Iris Guideline 6

Guideline Six
A strategy for relapse prevention and treatment

resistance should be implemented.
Background
The avoidance of early relapse is crucial, as frequent, or long untreated episodes

of psychosis increase the risk of further relapse. The presence of more than one
relapse and residual symptom in the first two years is a major prognostic factor in
its own right. Relapse risk has also been linked to acute and chronic stress
(Kuipers and Bebbington, 1994).
Requirements
Relapse Prevention
1. Clients and families should be informed about the risk for relapse and how
they can help to reduce this.
2. Relapse risk assessment should form port of the ongoing assessment

process and embrace:
o Vulnerability: untreated psychosis, previous exacerbations

o Prophylaxis: utility of and adherence to medication regimes
o Stressors: both acute (life changes, cannabis abuse) and
long-term (intrafamilial stress, unstable life patterns)
3. An individualised, shored and documented relapse prevention plan should

be developed and rehearsed with the client and social network (see Tool
Kit). This should include:
o Individualised signs of relapse (‘relapse signature’)

o Development and rehearsal of a linked ‘relapse drill’,
involving, where appropriate, targeted and time limited
neuroleptic medication.
o An active relapse monitoring procedure.
4. The experience of relapse/exacerbation should be viewed as on

opportunity to review the relapse signature and operation of the relapse
prevention procedure.
Treatment Resistance
1. The continued experience of psychotic symptoms within 6 months of first

treatment suggests that such symptoms are likely to continue (Lieberman
et al, 1993). The review at this point should declare the presence of drug
resistant symptoms and determine an appropriate strategy (see Tool Kit).
2. The trial use of atypical antipsychotics such as Clozapine should be
considered.The combinations of cognitive therapy with medication has also
shown considerable promise for drug resistant symptoms (Garety et al,
1997) and should be considered.
3. Teaching clients and carers how to deal with and cope with such
symptoms to minimise distress may be required (Tarrier et al, 1998).
Getting it right....
Simon has a 2 year history of psychotic illness. After two lengthy hospital
admissions under section he is now agreeing to try medication and to
accept follow-up from the CPN team. His medication has helped with
sleep, concentration and clarity of thought but he remains low in mood
poorly motivated and finds it difficult to mix socially. Using early signs
monitoring and family support, Simon is learning to recognise his
symptoms of relapse. He agreed to attend a day unit informally when he
felt depressed and was able to share his worries with the CPN. His
admissions and relapses hove reduced.
Where things can go wrong....
John was discharged after a 12-week hospital admission with hypomania

to his parents home. He had previously been living alone. He was to be
followed up by another team but the referral letter was not written until
4 weeks after discharge. Whilst on the word, John had indicated his
reluctance to adhere to medication and, in fact, did not obtain a repeat
prescription. His parents ore worried about whet to do in the event of
deterioration. Lost time, he left home and caught a train when acutely
disturbed prior to his admission and the family ore worried that police
will have to be involved again.
Ask Yourself.....
Does the family/client/keyworker/GP know what to do (in
writing) with clear practical steps to take, if things go
wrong, including:
• Advice on medication adjustment to manage over the

weekend and at night, to defuse an escalating crisis?
• A clear plan to access respite/day/inpatient care?
• A clear plan to access out-of-hours support?
• A clear plan of who to contact in the absence of a named

worker?
• Does the letter/summary to the GP contain the above in

formation in a clear form?
• Is there a service response time standard which is audited?
National Service Framework Links: Standards 4 and 5 repeatedly

require clarity about action to be taken in a crisis and for this to be
shared between client, carer and professional.

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Guideline Six

A strategy for relapse prevention and treatment

The avoidance of early relapse is crucial, as frequent, or long untreated episodes

2. Relapse risk assessment should form port of the ongoing assessment

o Vulnerability: untreated psychosis, previous exacerbations

3. An individualised, shored and documented relapse prevention plan should

o Individualised signs of relapse (‘relapse signature’)

4. The experience of relapse/exacerbation should be viewed as on

1. The continued experience of psychotic symptoms within 6 months of first

Where things can go wrong....

John was discharged after a 12-week hospital admission with hypomania

• Advice on medication adjustment to manage over the

• A clear plan to access respite/day/inpatient care?

• A clear plan to access out-of-hours support?

• A clear plan of who to contact in the absence of a named

• Does the letter/summary to the GP contain the above in

• Is there a service response time standard which is audited?

National Service Framework Links: Standards 4 and 5 repeatedly

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