recovery in which a person has achieved and demonstrates the change to becoming ill as a process. Kazadi et al. (2008) explain relapse as a worsening or a re-emergence of symptoms that are psychotic which implies that a person went from a few symptoms or symptom free to psychotic with no realisation of change or relapse. While this is possible it is not the case for all individuals. The meaning of relapse when in mental health is used to explain an assessment of a persons’ symptoms that indicates a break in wellness and recovery, although is too often focused on as negative problems and difficulties (Wykes and Drake, 2012). Thornicroft and Essock (2012).Chapter TwoIn this chapter I will looking at the findings of individual themes found within my chosen literature. I will critically analysis the literature and demonstrate the connection between the themes and relapse factors that are found with people with Schizophrenia. Themes identified can be found in the Thematic Analysis, Appendix 3. The thematic analysis matrix is a way of appraising the literature to find common themes within the chosen topic (Aveyard, 2014). The most common theme located within the literature search for patients with schizophrenia and a factor of relapse is nonadherence to medication, Moritz et al. (2014) state that around 50 to 75% of people with Schizophrenia do not take their prescribed medication. Inclusion and exclusion criteria in Appendix X excluded inpatients due to the protective factor of the service, this is not to say patients do not relapse however, monitoring and support provided is of a higher degree WHY. Sariah et al. (2014) impart that nonadherence is one of the main factors of relapse and that other common themes such as side effects are the lead cause to a number of relapses. Kazadi et al. (2008) agree with Sariah et al. (2014) in that nonadherence is due to patient related factors and linked to other common themes, again side effects and also substance abuse and lack of insight. See appendix 3 on common themes.Zhou et al. (2017) explain that nonadherence has a negative impact on the course of schizophrenia for patients as well as on the cost of healthcare and treatment. Despite Zhou et al. (2017) and Kadazi et al. (2008) being nine years apart with their research paper they are still discussing the same issue of nonadherence and clearly demonstrating that relapse is still an issue in people with Schizophrenia. Zhou et al. (2017) found that of 236 participants 61 of these, 25.8% discontinued prescribed medication a year after discharge from hospital. This statistic was challenged in the paper, Zhou et al. (2017) write that it was lower in another paper they cite but similar in others. They go on to say that that discrepancy may be explained by socio-cultural differences, relating to a common theme in appendix x, lack of social support. Zhou et al. (2017) write that many patients without family support are more likely at greater risk of nonadherenceI think so yes remember argument this paper said this however this paper said this… a similar theme was found in both however blah blah blah < that’s being critical in papers the was the area rural in the study therefore are the results translatable or valid etc little things like that if you pick them out then they will say you’re being criticalChapter ThreeIn conclusion; the literature within the time frame chosen for this review demonstrates that nonadherence has made no real change, patients with schizophrenia continue not to take part with their antipsychotic medication. Those on long acting injections have also been known to relapse!!!