There may not ever be a last episode, but there are ways to fend off and mitigate the next one.
Doctors never talked to Elly L. about relapse.
Although she was hospitalized during a manic episode and diagnosed with bipolar disorder, doctors never mentioned that it could happen again. Instead, Elly was stabilized, handed a prescription for mood stabilizers and discharged. She had no idea that she’d be battling mania and depression for the rest of her life.
“I was told that as long as I took my medications, I’d be okay,” recalls Elly, a mental health coach in Toronto, Ontario.
Elly experienced at least eight relapses between her diagnosis in 1978 and 1991. Each time, she was hospitalized, often placed in restraints and taken to the psychiatric ward in a police car or ambulance. Upon discharge, Elly always promised herself it would be her last hospital admission—but she had no idea how to stave off future relapses.
In bipolar disorder, relapse is defined as the return of depression or a manic or hypomanic episode after a period of wellness. According to a 1999 study published in the American Journal of Psychiatry, 73 percent of those diagnosed with bipolar disorder experienced at least one relapse over a five-year period; of those who relapsed, two-thirds had multiple relapses.
“You can never say that someone with bipolar disorder has had their last episode; relapse is part of the illness,” explains Alan C. Swann, MD, professor and vice chair for research in the Department of Psychiatry and Behavioral Sciences at The University of Texas Medical School at Houston and director of research for the University of Texas Harris County Psychiatric Center. “Relapse is self-perpetuating; once it happens, the more likely it is to happen again.”
Searching for answers
It’s possible to do all of the right things— follow a proper medication regimen, eat well, exercise, minimize stress and get enough sleep—and still experience relapse. Unfortunately, there is no clear understanding of why this happens.
“There may be changes in the cellular level that cause cycling but their cause is unknown,” says Joseph R. Calabrese, MD, director of the Mood Disorders Program at the Case Western Reserve University School of Medicine in Cleveland, Ohio.
While the neurological causes of relapse are unknown, a few things are certain: Those who are diagnosed with bipolar II are more likely to relapse than those with bipolar I. Their episodes of depression, mania or hypomania are often shorter than the episodes experienced by those with bipolar I but tend to return more often, according to Calabrese. It’s also far more common to relapse into depression than into mania or hypomania. Calabrese estimates that in bipolar II, there is a 40-to-1 ratio of depression to mania; the ratio of depression to mania drops to 3-to-1 in bipolar I.
I was told that as long as I took my medications, I’d be okay.- E.L.
“The key to recovery is a low tolerance for relapse,” says Calabrese.
In fact, Dr. Roger S. McIntyre, MD, associate professor of psychiatry and pharmacology at the University of Toronto and head of the Mood Disorders Psychopharmacology Unit at the University Health Network, believes that even the mildest symptoms of depression and mania should be treated as potentially hazardous.
“The takeaway message is that we need to seek complete elimination of symptoms as our treatment objective,” he says.
Aside from the obvious impacts of relapse, which can range from an increased need for sleep and low mood during depression to racing thoughts, sexual promiscuity and hospitalization during mania, there is another reason it’s important to protect against relapse.
It was like getting on a roller-coaster ride; I was excited about it.- M.A.
“People who have had multiple relapses—somewhere in the range of 20 to 30 relapses over a few decades—tend to have worse brain scans,” notes Allan Young, MD, PhD, chair of the Department of Psychiatry and the director of the Institute of Mental Health at the University of British Columbia in Vancouver, Canada.
As a result of relapse, brain scans show a loss of brain volume and structure, a decrease in grey matter and tiny lesions in white matter, which may lead to impaired cognition and emotional regulation and, in extreme cases, fine level paralysis.
Relapse also contributes to metabolic syndrome, which includes symptoms such as high blood pressure, high cholesterol as well as an increased risk of heart disease, according to Calabrese. The more times relapse occurs, the more likely health problems are to develop.
“If you don’t worry about relapse, you’re allowing your illness to morph into increasingly longer and more severe periods of depression and mania and that’s where the morbidity, mortality and suffering occur,” says Calabrese.
For years after his 1997 diagnosis, Michael A. craved the high he felt during mania and often stopped taking his medication to trigger a relapse into a manic state.
“It was like getting on a roller-coaster ride; I was excited about it,” recalls the 40-year-old from Bronx, New York.
In 2002, after Michael intentionally relapsed into full-blown mania, he went on a spending spree and charged 15 video game consoles on his credit card. Hours later, the mania spiraled into depression and Michael was admitted to the hospital and placed on suicide watch. Over the course of eight years, he was hospitalized five times because he relapsed after discontinuing his medications.
“People who stop taking their meds have an 80 percent chance of relapsing within three months,” Young says. “Medication holds the illness in check; when you stop taking your medications, things go awry.”
Though medication remains one of the primary treatments for bipolar disorder, research has shown that regardless of the drug regimen, medication alone is not enough to prevent relapse.
The best approach for preventing relapse is a combination of medication and the avoidance of activities that may trigger a new episode of illness.
It wasn’t until she started attending a support group through the National Alliance on Mental Illness (NAMI) that Adria A., 41, realized that she could have some control over bipolar disorder. Diagnosed in 2000, Adria relapsed twice before she was introduced to NAMI and encouraged to create a relapse prevention plan. Now, she keeps a poster-sized grid in her New York apartment to track her thoughts, feelings and actions in several areas of her life, including finances, family, employment and health, to identify possible triggers for relapse.
“Charting things helps me recognize patterns and keeps me from making poor choices,” says Adria. “When I feel like I’m experiencing a setback, I reach out to my support group or my therapist because I know I can’t let [my triggers] spiral into something I can’t handle.”
It’s been almost two years since Adria experienced her last relapse; she credits her relapse prevention plan with helping her take immediate action when faced with possible signs of relapse.
In 2007, a team of researchers at the Australia-based Mental Health Research Institute of Victoria found that participants with bipolar disorder who monitor their mood and recognize triggers and early warning signs of oncoming illness experienced half the number of relapses as the control group.
“If you can pick up on the early stages of relapse before it develops into a full-blown illness, you can decrease the length and severity of the episode,” says Swann. “Creating strategies aimed at heading episodes off early is so important.”
According to Swann, those with bipolar disorder often recognize a pattern of symptoms that precede relapse; the signs tend to be consistent for each person. For example, an increased need for sleep may signal a relapse into depression while irritability could be a sign of an oncoming manic or hypomanic episode.
Mindfulness-based cognitive therapy (MBCT) also appears to be an effective tool for combating relapse. A 2008 study published in the Journal of Affective Disorders found that MBCT, which uses cognitive therapy and meditation to help bipolar patients become more aware of their thoughts, helps reduce anxiety that may trigger relapse.
Elly started practicing yoga and meditation in the 1980s to help deal with racing thoughts. She still rolls out her yoga mat at least twice a day and believes it’s one of the reasons she hasn’t experienced a relapse since 1991.
I know I can’t let [my triggers] spiral into something I can’t handle. -A.A
“I started viewing bipolar disorder very holistically,” she says. “Yoga and meditation brought calmness and the deeper I got [into the practice], the more helpful it was at calming me down when I had racing thoughts or felt overwhelmed.”
A family affair
For Michael, who had eight relapses and several hospitalizations between 1997 and 2005, family was the key to managing his illness.
Michael acknowledges that his reckless behavior during mania had a profound impact on his life but it wasn’t until 2003, when he flew from New York to California without telling anyone of his plans, that he realized how his illness impacted his family and made the commitment to get well.
“My family was frantic and started thinking about calling the New York City morgue because they thought I might be dead,” Michael recalls. “I felt so bad when I heard that they lived in fear of my next relapse and I understood that being bipolar wasn’t just about me, it was about my family, too.”
As part of his commitment to preventing relapse, Michael attended therapy sessions with his parents. Over the course of five years, the therapist worked with the family to understand bipolar disorder and develop strategies to improve their communication skills and rebuild their relationship.
“I finally realized that what my family wants most is to prevent me from relapsing and going back into the hospital; they want me to be well,” says Michael. “It’s so nice to have people looking out for me because I don’t want to have another relapse and with their support, I know I have a better chance.”
According to a 2003 study in the Archives of General Psychiatry, 35 percent of those who participated in family therapy experienced relapse after two years, compared with relapse rates of 54 percent for those who received no family therapy. Moreover, a study in the British Journal of Psychiatry in 2010 found that family therapy reduced conflict, improved communication, increased empathy, leading to longer periods of wellness and less severe manic and depressive symptoms.
“Family members start recognizing that this is an illness, not something the patient is doing to make people angry or reflection of an ill temperament,” principal investigator David Miklowitz, PhD, wrote in the study. “When families start thinking of the behaviors associated with the disorder as biologically or genetically driven, they tend to be more tolerant.”
Attitude is everything
When 32-year-old Rachael B. was diagnosed with bipolar disorder in 2003, her doctor emphasized the risk of relapse. Determined to avoid additional episodes of depression and mania, Rachael began tracking her moods, identifying triggers and taking steps to stay well, including eating right, exercising and getting enough sleep. Over the next four years, she didn’t have a single relapse. She lapsed into countless periods of depression (and a few episodes of mania) again after her daughter was born in 2007.
“I knew when I decided to have a child that I was risking my mood stability,” says the Web consultant from Naples, Florida. “Sometimes, things are going really well one day and I wake up the next morning and I’m depressed. There are times that I’m nervous before bed because I never know what the next morning is going to bring.”
Though Rachael worries about the impact of her illness on her business and admits to feeling like a bad mother when she can’t get out of bed, she is convinced that she can regain control over her relapses. She tries to maintain a regular workout schedule, avoids processed foods and chemical additives, takes medication and sees a therapist on a regular basis. Over the past three years, she’s whittled the length of her depressive episodes from six weeks to two weeks and decreased their frequency, too.
“Being an active participant in my care makes me feel more hopeful about my path,” she says. “I was stable for years without any more ups or downs than someone who doesn’t have bipolar disorder. I know that it’s possible to get back there; it just might take some time. In the meantime, I have hope.”
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Coping with relapse
It’s possible to minimize the impact of relapse by implementing a few strategies.
Take your meds: Medication adherence can help prevent recurrent depressive and manic or hypomanic episodes. If relapse occurs, “your dose might need to be adjusted or a new medication might need to be added,” says Swann. Relapse isn’t an open invitation to stop taking meds.
Avoid triggers: Adequate sleep, physical activity and social contact are all important for preventing relapse, according to Young. “It’s important to develop strategies to protect these rhythms,” he says. “Maintaining them can help protect against relapse or minimize its severity.”
Know your risks: Just like bipolar disorder has a genetic component, the course of the illness runs in families, too. If others in the family have been diagnosed with bipolar disorder, take note of their relapse triggers and look for patterns with your own experiences, advises Swann.
Take immediate action: At the first signs of possible relapse, talk to a healthcare professional. “When symptoms of the illness start to come back and are very mild, it’s relatively easy to treat,” Calabrese says. “It’s harder when it drags on for weeks or months and takes on a life of its own.”