GRAPHICAL ABSTRACT

INTRODUCTION

Schizophrenia represents a serious global mental health issue, with profound implications and complexities for those diagnosed and their caregivers [1,2]. The World Health Organization estimates that approximately 1 billion people worldwide, or 1 in 8 individuals, are living with a mental disorder [3]. In Indonesia, the incidence of severe mental disorders, including schizophrenia, rose from 1.3 cases to 7.0 cases per 1000 individuals in 2018 [4,5].

Schizophrenia is a chronic mental illness associated with functional disability across social, cognitive, and emotional domains [6]. The impairment associated with schizophrenia hinders recovery [7], with recovery rates ranging from approximately 13.5% to 50.0% [8]. This low figure is also linked to the condition’s comparatively high relapse rate. Recurrence rates of 28%, 43%, and 54% have been reported for the first, second, and third years of follow-up, respectively [8]. As previous reported, relapse rates for mental disorders are estimated to be 50%, 70%, and 100% during the first, second, and fifth years after hospital discharge [1,9-11]. Several factors, including medication adherence and family dynamics, influence the recurrence of mental disorders [12-14]. Consequently, family-centered relapse prevention is a key strategy in the management of schizophrenia [12,14].

Family often represents the primary support system for patients, whether they are healthy or ill [15]. In the context of relapse prevention, family support constitutes a form of direct care, making it imperative for families to understand the challenges faced by individuals with mental disorders. Nonetheless, the level of family knowledge regarding relapse prevention warrants consideration. Research in various parts of the world has indicated that families frequently turn to spiritual remedies and shamans for the treatment and prevention of schizophrenia relapse, attributing the condition to malevolent spirits, magic, curses, or disbelief [16,17].

Significant factors associated with schizophrenia relapse include family knowledge and emotional expression [18-22]. Suboptimal family care for individuals with schizophrenia often involves a lack of information within the family about the disorder and its treatment [22], which influences relapse rates among patients with schizophrenia.

The impacts of relapse on families include heightened stress and emotional strain [18-22]. Medication non-adherence is a major risk factor for patient relapse [9,23]. Additional contributors include the inability to recognize and manage the signs and symptoms of relapse [8,24]. The family dynamic also influences relapse, with contributing factors such as insufficient family support, high levels of expressed emotion within the family, inadequate knowledge about psychosis, and challenges in providing care for patients with schizophrenia [16,25,26].

A variety of publications addressing relapse prevention in patients with schizophrenia have emerged, including a review focused on this topic [27]. Additional studies [28-30] have explored various interventions aimed at preventing relapse in patients with schizophrenia, encompassing psychoeducation, family therapy, supportive therapy, monitoring, behavior modification, prevention strategies, and self-intervention techniques. One report [8] examined the perceptions and roles of families in relapse prevention among individuals with mental disorders, including schizophrenia. The authors recommended improving patients’ knowledge, coping abilities, and family support to help avert relapse and alleviate the burden on patients. Despite these efforts, no comprehensive and objective review has yet been published regarding trends in relapse prevention for schizophrenia.

Given growing concerns about escalating schizophrenia relapse rates, this assessment is particularly relevant. Addressing risk factors for schizophrenia relapse can improve patient quality of life; thus, relapse prevention is of high importance. From a healthcare perspective, this study was conducted to potential strategies for preventing schizophrenia relapse, while also identifying limitations and suggesting possible future directions.

This exploratory review and bibliometric study examined key findings, methodologies, and trends in relapse prevention for individuals with schizophrenia, aiming to synthesize the current body of research on this topic. It included a thorough examination of relapse prevention interventions for people with schizophrenia and assessed how these interventions affect the quality and sustainability of relapse prevention efforts. Bibliometric analytics were employed to identify the most prominent authors, journals, countries, and topics within the area of schizophrenia relapse prevention. This analysis is anticipated to provide valuable insights into the state of research on schizophrenia relapse prevention and to potentially reduce future schizophrenia relapse rates.

METHODS

Type of Research

This exploratory review examined research on schizophrenia relapse prevention, utilizing data from the Scopus database spanning the years 1973 to 2023. The search methodology involved the extraction of relevant information by employing the keywords “relapse AND schizophrenia” AND “prevention.” This search targeted article titles, abstracts, and keywords, with the results limited to English-language publications within the designated timeframe. The compiled dataset comprised 683 original articles and 279 reviews, all sourced from journals, for a total of 962 publications. The data processing approach involved the retrieval of relevant information from the Scopus database using the specified keywords. The 962 publications were then screened using Open Refine within Microsoft Excel (Microsoft Corp., Redmond, WA, USA). Subsequently, the refined dataset was subjected to further analysis employing Tableau and VOSviewer for visual representation and interpretation. This multistage approach provided a comprehensive understanding of the current state of research on schizophrenia relapse prevention through the year 2023.

Bibliometric Analysis

Bibliometric analysis is employed to examine research developments and trends within a field, evaluate the impacts of articles and authors, and appraise the prospects for future research. The results of this analysis can assist researchers in identifying potential areas of study and finding prospective collaborators [31]. The metrics employed in the present bibliometric analysis include examination of the number of publications, the number of citations, and the h-index. The number of citations reflects the frequency with which an author’s work is referenced by peers. The h-index considers both the quantity of an author’s publications and the number of citations each has garnered. Overall, bibliometric analysis offers valuable information for researchers, policymakers, and stakeholders engaged in the advancement of a scientific domain.

Following bibliometric analysis, a literature review was conducted. Initially, the titles and abstracts in the search results were examined based on predetermined eligibility criteria. Subsequently, the full articles selected during the title/abstract screening phase were evaluated to ensure compliance with the eligibility criteria. These criteria were established impartially and independently. (1) The inclusion criteria were as follows: articles or reviews, with a study period between 2013 and 2023, in the final publication phase, and available in English. (2) The exclusion criteria were as follows: publications in languages other than English; theses, dissertations, books, book chapters, and conference papers; and grey literature.

A flow diagram illustrating the article selection process for the literature review is presented in Figure 1.

Systematic Review Analysis

Systematic review analysis is a systematic method used to collect or synthesize data from previous studies to answer specific research questions. Systematic review analysis involves several stages, including the development of research results, the assessment of the quality of evidence, and evaluation to determine conclusions.

Ethics Statement

This article is a review article that uses bibliometric analysis, not original research, and therefore does not require ethical approval.

RESULTS

Trends in Publications on Schizophrenia Relapse Prevention by Document Type

The bibliometric analysis visualization presented in Figure 2 illustrates an upward annual trend in the literature on relapse prevention in schizophrenia. The findings for both articles and reviews represent the evolution of this research. From 1993 to 2023, the number of documents published exhibited an average annual increase of 8.8%, with a total of 1097 documents (279 reviews and 683 articles). High variability, with considerable fluctuation in publication numbers, was observed for both articles and reviews over the 40-year period. Current research on this topic is garnering increasing interest and is anticipated to continue expanding, in line with government initiatives prioritizing community-based interventions for mental health disorders. Consequently, schizophrenia relapse prevention is emerging as an increasingly attractive area of research.

Contributions by Country

The number of publications produced by a country can reflect the level of engagement and the distribution of authorship on a topic. As shown in Figure 3, among the 37 contributing countries, only 32 have published 5 or more documents. The United States is at the forefront of research on relapse prevention in schizophrenia, with more articles on the topic than any other country. The United States has collaborated with 33 other nations, establishing a total of 208 collaborative links. Germany, the United Kingdom, and Switzerland are the main contributors to this collaborative network.

Author Keyword Co-occurrence Network Analysis

Among 93 keywords (“items”) identified, 10 clusters were established, each color-coded (Figure 4). The clusters are as follows: 1 (red), 2 (green), 3 (blue), 4 (yellow), 5 (dark purple), 6 (dark blue), 7 (orange), 8 (brown), 9 (light purple), and 10 (pink). As shown in Figure 4, cluster 2 (green) is the most prominent, comprising 17 items and 113 occurrences focused on relapse prevention. The term “relapse prevention” is linked to several other clusters within the author keyword analysis co-occurrence network. These include cluster 1 (red), which relates to antipsychosis and includes 15 items and 63 occurrences, and cluster 3 (blue), comprising 10 items and 26 appearances and focusing on digital technology (technology, health, and mobile health). In addition, clusters 4 (yellow) and 6 (light blue) focus on antipsychotic medications. Cluster 5 (dark purple) relates to family interventions, containing 9 items and 14 occurrences, while cluster 6 (dark blue) covers adherence and includes 8 items and 12 occurrences.

Cluster 7 (orange), which focuses on initial interventions, contains 7 items and 49 occurrences. Cluster 8 (brown), comprising 6 items with 15 occurrences, relates to electroconvulsive therapy. Cluster 9 (light purple) also has 6 items and 15 occurrences, with a focus on olanzapine. Finally, cluster 10 (pink) features 5 items with 7 occurrences, concentrating on pharmacology.

The results of this bibliometric analysis on schizophrenia relapse prevention suggest potential future research directions, as demonstrated by the visualization of keyword occurrences over time. In Figure 5, keywords that have been widely used in previous studies are indicated by light blue nodes. In comparison, keywords with yellow nodes denote current areas of focus, which (in combination with other keywords) may help predict areas of future breakthroughs. The latter category includes “family,” “cognitive remediation,” “m-health,” “digital technology,” “psychotic disorder,” “mental health,” “antipsychotic,” and “hospitalization.” The bibliometric data revealed a number of publications associated with the keyword “digital technology,” signifying its emergence as a novel area of interest. A subsequent literature review and analysis yielded the results detailed in Table 1 [32-49].

DISCUSSION

This bibliometric study represents the first global review of research on schizophrenia relapse prevention. It encompasses a substantial body of published work, offering a comprehensive overview of the field on an international scale. The study reveals a pattern of increasing annual trends in the literature concerning relapse prevention in schizophrenia (Figure 2). Within the analysis, both articles and reviews exhibited fluctuations. The variability in the volume of literature on this topic can be attributed to the complexity of schizophrenia, which has a range of symptoms. Previous research has often focused on clinical treatment interventions or the management of acute symptoms. Moreover, the prevention of schizophrenia relapse necessitates an understanding of the risk factors that contribute to relapse and the development of effective preventive measures. Interest in this area of research is growing and is expected to continue to expand, particularly considering government programs prioritizing community-based interventions for mental health disorders. Thus, schizophrenia relapse prevention is becoming an increasingly prominent area of study.

Data from the top 10 authors and 15 institutions contributing to schizophrenia research were evaluated. Notably, several of these top authors have collaborated as co-authors. Consequently, when analyzing data pertaining to individual authors, the results should be interpreted as a replication of the data. Figure 3 details the top 10 countries by number of publications. The United States leads with the most publications, followed by Germany and the United Kingdom. Moreover, the United States excels in quality as well as quantity, exhibiting the highest citation count (n=20 519) among countries. This achievement likely stems in part from United States government policy, which allocates a substantial 3.5% of its budget to research and development. The United States has maintained its position as a frontrunner in scientific research across various disciplines, including schizophrenia research. Based date on the National Science Foundation [50] that the United States was responsible for approximately 25% of the world’s scientific publications.

Germany ranked second with 200 publications, demonstrating a robust research sector through both the quantity and the quality of its output. This strength is further evidenced by a total citation count of 7309, indicating considerable impact and investment in research and development. According to a recent publication by the German Academic Exchange Service, Germany invests approximately 90.3 billion euros in research, which is about 2.9% of its gross domestic product. This investment ranks Germany among the top 10 countries globally for research spending. Moreover, the private sector plays a key role in advancing research in Germany by financing projects at universities and research institutes, fostering the development of products that benefit their businesses.

The United Kingdom ranked third in the total number of publications, demonstrating considerable research output with 138 papers and a total of 6929 significant citations. It holds the second position globally in science and research, with 54% of its research output deemed world-leading, outperforming the United States, Canada, Germany, Japan, and Brazil. According to the latest research findings, the United Kingdom tends to provide the best treatment for schizophrenia. The United Kingdom Department of Health has established that the primary treatment for this condition is antipsychotic drug therapy. Additionally, individuals with schizophrenia are universally offered cognitive behavioral therapy by adult clinical psychologists.

Figure 3 illustrates the collaboration network among countries regarding relapse prevention in schizophrenia, highlighting various clusters. The United States is at the forefront, leading in collaborations with other nations. American scientists frequently engage in international partnerships, increasing their citation statistics. This finding aligns with research by Heras-Mozos et al. [51] and Maramis et al. [12], which indicates that papers authored by international teams display higher average citation rates. Germany ranks second in collaborations, with 198 connections and partnerships with over 10 countries. Figure 3 also depicts the temporal evolution of national contributions, with purple nodes representing those with a substantial number of publications in earlier studies. Notable countries in this category include Italy, Hong Kong, China, Hungary, Finland, and Ireland.

Another important element indicative of article content is the choice of keywords (Figures 4 and 5). Analyzing frequently used keywords can reflect core aspects of schizophrenia relapse prevention. Therefore, keyword mapping is essential to identify patterns across research areas and to uncover gaps in the literature.

In these figures, the size of the circle representing each cluster, which denotes specific keywords in scientific publications, reflects the frequency of those keywords’ usage. Larger circles indicate a higher number of publications incorporating those terms. As outlined by Olivares et al. [20], the color of the circle signifies the relationship between keywords.

Keywords with light blue nodes have been extensively utilized in previous studies, while yellow keywords represent new terms that are currently under investigation by researchers. The categories include “cognitive remediation,” “m-health,” “digital technology,” “psychotic disorders,” “mental health,” “antipsychotic agents,” and “hospitalization.” Collectively, these clusters contribute to the development of innovative and sustainable strategies aimed at preventing relapse in patients with schizophrenia, thus improving their quality of life.

Table 1, reflecting the systematic review analysis, illustrates the global advancement of digital technology in accessing health-related applications through mobile phones, which represents a logical progression in health condition management [52]. The use of internet-based and mobile-based interventions can improve cost-effectiveness [53]. For instance, studies have demonstrated the effectiveness of digital technologies in reducing hospitalization days among individuals with schizophrenia. Specifically, during a 6-month period, the intervention group experienced a mean of 5 fewer hospital days (β=-4.58; 95% CI, -9.03 to -0.13; p=0.044) compared to the control group [32]. Digital technologies encompass personalized relapse prevention planning that includes face-to-face meetings and medication management via smartphones and computers, as well as web-based prescriber decision support systems. These findings align with research [35], indicating that digital technology is effective for monitoring early warning signs, in conjunction with peer support and clinical triage, to detect and prevent relapse in schizophrenia. While several studies have employed digital technology for relapse prevention in mental disorders such as depression, anxiety, and eating disorders [54], little research is available on the use of digital technology for relapse prevention in schizophrenia.

This study has several limitations. First, it was dependent on the Scopus search engine for data collection, excluding studies not indexed by this database. Second, citation counts derived from Scopus tend to be more conservative than those from Google Scholar, potentially resulting in an underestimation of the citation figures. Finally, the reported number of papers from specific institutions and researchers encompasses a variety of paper types, including original research, reviews, viewpoints, editorials, case reports, and letters to the editor. Consequently, the total count of articles may not accurately represent the volume of original research output by the researchers in question.

In general, our findings suggest a marked interest in schizophrenia relapse prevention research among researchers worldwide. However, this interest remains concentrated within a select few research centers, highlighting the need for broader participation in schizophrenia research. The findings emphasize the importance of expanding efforts in schizophrenia relapse prevention research across the globe. To bridge this gap, it is imperative to undertake multicenter studies, improve the research capabilities of clinicians from various educational institutions and sectors, and design studies with increased translational potential to improve outcomes in schizophrenia relapse prevention. Achieving these goals necessitates substantial investment, and funding bodies must be made aware of this critical need. At the policy level, research policies must be formulated that are tailored to the needs of individual countries. These policies should aim to strengthen infrastructure and provide the necessary financial support for schizophrenia relapse prevention research. Furthermore, they should encourage research activities that yield translational benefits for individuals with schizophrenia, covering immediate, medium, and long-term outcomes.

CONCLUSION

This bibliometric analysis of research on schizophrenia relapse prevention reveals an increasing trend in the number of publications, with the United States as the foremost contributor. Leading authors in this field are John M. Kane, Stefan Leucht, and Christoph Correll. Prominent clusters identified in the author keyword co-occurrence network relate to relapse prevention, antipsychotic treatment, digital technology, and family interventions. The results suggest potential research avenues, such as the incorporation of family interventions, cognitive remediation, and digital technology into relapse prevention strategies.

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

None.

Author Contributions

Conceptualization: Syarif I. Data curation: Amqam H. Formal analysis: Syamsuddin S. Funding acquisition: None. Methodology: Amqam H. Project administration: Russeng S. Visualization: Amir Y. Writing – original draft: Syarif I. Writing – review & editing: Syarif I, Amqam H, Syamsuddin S, Hadju V, Russeng S, Amir Y.

Acknowledgements

Figure. 1.

Table data processing flowchart.

Figure. 2.

Trends in journal publications per year in schizophrenia research.

Figure. 3.

Number of published documents by country.

Figure. 4.

Author keyword co-occurrence network, categorized into clusters.n

Figure. 5.

Author keyword co-occurrence network, 1973-2023.

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