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Visions Journal

When Psychosis Comes Back

How to make and use a relapse prevention plan

Tom Ehmann, PhD, RPsych

"Blips and Dips in the Recovery Journey" issue of Visions Journal, 2019, 15 (2), pp. 31-33

Psychosis is characterized by delusions, hallucinations or other phenomena that decrease an individual’s contact with reality. It is a condition found in many disorders, including schizophrenia.

Developing a first episode of psychosis is a frightening and highly disruptive event. People who experience the onset of a psychotic disorder may be unable to go to work or school, maintain or develop social relationships, play sports, engage in hobbies or keep up with everyday activities. In short, life gets put on hold for weeks, months or even years. Since psychotic disorders usually begin in the late teens and 20s, developmental tasks—such as entering the workforce, attending advanced education and developing intimate relationships—get derailed.

Fortunately, there are Early Psychosis Intervention (EPI) programs in much of BC. These programs operate according to provincial standards and guidelines1 that provide the best chance for a person to recover and successfully reach developmental milestones. Other early-psychosis services may also be available in more rural areas.

What do we know about relapses?

“Relapse” is the term used to describe what happens when psychosis returns. This may include a return of hallucinations, delusions or other symptoms. Relapse is common and creates ongoing problems. The relapse rate has been reported to be as high as 80% over the first five years among persons who were successfully treated for a first episode of psychosis.2 One study done before the establishment of specialty early-psychosis services found that about two of three people treated for a first episode of psychosis had a relapse within 15 years, and one in six of these did not get better again.3

Relapses, like the first episode, disrupt life and can be demoralizing. The experience of a hospital stay, having to take time off school or work, and the stress that a relapse places on families and other relationships can lead to disappointment and fear for the future. More relapses are associated with poorer long-term outcomes, especially when the relapses are more severe and longer-lasting. The psychotic symptoms become harder to treat over time and the person becomes less able to achieve developmental goals and function reasonably well.4

The factors that trigger a relapse in one person may not be the same as the factors that trigger a relapse in someone else. Some factors may not affect one person at all but may be significant enough to cause a relapse in another.

One factor that contributes to relapse in many people is stopping antipsychotic medication. For example, a recent study found that 67% of first-episode clients who discontinued medication relapsed after one year.5 Other studies reported that poor adherence to medication can increase the chances of relapse fourfold, while substance use can increase it threefold.4 On the other hand, many persons who show good functional recovery may benefit over the long term with physician-monitored dose reduction or discontinuation.6 Other common factors associated with relapse include the following:

  • the use of drugs such as amphetamines and cannabis
  • psychosocial stressors such as interpersonal problems, poverty and homelessness
  • being male
  • not being actively involved in education, employment or training after onset
  • slow initial onset of the psychosis
  • treatment delays at onset of psychosis
  • previous psychiatric-hospital admissions3, 5

What can be done to avoid relapses?

The problem of relapses means that prevention, or at least the goal of making relapses shorter or less severe, should be an important part of a treatment plan. The following steps can help:

  1. Getting into an EPI program. Specialist early-psychosis programs like EPI prevent relapses, lessen the severity of relapses and decrease the need for hospitalization more than typical mental health treatment services.4 Specialty services consist of a set of intensive interventions, supports and principles that consider the age and stage of the person and are delivered as a complete package with frequent contact from knowledgeable staff. Research has yet to determine exactly what elements make services like EPI better, but we do know that if the package is properly delivered, then the outcomes are superior to those we can expect from typical mental health care services.
  2. Following the treatment plan. If reducing antipsychotic medications is part of the treatment plan, the client should work closely with the psychiatrist to do it exactly as planned and with very close monitoring. Besides regular visits with a clinician, knowing how to monitor response to the treatment plan is important.
  3. Developing a relapse prevention plan. Within EPI, every client must have a relapse prevention plan. This plan is used by the client, the clinician and the family. The clinician should provide a written copy to the client and the family, and include the plan in the client’s chart. Relapse prevention plans should be reviewed and updated regularly. Even if the client doesn’t have access to an EPI program, the client and the clinician can work together to develop a plan.

What does a relapse prevention plan look like?7

A relapse prevention plan acts as an individualized blueprint for monitoring when a relapse might be starting so that intervention can happen quickly and effectively. The plan starts with having a good treatment team and includes identifying early warning signs of a relapse and options to minimize the factors that could be triggering the relapse.8 The plan requires that the client look back at what happened in the months before they became psychotic, think about what symptoms and changes they first experienced and consider how they coped with those symptoms and changes. Every person is different when it comes to triggers, warning signs and the best ways to cope or intervene.

A relapse prevention plan includes three sections: a list of potential triggers, early warning signs that a relapse may be starting and descriptions of supportive plans in the event that a relapse occurs.

Triggers are factors that increase the risk of psychosis flaring up. Triggers vary but often include drug or alcohol use or different kinds of stress like conflicts; work, school or family problems; poor sleep; and disturbing events.

Early warning signs are signals that something is not right. Many people experience changes in behaviour, thoughts or feelings before other symptoms of psychosis appear. Common early warning signs can include

  • changes in sleeping patterns
  • changes in mood
  • difficulty concentrating
  • increased sensitivity to sound, light or colour
  • increased or decreased talking
  • lack of enjoyment
  • decreased personal hygiene
  • lack of desire to do things or spend time with family or friends
  • increased annoyance with others
  • increased suspicion of others

Early warning signs may be normal responses to stress. Responding to early warning signs by doing things that reduce stress helps reduce the risk of relapse.

The third section of the relapse prevention plan is devoted to supportive plans, which can include plans to

  • contact people who can provide support, like an EPI clinician or psychiatrist, family or close friends, and share the plan with them
  • increase contact with a clinician
  • stop drug use other than prescribed medications and avoid other potential relapse factors
  • reduce stress by using relaxation strategies, minimizing stressful tasks and engaging in calming or enjoyable activities
  • engage in medication strategies (pre-arranged with a psychiatrist) such as increasing the dose or using another type of medication for a short time

The return of psychosis doesn’t mean that watching for early warning signs won’t be helpful. Sometimes it takes time to figure out which early warning signs to watch for and how best to intervene. The relapse prevention plan provides the tools to do just that.

 
About the author

Dr. Ehmann has researched and facilitated service development involving psychotic disorders for over 30 years. He was lead author of the BC EPI Standards and Guidelines and the Dealing With Psychosis Toolkit. Currently he serves as consultant to the provincial EPI Advanced Practice, introducing evidence-based practices and improving services across the province

Footnotes:
  1. British Columbia Ministry of Health (2010). Standards and guidelines for early intervention (EPI) programs. Ministry of Health, Government of British Columbia. www.health.gov.bc.ca/library/publications/year/2010/Standards-and-guidelines-for-early-psychosis-intervention-(EPI)-programs.pdf.
  2. Robinson, D., Woerner, M.G., Alvir, J.M., Goldman, R., Geisler, S., Koreen, A., Sheitman, B., Chakos, M., Mayerhoff, D. & Lieberman, J.A. (1999). Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Arch General Psychiatry, 56(3), 241-247. www.ncbi.nlm.nih.gov/pubmed/10078501.
  3. Wiersma, D., Nienhuis, F.J., Slooff, C.J. & Giel, R. (1998). Natural course of schizophrenic disorders: A 15-year followup of a Dutch incidence cohort. Schizophrenia Bulletin, 24(1), 75-85. https://doi.org/10.1093/oxfordjournals.schbul.a033315.
  4. Alvarez-Jiménez, M., Parker, A.G., Hetrick, S.E., McGorry, P.D. & Gleeson, J.F. (2011). Preventing the second episode: A systematic review and meta-analysis of psychosocial and pharmacological trials in first-episode psychosis. Schizophrenia Bulletin, 37(3), 619-630. doi: 10.1093/schbul/sbp129.
  5. Di Capite, S., Upthegrove, R. & Mallikarjun, P. (2018). The relapse rate and predictors of relapse in patients with first-episode psychosis following discontinuation of antipsychotic medication. Early Intervention in Psychiatry, 12(5), 893-899. doi: 10.1111/eip.12385.
  6. Wunderink, L., Nieboer, R.M., Wiersma, D., Sytema, S. & Nienhuis, F.J. (2013). Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy: Long-term follow-up of a 2-year randomized clinical trial. JAMA Psychiatry, 70(9), 913-920. doi: 10.1001/jamapsychiatry.2013.19.
  7. The description of the relapse prevention program has been adapted from a plan developed within the Fraser EPI Programs.
  8. Birchwood, M., Spencer, E. & McGovern, D. (2000). Schizophrenia: Early warning signs. Advances in Psychiatric Treatment, 6(2), 93-101. doi: https://doi.org/10.1192/apt.6.2.93.

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