Relapse in schizophrenia: Definitively not a bolt from the blue

•Early warning signs (EWS) of schizophrenia relapse were analyzed using a telemedicine system.•Previous studies demonstrated symptom increase 2–4 weeks before relapse.•Here, the onset of continuous changes in EWS occurred 2 months prior hospitalization.•EWS precede relapse of schizophrenia much earlier than previously suggested. Detailed study of the period before schizophrenic relapse when early warning signs (EWS) are present is crucial to effective pre-emptive strategies. To investigate the temporal properties of EWS self-reported weekly via a telemedicine system. EWS history was obtained for 61 relapses resulting in hospitalization involving 51 patients with schizophrenia. Up to 20 weeks of EWS history per case were evaluated using a non-parametric bootstrap test and generalized mixed-effects model to test the significance and homogeneity of the findings. A statistically significant increase in EWS sum score was detectable 5 weeks before hospitalization. However, analysis of EWS dynamics revealed a gradual, monotonic increase in EWS score across during the 8 weeks before a relapse. The findings—in contrast to earlier studies—suggest that relapse is preceded by a lengthy period during which pathophysiological processes unfold; these changes are reflected in subjective EWS.