Recognizing Relapse

Recently, a long-standing patient of mine with a history of recurrent major depressive disorder developed symptoms of relapse of anxiety and depression. She’d been doing well at her last appointment and so her changes in well-being were unexpected. As we explored possible contributors to her troubling symptoms it became clear that the changes seemed temporally related to lowering one of the doses of her medication about two months earlier.  

Psychiatric disorders are common in the population and thus common among patients in general medical practices. Even for those individuals whose psychiatric condition has been well-managed, there exists the possibility of relapse or decline in well-being. There are a number of possible causes of relapse, including a recent decrease in medication that the patient had been taking for the psychiatric condition. Sometimes medications are intentionally lowered by physicians or psychiatrists, particularly if there’s concern about polypharmacy or adverse side effects, or if it was felt that the patient likely no longer needed the medication. Sometimes patients change the doses of their medication on their own initiative. This might happen inadvertently due to error, or it might happen deliberately if the patient felt he/she didn’t need or want the medication. Relapse or worsening of psychiatric symptoms can also develop in the setting of new or worsening medical or social stressors for the patient, or may be triggered by substance use. 

It’s important to recognize and respond to early signs of relapse in our patients. Usually, the sooner signs of early relapse are addressed, the faster the patient will improve and regain mental well-being.  

While signs of early relapse will vary among people, a few changes are especially common:

1. Change in sleep pattern, especially difficulty falling or staying asleep 

2. Change in appetite, especially lower appetite and unintended weight loss 

3. Having difficulty getting out of bed or motivating oneself 

4. Becoming quieter or more socially withdrawn; or conversely, becoming overly talkative 

5. Experiencing persistent anxious thoughts that dominate and distract thinking 

There are often additional signs of relapse that will be particular to that individual. It’s very helpful to review with patients what they recognize as early signs of illness, as similar symptoms will tend to return with recurrence of an episode of illness. For example, one patient with a depressive disorder may tend to ruminate about finances whenever depressed while another might tend to develop irritability and insomnia when depressed.  

It’s helpful to have a conversation ahead of time when the patient is doing well about what the markers of early changes in mental well-being are for that individual. Patients should be encouraged to contact their physician or psychiatrist if these changes occur and persist over several days to one week. Being proactive in this way solidifies the therapeutic relationship and underscores the message that we are partners with our patients in promoting and maintaining optimal medical and emotional well-being. 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.