Relapse Prevention

Relapse

The initial transgression of problem behaviour after a quit attempt is defined as a

“lapse,” which could eventually lead to continued transgressions to a level that is
similar to before quitting and is defined as a “relapse”.

Another possible outcome of a lapse is that the client may manage to abstain
and thus continue to go forward in the path of positive change, “prolapse”.

Many researchers define relapse as a process rather than as a discrete event

and thus attempt to characterize the factors contributing to relapse.
Relapse' is a word that is used in many different ways in a variety of contexts. It is
defined in the Macquarie Dictionary as "to fall or slip back into a former state,
practice, etc". In the Australian Concise Oxford Dictionary, it is defined as
"deterioration in a patient's condition after a partial recovery".

It is used most commonly within a medical context, where it is a word that is

clearly understood by health practitioners to mean returning to a diagnosable
state of mental illness: a mental state that has previously been diagnosed and the
symptoms of which have returned to the point where the threshold has again been
reached for diagnosis. Relapse is evident by recontact with services in the form of
another acute episode of illness that requires service intervention, often
hospitalisation.
Common Signs
- Suffering changes in mood.
- Losing your sense of humour.
- Becoming tense, irritable, or agitated.
- Finding it difficult to concentrate.
- Retreating from social situations and neglecting outside activities and social
relationships.
- Saying or doing irrational or inappropriate things.
- Developing ideas that other people find unusual, strange, or unbelievable
- Neglecting your personal care.
- Neglecting to take your medication.
- Dressing in unusual clothes or unusual combinations of clothes.
- Sleeping excessively or hardly at all.
- Eating excessively or hardly at all.
- Becoming increasingly suspicious or hostile.
- Becoming especially sensitive to noise or light.
Common Causes
- Poor understanding of your mental disorder in general, and of the symptoms
of a relapse in particular
- Non-compliance with medication or decreased dose of medication
- Drug and alcohol misuse
- Lack of sleep or irregular pattern of sleep
- Stress
- Lack of social relationships and support
- Felt stigma
- Poor physical health
Relapse Prevention

Within the medical literature, relapse prevention generally refers to illness

management through compliance with medication regimes. It is widely accepted
that people who have been seriously affected by mental illness are at risk of
relapse if they do not take their medication as prescribed. Consequently, much
of the relevant literature focuses on encouraging compliance with medication
regimes through psycho-education and cognitive behavioural techniques (see
Mueser et al 2002).
Relapse prevention is also generally acknowledged to involve recognising early
warning signs of relapse and responding quickly and effectively. Awareness of
early warning signs and planning around how to respond to these were seen as
key tools for preventing relapse.
Components of Relapse Prevention

Currently, there is no comprehensive framework agreed for relapse prevention

within the context of mental illness. There are frameworks available for recovery
and for psychiatric rehabilitation, but the focus of these is quite different,
although highly relevant to relapse prevention. Review of the national and
international literatures shows that most relapse prevention initiatives are single-
issue medically-based responses that prioritise maintenance medication and
recognition of early warning signs. The chronic illness management and
rehabilitation literatures provide useful guidance, but have not been applied in
the context of mental illness. It is possible, however, to identify the core
components of relapse prevention for mental illness and show how these
contribute to providing effective continuing care within a recovery orientation.
Fundamentally, relapse prevention requires awareness, planning, and the provision
of timely and appropriate intervention responses.

Laurie Curtis operationalises relapse prevention as the 4As of crisis prevention:

awareness, anticipation, alternatives and access (Curtis 1997). To implement such
an approach, actions need to be undertaken by all those involved in the continuing
care and recovery of people with mental illness: by people who have experienced
mental illness, their families and carers, clinical service providers and planners,
non-clinical service providers and planners, policy makers, and communities.
Awareness

Awareness is the first component of effective relapse prevention, and is made up

of the essential elements of acceptance and recognition. These factors
determine whether people at risk of recurrent mental illness, and the people and
services that they are in contact with, are able to accept and recognise changing
mental health needs so as to be able to respond appropriately.
Anticipation and Planning

Anticipation of potential future scenarios and appropriate planning are essential

to relapse prevention. Planning is what empowers people with mental illness to
make the decisions they choose, rather than have decisions made for them.
Planning needs to be undertaken when the consumer is relatively well and able
to make such decisions. It needs to be undertaken on several levels: daily plans,
wellness plans, relapse and crisis plans.
Alternatives

People who have experienced mental illness, and their families and carers, need
a wide range of service alternatives that can be tailored to their personal context
and that address their particular risk and protective factors for wellbeing.
However, very few local areas adequately provide the range of services that are
needed to support people who have experienced mental illness in the
community. Better provision of community support services, along with the
development of effective partnerships and communication strategies between
different services and sectors is an urgent need in most jurisdictions. The entire
range of evidence-based psychological, pharmacological and psychosocial
support options needs to be available and accessible to enable people with
mental illness to find the techniques that best support their recovery.
Accessibility of Interventions
Effective relapse prevention requires early intervention through access to
appropriate supports and services. This means, firstly, the development of
effective personal coping skills and illness self-management strategies in
response to early warning signs. Secondly, it requires a service system that
responds to early warning signs, not just acute crises. Furthermore, relapse
prevention needs to commence during the earliest stages of treatment; as part of
the ongoing process of continuing care that needs to be put in place at the outset.
Relapse prevention requires a different service response. It requires truly listening
to consumers and their families and carers and taking their concerns seriously. If
intervention is early enough, it should not require an acute service response. The
aim is to prevent crises in the form of rehospitalisation and police intervention.
This is not, however, the experience of many people seriously affected by mental
Necessity of Relapse Prevention

Relapse prevention is desirable for several pragmatic reasons.

Firstly, it reduces the negative impact of mental illness on individuals and their
families and carers, as well as their communities. Prolonged and repeated
periods experiencing the symptoms of mental illness severely disrupt a person's
life and erode their confidence and wellbeing (Ralph 2000). The more relapses,
the more disabled a person is likely to become; there is evidence that each
relapse increases both residual symptoms (Shepherd et al 1989) and social
disabilities (Hogarty et al 1991).
As a result, people who experience repeated episodes of mental illness are more
dependent on their families and carers. This greatly increases the burden on
families and carers, contributing to their distress and reducing their quality of
life. It has been estimated that individual carers contribute, on average, 104
hours per week caring for a person with mental illness (MHCA & CAA 2000).
Repeated relapses impact in multiple ways on families and carers, including
severely limiting the employment and social opportunities for those with a major
role in caring for someone with mental illness (CAA 1998, CAA 1997).
Preventing relapse vastly improves the quality of life of people with mental
illness and enables them to more fully participate in work, leisure and
relationships. Effective relapse prevention enables people to gain mastery over
their symptoms, which increases their sense of control over their lives (Mueser
et al 2002). A greater sense of control and efficacy can reduce the feeling of
being 'entrapped' by the illness, a feeling that is commonly reported by people
with mental illness and that may lead to depression (Birchwood et al 1993).
Being able to participate in meaningful activities is also important to the
productivity of communities. The lack of participation of community members
with mental illness is a considerable cultural and economic loss to communities.
Mental disorders were the leading cause of years of 'healthy' life lost due to
disability in 1996, accounting for nearly 30% of the total years of healthy life lost
(AIHW 2002 p109)
Secondly, preventing relapse reduces the cost of mental illness to the
community. People who experience recurrent episodes are more dependent on
health and community services, and every relapse that requires medical
intervention imposes a cost on the health care system. In a recent randomised
controlled trial in the UK, costs for the patients who relapsed were over four
times higher than those for the non-relapse group (Almond et al 2004).
Indirect evidence of the effectiveness of relapse prevention is available, however,
from several sources. Randomised controlled clinical trials show that effective
treatments that can prevent or reduce the severity of relapse have positive effects
by reducing hospitalisations, decreasing length of stay if a hospitalisation is
required, increasing the number of days in the community, reducing the level of
symptomatology, and increasing the likelihood of obtaining employment (Mueser,
Bond & Drake 2001). The European EPSILON study revealed that higher needs,
greater symptom severity and longer psychiatric history are associated with
higher health care costs (Knapp et al 2002). Furthermore, a study examining the
cost of mental health care in the United States from 1993 to 1995 by analysing
insurance records for mental health claims, reported that greater use of outpatient
care (which is more likely to be focused on relapse prevention) decreased the
costs of care by reducing the level of more expensive inpatient care (Outcomes
and Accountability Alert 1999).
Relapse Prevention Interventions

In the medical and academic literatures, relapse prevention interventions have

been categorised as including the following types of approaches: training in
recognition of early warning signs; programs that encourage compliance with
medication; coping skills training; and broad-based psycho-education programs.
Both service-based and self-help programs are, therefore, clearly relevant to
relapse prevention, although self-help and peer-based approaches have been
researched less frequently and rigorously in terms of outcomes.
Recognizing Warning Signs

Intervention approaches tagged specifically in the literature as relapse prevention

are programs that focus on teaching people how to recognise their early warning
signs and the environmental triggers of their symptoms. Such programs generally
involve training in identification of early warning signs and stress management. In
their review, Mueser et al (2002) report that randomised controlled trials of five
such programs all reported decreases in relapse and rehospitalisation. Results
from a large uncontrolled study of the use of early warning signs (Novacek &
Raskin 1998), as well as a study of family members being trained in recognising
early warning signs (Pitschel-Walz et al 2001) also reported positive outcomes in
terms of reducing relapse and rehospitalisation, as well as decreasing treatment
costs.
One of the few interventions clearly identified as relapse prevention is teaching
people to recognise the early warning signs of their mental illness. Novacek and
Raskin (1998) report evidence from a large uncontrolled study of 370 people
with severe mental illness, showing that teaching recognition of early warning
signs was associated with better outcomes, which included fewer relapses and
hospitalisations and reduced treatment costs.
Early warning signs vary between individuals, and a personal set of early warning
signs is referred to as a 'relapse signature'. There is ample evidence that people
with psychosis are often aware of these signs, which generally prompt them to
undertake personal coping strategies to actively intervene (eg, McCandless-
Glimcher et al 1986).

Some people are not able to recognise their early warning signs, however. There
are those who actively deny their symptoms and have no insight into their mental
illness. Others have 'past insight', or retrospective insight, into their relapse
signature, but lose 'present insight' early in the relapse process. For these people,
family members and significant others may be involved in monitoring early
warning signs. Effective training programs have been developed to help families
and carers do this. There are also standardised measures of early warning signs
that can be applied (Birchwood et al 1989).
When early warning signs are noticed, people need to know how to respond
effectively and what their role in the response is. This requires having a relapse
prevention plan.
Compliance to Medications

Medication non-compliance is a major risk factor for relapse. This is the case for
psychotic illnesses (eg, Marder 1998) as well as depression (eg, Geddes et al
2003). There is clear evidence that maintenance medication and taking
medication as prescribed significantly reduces the risk of relapse.

Despite this, many people do not take their medication as prescribed.

The majority of interventions aimed at preventing relapse, focus on compliance
with medication. Mueser et al (2002) differentiate between programs that use
psycho-education to encourage taking medications as prescribed and cognitive-
behavioural programs that use techniques such as behavioural tailoring,
simplifying the medication regime, motivational interviewing, and social skills
training (to improve interactions with prescribing practitioners so as, for
example, to be better able to discuss the side effects of medications).
Coping Skills Program

Coping skills programs aim to help people manage stress or deal with persistent
symptoms. Randomised controlled trials were reviewed for four coping skills
programs by Mueser et al (2002). All these programs were quite different in their
approach, ranging from an interactive approach centred around cognitive
appraisal of perceived threat, to enhancing a sense of empowerment, but all had
in common the use of cognitive-behavioural techniques. All four programs
reviewed were shown to be effective in terms of reducing symptom severity.
Cognitive-behavioural approaches generally focus on modifying dysfunctional
beliefs as well as improving coping skills, such as distraction. Mueser et al
(2002) report on the outcomes of eight randomised controlled trials of cognitive-
behavioural therapy (CBT) programs. A consistent outcome of all the studies
was that CBT was more effective than supportive counselling or standard care in
reducing the severity of psychotic symptoms.
Psychoeducation Programs

Broad-based psycho-education programs provide people with information about

their mental illness, generally focusing on symptoms, stress-vulnerability, and
treatment options. In a review of the outcomes of four randomised controlled
trails of broad-based psycho-education programs, Mueser et al (2002) reported
that while these increase people's knowledge about mental illness, they do not
impact on other outcomes. This is a finding that is consistent with other health
applications of psycho-education programs: improving knowledge does not
automatically lead to changes in behaviour (see Whitehead & Russell 2004).
Self Help Groups

Self-help groups provide social contact and fellowship. Many people with mental
illness are socially isolated, as a result of the symptoms of their illness or the
disruption to their lives that the illness has caused (Goldberg, Rollins & Lehman
2003). There is a growing evidence base of the positive impact of self-help
groups on the social networks of people with mental illness (eg, Hardiman &
Segal 2003). While the social support provided specifically by self-help groups
has not been systematically studied, the positive effects of social support in
general on health and wellbeing are firmly established in the literature (eg,
House, Liandis & Umberson 1988).
Issues Related: Individual

- having information and support to accept and understand their health

condition in ways that are developmentally and culturally appropriate
- developing understanding of the following topics:
Early warning signs of relapse, including symptom and reality checks
Risk factors for relapse, including relapse triggers
Protective factors for relapse and wellness needs
Effective clinical services and approaches
Effective psychosocial and psychiatric rehabilitation services
Illness self-management tools;
being the central force in their own treatment planning and continuing care;
expecting services to engage them in continuing care planning that is regularly
reviewed and comprises, as appropriate to the individual consumer's
circumstances: discharge plans from acute and inpatient care; ongoing relapse
prevention and wellness plans; crisis plans; as well as support to develop self-
management plans; and

being fully involved in the planning and evaluation of mental health services and
empowered to advocate for service development and quality improvement
Issues Related: Family and Carers
- having information and support to accept and understand the health
condition of the consumer, and their role in supporting the consumer's
ongoing wellbeing;
- being involved in treatment planning and continuing care as appropriate and
agreed by the consumer;
- ensuring that appropriate continuing care planning takes place and is
regularly reviewed and that their role in this is explicitly acknowledged and
negotiated;
- being able to advocate for service development and having their role in the
planning and evaluation of mental health services recognised; and
- having family and carer support services in place to maintain their own
wellbeing.
Issues Related: Primary Care Services
- understanding and negotiating their role in the continuing care of a person
who has experienced mental illness, particularly their role in relation to
recognition of early warning signs and agreed early intervention responses
- ensuring that the physical health needs of people who have been seriously
affected by mental illness are met;
- providing integrated and seamless continuing care pathways by working in
effective partnership with specialist mental health services, other primary
care services, allied health services, and providers of psychosocial and
psychiatric rehabilitation services; and
- being actively involved in discharge planning and continuing care plans.
Issues Related: Clinical Service Providers
- making relapse prevention a routine component of treatment and continuing
care;
- prioritising consumer participation, and that of families and carers if
appropriate, in treatment and relapse prevention planning;
- ensuring continuity of care beyond the acute episode by providing integrated
and seamless continuing care pathways through working in effective
partnership with primary care including general practice, allied health
services, and providers of psychosocial and psychiatric rehabilitation
services;
- implementing effective and comprehensive discharge planning to provide
continuity of care through ensuring that the necessary pathways and
appointments for follow-up care are in place prior to discharge; and
- having positive attitudes that support a recovery orientation.
Issues Related: Community

- understanding the impact of everyday actions, particularly stigma, on the

wellbeing of people who have experienced mental illness and their families
and carers;
- refusing to allow discriminatory practices or stigmatising views of people
with mental illness; and
- becoming more accepting, inclusive and supportive of people with mental
illess within our communities.
THANK YOU