Maladaptive coping linked to higher relapse risk in first episode psychosis

Patients with first-episode psychosis who rely more heavily on maladaptive coping strategies, such as self-distraction and substance use, face significantly higher odds of relapse, hallucinations and delusions over the following year, according to an article published in Schizophrenia Bulletin.

‘Coping Style as a Predictor of Relapse and Functioning in First Episode Psychosis’ was led by Anna Georgiades, Ph.D., from the Institute of Psychiatry, Psychology & Neuroscience at King’s College, London. She and her team followed 269 adults with first episode psychosis recruited from 10 National Health Service early intervention sites across the United Kingdom as part of the Social Mind project at King's College London. Participants completed structured clinical interviews at baseline and at 4, 8 and 12 months, and their coping styles were measured at baseline using the Brief COPE, a 28-item self-report tool that separates adaptive strategies, such as active coping, planning and reappraisal, from maladaptive ones, such as self-distraction, denial, substance use and behavioral disengagement.

What the study found

Relapse occurred in 9% of participants by 4 months, 14% by 8 months and 20% by 12 months. Maladaptive coping at baseline was significantly associated with higher odds of relapse within 12 months, corresponding to an approximate 6% increase in relapse odds for each one-point increase in maladaptive coping scores, though the association did not reach significance at the earlier 4- and 8-month time points. Maladaptive coping was also tied to higher odds of hallucinations at every follow-up point and to delusions at 8 and 12 months, with each point increase corresponding to roughly a 7% to 9% rise in odds. It was linked to poorer clinician-rated functioning on the Global Assessment of Functioning scale as well, most consistently on the symptom-severity domain.

Adaptive coping showed the opposite pattern but a less durable one. Higher baseline adaptive coping was associated with lower odds of hallucinations and delusions and with better functioning at 4 months, but those associations weakened and were no longer statistically significant by 12 months.

The researchers said this likely reflects the limits of a single baseline measurement rather than a real decline in the value of adaptive coping over time.

"Stress has repeatedly been implicated in the onset and exacerbation of psychosis symptoms," the study's authors wrote in Schizophrenia Bulletin, citing coping as a particularly relevant response to that stress for this patient population.

Predicting relapse with machine learning

Beyond group-level statistics, the researchers used machine learning to test whether coping data could predict relapse for individual patients. A model built on maladaptive coping alone predicted 12-month relapse with an area under the curve of 0.77 and 75% accuracy, outperforming a model built on adaptive coping, which reached an AUC of 0.73 and 70% accuracy. Within the maladaptive domain, self-distraction and substance use were the strongest individual predictors of relapse; within the adaptive domain, spiritual or religious coping and active problem-solving contributed most.

Georgiades and her team cautioned that substance use, though classified as a maladaptive coping strategy in the analysis, carries its own direct neurobiological effects and may sometimes reflect a co-occurring substance use disorder rather than a coping response, meaning its outsized contribution to the model should be interpreted carefully.

What it could mean for behavioral health providers

The findings point to coping style as a modifiable target for early intervention services treating first episode psychosis, the authors write in the study.

They also noted that cognitive behavioral therapy for psychosis already delivered within these programs could be adapted to more directly assess and address coping patterns at intake.

"Targeting both the reduction of maladaptive coping and the promotion of adaptive coping may represent clinically meaningful intervention strategies associated with symptomatic and functional recovery and reduced relapse risk in FEP," they wrote, adding that problem-solving and faith-based approaches aligned with a patient's own values may be worth emphasizing.