Relapse

• Relapse
• Signs of a relapse
• What to do if you think your relative is becoming unwell
• Planning for a relapse

Relapse

Some people will only ever experience one episode of psychosis. However, many people who are given a diagnosis of schizophrenia, bipolar disorder or schizoaffective disorder will have further episodes at some time. When the symptoms start again or worsen, mental health professionals call this a relapse.

If someone stops taking their presribed long-term medication, they are more likely to have a relapse. This will typically not happen immediately, but is likely to happen over the next few weeks or months.

Some women who have a diagnosis of bipolar disorder or schizoaffective disorder will experience a relapse after the birth of a child (see Puerperal psychosis page).

Research has shown that people who misuse drugs and alcohol are more likely to have a relapse.

Studies have also consistently shown that people who have family therapy for psychosis with their relatives are less likely to relapse. 

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Signs of a relapse

There may be early warning signs that someone is becoming unwell again: these signs will be different for each individual. Mental health professionals sometimes call personal warning signs a 'relapse signature'. However, early signs of a relapse do not always follow a similar pattern. Your relative's behaviour may not necessarily be the same as it was before he or she first became unwell, or the same as it was before their last relapse.

There may be changes in the way your relatives thinks, feels or behaves. These changes could happen gradually, or they may happen quite quickly.

Before experiencing the symptoms of psychosis again, people may start to spend more time on their own, or shut themselves away and not want to be with family members or friends. Their mood may change and they may start to feel more anxious, worried or upset. They may start to neglect their personal care and seem to be more distant. They may go off their food, or become more suspicious and wary, or may start talking in a strange and confused way. They may lose interest in study or work.

If your relative has a diagnosis of bipolar disorder, they may start staying awake for long periods of time, become increasingly irritable, or conversely, be very happy and energetic before an episode of mania. They may start making exciting plans and organising for the future. They may eat more quickly and be more talkative, or start going out a lot and staying up late.

It's important to remember, however, that if you are constantly on the look out for signs of a relapse, this can feel rather intrusive for your relative, and your relationship with them may suffer. While it is helpful to try to notice any signs of a relapse early rather than just waiting for things to get worse, there is a balance to be struck between being aware of new problems developing and being over alert to normal variations in mood or behaviour than anyone can have. Sometimes people will naturally have ups and downs, and these may stablilise in a few days.

However, it can be particularly helpful to talk with your relative when they are feeling stable about what they would like to happen if they become very unwell again, and what they would like you to do, or not to do.

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What to do if you think your relative is becoming unwell

If you are worried that your relative may be heading towards a relapse, try to persuade them to talk to their care coordinator, or make an appointment to see their GP. They may be reluctant to seek professional help, or may deny that anything is wrong. If so, you could phone or visit their GP and express your concerns, or talk to their care coordinator, or the duty person in their community team (if they have one) and ask one of them to visit your relative at home.

If you have a good relationship with your relative’s psychiatrist, you could phone them and talk about your worries. He or she can then suggest what you should do next. You could also phone your own GP and ask for their advice.

If your relative’s mental health deteriorates rapidly, you may need to take urgent action (see In an emergency page).

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Planning for a relapse

Relapse can be traumatic for both the individual who is becoming unwell again and for their families.

Your relative can have more influence over the treatment and care they receive during a relapse by planning ahead. They can write down what sort of treatment they would like if they become seriously unwell again, and spell out which people they would like to be involved in decisions about their care (for example their families) in the event of a relapse.

These sort of written documents may be called 'advance statements', 'advance directives', 'advance decisions', 'joint crisis plans', 'advance agreements', or 'crisis cards.'

Most of these documents have no legal status, except for an advance decision made under the Mental Capacity Act (see Mental health law and compulsory treatment page). But the National Institute for Health and Clinical Evidence recommends (in its guideline on schizophrenia) that 'healthcare professionals should endeavour to honour advance decisions and statements wherever possible.' The guideline says health professionals should work collaboratively with people with schizophrenia to develop advance decisions and advance statements, 'especially if their illness is severe and they have been treated under the Mental Health Act.'

Joint crisis plans are currently not in use in mental health services in the UK but research projects testing their effectiveness have shown that people are less likely to have compulsory treatment if they have put this sort of advance statement in place when they are well. A joint crisis plan is drawn up after a discussion between someone with a diagnosis of a mental health problem and the mental health professionals involved in their care. Relatives and friends are encouraged to go to the meetings involved in drafting and agreeing a joint crisis plan.

A crisis card is something produced solely by an individual, expressing his or her wishes.

Treatment plans drawn up under the Care Programme Approach should also include people’s wishes and preferences in the event of a crisis (see Mental health services page).