Relapse

• Signs of a relapse
• What to do
• Advance statements

Signs of a relapse

Some people will only experience one episode of psychosis. However, the majority of people will have further episodes. When the symptoms start again or worsen, mental health professionals call this a ‘relapse’.

You may notice changes in your relative’s behaviour that could herald a relapse. These changes – in the way they think, feel or behave – could happen gradually, or they may happen quite quickly.

People may start to spend more time on their own, or shut themselves away and not want to be with family members or friends. 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, an episode of mania is commonly preceded by missing one or two night’s sleep, by increased irritability, or conversely, by a very happy and energetic mood. He or she 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.

Behaviour before a relapse may not necessarily be the same as your relative’s behaviour was before he or she first become unwell, or before their last relapse. Sometimes, however, early signs of a relapse do follow a similar pattern each time.

If you are constantly on the look out for signs of a relapse, your relationship with the person who is unwell may suffer. It may be more helpful to talk with them when they are feeling stable about what they would like to happen if they do become very unwell again, and what they would like you to do, or not to do.

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

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What to do

If you are worried that your relative may be heading towards a relapse, try to persuade them to talk to their care co-ordinator, 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 you relative’s mental health deteriorates rapidly, you may need to take urgent action (see In an emergency page).

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Advance statements

Advance statements are written documents detailing your relative’s preferences for treatment during a future crisis, and saying who they would like to be involved in decisions about their care. The idea is that people can plan for a relapse and have more influence over what happens by preparing advance statements while they are feeling well.

You may see advance statements referred to as advance directives, advance decisions, joint crisis plans, advance agreements, or crisis cards.

These names all describe a document written in case someone becomes seriously unwell again. The differences are that some have a legal status (though most in this country don’t), and that some are drawn up in collaboration with mental health professionals.

The only sort of advance statement that is recognised by law in England and Wales is an Advance Decision which can be made under the Mental Capacity Act. The Mental Capacity Act cannot be used to provide treatment where someone has made a valid Advance Decision refusing treatment. However, an Advance Decision can be over-ridden by the Mental Health Act.

In Scotland, Advance Statements are included in the Mental Health (Care and Treatment) (Scotland) Act 2003. However, in certain circumstances, treatment may be given that conflicts with the wishes someone has written in an Advance Statement.

In the USA, Advance Directives have the backing of the law, but if you see advance directives referred to in this country, they have no legal status.

Joint crisis plans are drawn up after a discussion between someone with a diagnosis of a mental health problem and the mental health professionals involved in their care. Someone who is not involved in an individual’s treatment is included in that discussion to help negotiate the plan. Relatives and friends are encouraged to go to the two meetings involved in drafting and agreeing a joint crisis plan. If the mental health professionals do not agree with the individual about plans for care in a crisis – if they disagree about the need for medication or hospitalisation, for example – the document then becomes a crisis card. A crisis card is something produced solely by the individual, expressing his or her wishes.

Joint crisis plans are currently not in use in mental health services in the UK but research projects testing their effectiveness have so far shown that people are less likely to have compulsory treatment if they have negotiated this sort of advance statement. A large trial of joint crisis plans is currently taking place, involving people with a history of psychosis. The CRIMSON trial is funded by the Medical Research Council and is being run by the Institute of Psychiatry, and the Universities of Birmingham and Manchester.

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)

The NICE Guideline on Schizophrenia says: ‘advance decisions and advance statements should be developed collaboratively with people with schizophrenia, especially if their illness is severe and they have been treated under the Mental Health Act.’ It also says that ‘healthcare professionals should endeavour to honour advance decisions and statements wherever possible.’