Pathways of recovery: preventing further episodes of mental illness (monograph)

Awareness of early warning signs

Page last updated: 2006

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.

Considerable research has been undertaken into understanding early warning signs, particularly for psychosis and schizophrenia. These disorders are known to have a prodrome, or period when there are subtle, but identifiable, changes in thought, affect and behaviour that signal the onset of an episode of illness. However, it should be noted that the term 'prodrome' derives from the medical literature and "implies a disease progression that cannot be disrupted" (Birchwood, Spencer & McGovern 2000 p93); therefore, referring to these symptoms as early warning signs is a more accurate conceptualisation and allows for the possibility of preventive efforts to intervene to arrest the development of a full-blown episode.

There are common early warning signs for psychosis that are frequently reported and relatively predictable (see Birchwood, Spencer & McGovern 2000 p98). For depressive and anxiety disorders, the early warning signs have not been as thoroughly researched and are less well understood, although the indicators of the presence of depression and anxiety are well documented (see Beyond Blue website ( Sub-syndromal levels of these disorders are highly predictive of relapse to a full episode (Cuijpers & Smit 2004).

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. An example of such a plan is presented in table 2. This particular plan contains a 'relapse drill', which is a three-stage action plan with responses corresponding to the type of warning signs. It recognises that the earliest signs are usually non-specific and, therefore, early interventions for these early symptoms are based around relaxation and stress reduction. Interventions with greater risk attached (such as increasing medication) are reserved for when the relapse signature is clearly indicating the onset of a psychotic episode.

Research pertaining to the effectiveness of different types of relapse plans has not been undertaken. Such plans need to be individually tailored and regularly reviewed as an individual's relapse prevention needs will change over time. However, there are likely to be common elements that should be considered for all people at all points in time. Identifying these common elements would significantly progress our understanding of relapse prevention. Routinely implementing such planning within continuing care pathways for people seriously affected by mental illness would reduce relapses and increase the scope for recovery. Top of page

Table 2. Relapse prevention sheet in response to different types of early warning signs

The relapse prevention sheet is presented as a series of lists in this HTML version for accessibility reasons. It is presented as a table in the PDF version.

In response to the below relapse signatures:
  • increased feelings of inadequacy
  • preoccupied about self-improvement, including constantly monitoring yourself for faults
  • increased feelings of anxiety and restlessness
respond with relapse drill step 1 - stay calm - yoga or meditation:
  • contact keyworker/services to go out and discuss feelings
  • make time for yourself, use partner and mum for support
  • coping with thought/problems.
In response to the below relapse signatures:
  • racing thoughts/intrusive thoughts
  • feelings of elation/spirituality
  • do not need to sleep (one night or more)
  • suspicious of people close to you
  • not wanting to eat
respond with relapse drill step 2 - distraction techniques:
  • take [insert number] mg [insert medication] from emergency supply
  • daily contact with services, if necessary (discuss feelings, reality-testing)
  • contact doctor regarding recommencing or increasing medication
In response to the below relapse signatures:
  • horrific thoughts and paranoia
  • beliefs of being punished by God or possessed by the devil
  • severe paranoia
  • tactile hallucinations
respond with relapse drill step 3 - admission to hospital or respite care.

The relapse prevention sheet also provides spaces to fill in the following details:
  • Keyworker:
  • Co-worker:
  • Present medication:
  • Carer contacts:
  • Triggers:
  • Hours of contact Mon-Fri (9.00-5.00) Tel:
  • Hours of contact Sat-Sun (10.00-5.00) Tel:
  • Out-of-hours contact:

Source: Birchwood, Spencer & McGovern 2000 p96