If you have been diagnosed with a serious mental illness such as schizophrenia, bipolar disorder, clinical depression or an anxiety disorder, and if you are being treated for your problem, there will be times when your symptoms seem to be under control and you are functioning well. However, sometimes it may also happen that you face challenges when the symptoms seem to get worse -- or return after having subsided. These setbacks are known as relapses.
A relapse comes with very real risks, and sometimes devastating consequences. After every relapse, it may become increasingly difficult to regain control over symptoms. In one study, care-givers reported that, as a result of relapse, their mentally-ill loved one was unable to work, and/or was hospitalized, or tried to commit suicide.
Because of these serious risks, it is important for someone with a mental illness (as well as for care-givers) to be aware of how a relapse may be prevented. While there is no guarantee – even with the best treatment plan – that a relapse will never happen, there are simple but effective steps that can be taken to help minimize the risks. They are based on the principles of self-management, which may sound daunting but is really about building small practical steps into your day.
There are three main steps to take to prevent relapse:
1. Be aware of relapse triggers. Some situations – or behaviours – called “triggers” can lead to a relapse. While each person will have his or her own triggers, the most common ones include:
» Stopping medication, or decreasing the dose without checking it out with the prescribing doctor. This is one of the most common causes of relapse; but relapses can happen even if a person is taking his or her medication as prescribed.
» Drug and / or alcohol abuse. Substance abuse often co-occurs with mental illness. If treatment is started only for the mental illness, then the side-effects of the medication may themselves propel the person to use alcohol or an illegal drug to alleviate those effects. For instance, someone with schizophrenia may be taking a medication for the hallucinations, but may suffer depression as a side-effect. (S)he may then smoke marijuana to deal with the depression. When the high subsides, the symptoms may return – often more strongly than before. The bottom-line is that when alcohol or drug abuse increases, mental health problems usually increase, too. Substance abuse can sharply increase the symptoms of mental illness or trigger new symptoms.
» Sleeping too little or too much. Unfortunately, sleep disturbances can also be a side-effect of some medications for mental illnesses.
» Stressful events such as job difficulties, or a marital crisis
» Conflict in relationships
» Lack of social relationships and support
» Felt stigma
» Poor physical health
» The onset of menopause in women. Studies suggest that menopause increases the risk of relapse in women who have had a previous history of a depressive disorder.
2. Know the early warning signs of a relapse.
These early warning signs begin to appear before full-blown symptoms return. If you are able to identify these signs, you give yourself a window of opportunity to challenge the onset of a relapse. It is also helpful to ask loved ones for feedback if they notice any of these red flags – people close to us often notice changes in ourselves before we ourselves do.
Some early-warning signs are subtle and can be hard to notice, while others are more obvious clues that a relapse is coming. Early warning signs may also differ from one person to another and from one mental disorder to another, For example, you might notice you need less sleep when you are getting a relapse of mania.
The most common early warning signs include:
Signs of stress build-up. Your may notice stress in four general areas:
» Physical signs in your body, like tense muscles or an upset stomach
» Emotional signs, like feeling overwhelmed or feeling upset
» Cognitive or thought signs, like thinking that everything is hopeless, or thinking that you aren’t appreciated
» Behavioural signs, like getting into arguments or acting aggressively
Lapses in taking your medication
Disturbed sleep patterns
Finding it difficult to concentrate.
Social withdrawal or isolation
Lack of interest in personal care and hygiene
Irrational thoughts and / or behaviours about food, eating and your weight. For instance: Beginning to worry that you have lost control over how much you eat; eating excessively or hardly at all; feeling that food dominates your life; thinking of yourself as fat when others say you are too thin. (All are early-warning signs of an eating-disorder relapse).
Increase in paranoia (such as seeing things or hearing voices that other people cannot see or hear, or believing people are against you). In general, developing ideas that other people find strange or unbelievable.
Becoming especially sensitive to sound or light
Confusing or nonsensical speech
Increase in risk-taking behaviours (such as extravagant spending, using alcohol/drugs)
3. Act to prevent a relapse
The first step in preventing a relapse actually needs to be taken when the mental illness initially presents itself, and it is this:
Do not delay seeking treatment. We have sufficient evidence today that the longer initial treatment is delayed in an illness like schizophrenia, the poorer the outcome: recovery is slower and less complete, and the chances of relapse are also higher.
But, delay in seeking treatment for mental illness is still the norm. A number of studies have shown that there is often an extended delay – up to a year, or even longer in many cases -- before a person with a mental illness is brought to medical attention. Sadly, in many families where one member is beginning to show signs of a mental illness, a kind of denial and a wishful-thinking process get underway: “It may be just a passing phase. If we let things be, they will work themselves out.” But this is the very worst kind of thing you can do.
Know your disorder. If you have been diagnosed with a particular mental illness, you should study it so that you know its characteristic symptoms; the distinct ways in which it can alter your thoughts, feelings and / or behaviours; at what point you and your doctor and therapist can consider that you have recovered sufficiently so that you can move to maintenance medication and follow-up therapy at longer intervals. All too often, therapists themselves make the mistake of considering that a person has recovered when in reality (s)he has not. For instance, in the case of an eating disorder like anorexia, all too often therapists consider people recovered because their behaviours are no longer disordered. Yet they score low on tests of body image and self-esteem, and that makes them vulnerable to returning to extreme diets, laxatives or excessive exercise when stress hits. It comes as no surprise then that, even with hospitalization, the rate of relapse in anorexia is 40 % within a year of being treated.
Do not make the mistake of stopping medication on your own. Severe mental illness (e.g., schizophrenia; bipolar disorder) is generally chronic. So don’t make the mistake of stopping medication once you begin to see improvement: maintenance medication is key to avoiding relapses. In the case of schizophrenia, for instance, if maintenance medication is discontinued, the relapse rate is as high as 50% to 75%. Conversely, research suggests that, in many cases, long-term treatment with medication can substantially reduce the risk of relapse.
The most common reasons for stopping medication: You might have been feeling well for some time, and decided you didn’t need to take the medicine any more. Or you might be fed up with side-effects, some of which you might find intolerable. If you are reluctant to continue your medication for these or other reasons, it’s best to speak to your doctor about this. (S)he may be able to decrease the dose, or switch you to another medication that suits you better.
Build healthy coping skills. A big part of coping skills is a healthy lifestyle. Healthy habits like eating well, exercising regularly, getting enough sleep and practising relaxation exercises can have a significant impact on aspects like your mood and your ability to tackle challenges.
Managing stress is a big part of wellness. You can control some things that cause stress -- for example, you can try to get enough sleep and use substances like alcohol wisely. But it’s unlikely that you can eliminate all stress from your life. This is why stress management skills are important. These skills help you to identify stress and take action by solving problems pro-actively.
The first step in stress management is learning to identify when you’re experiencing stress. (See the warning signs of stress build-up, listed above).
Think about situations that you find stressful. Problems with your job, money or relationships may come to mind easily. But remember, a situation doesn't have to be “bad” for it to cause stress. Stressful situations or events that people sometimes forget about include:
» Starting a new job or training course, or taking on new responsibilities
» A major vacation, or a milestone anniversary
» A new relationship or commitment
» Moving house, or carrying out major renovations in your house
» Other health problems (apart from the mental illness)
Once you’ve identified the stress-causing situations in your life, it’s time to take certain practical steps to manage them. Here are some tips to consider:
Start slowly. If possible, add in new stress gradually, rather than all at once. For example, if you want to take up a language course, it may be better to avoid the short-term, intensive-course option and prefer a course where the training is spread out over a longer period of time, and is therefore more manageable.
Give yourself time for self-care. Remember, self-care is even more important when you’re dealing with a stressful situation.
Cut back on ongoing responsibilities. We all take on responsibilities that aren’t always essential, like hosting family get-togethers. But it’s okay to put that on the back-burner if you need to spend time on new responsibilities or challenges.
Stay in contact with those who form part of your support system. Feeling comfortable with your psychiatrist and your therapist is important in preventing a relapse. Sometimes, a person under treatment for a mental disorder may notice the early warning signs of a relapse but feel embarrassed to admit it to the doctor and / or therapist because of being worried about disappointing him or her. Work with someone in whom you can confide your lurking fears about symptoms that may be creeping up on you again. Severe mental illnesses are difficult to battle alone.
Apart from your healthcare support team, reach out to caring friends and family members, who can also help you get back on track in case signs of a relapse are beginning to surface. Being part of a support group can also make the vital difference.
Prepare a crisis plan. You may not always be able to recognize warning signs and triggers or take action in time to prevent a relapse from happening. That’s why preparing ahead for these times can help you manage the crisis safely and quickly.
One strategy in preparing ahead is to create a crisis plan. Such a plan can include:
» A list of triggers and warning signs
» Things to do when you recognize warning signs
» A list of emergency contact information (e.g., your doctor/treatment team members; your loved ones)
» A list of your current medications and any other treatments (including alternative treatments)
» Medications that have helped in the past; and medications that have not helped:
Act as soon as you see any of the warning signs. Get in touch with your doctor right away; this may help to avert a full-scale relapse.
Remember that a relapse may impair your thinking, and thereby prevent you from recognizing the signs and symptoms of a possible setback. Therefore keep a copy of that list of early warning signs with your family, carers and / or close friends.
(The author is a former editor of 'Health & Nutrition' magazine, and now works as a counseling therapist)