Schizophrenia: relapse & crisis planning

The NHS suggests people ask someone they trust to tell them if they notice changes. Agree together on which signs to watch and how you’ll mention them.

A care plan usually lists the likely signs of relapse and the steps to take, with emergency contacts. Ask to see it, with the person’s permission.

Spotting early signs means the care team can adjust support before things get serious. Encourage the person to contact their care team, or offer to call with them.

Mention changes gently and specifically: “I’ve noticed you’ve been up most nights this week. How are you feeling?”

Alcohol and drugs, especially cannabis, can trigger psychosis and relapse. NAMI encourages families to help their loved one avoid them, and to get help if a substance problem develops.

The Substance Use guide has ideas for supporting someone who is struggling to cut down.

Research on families found that homes with a lot of criticism, hostility or over-involvement tend to see more relapses. Family programmes help everyone lower that tension.

Small things that help

• Keep voices low and conversations short when stress is high
• Notice and praise what is going well
• Protect regular sleep and meals for everyone
• Take breaks from each other when you need to

In the 1999 study of people after a first episode, stopping treatment was the strongest risk factor for relapse that could be changed. Any change to a treatment plan is best made together with the clinical provider, not alone.

NAMI’s crisis guide includes fillable forms for a portable treatment record, a crisis plan and a relapse plan. The NHS says a care plan may include an advance statement or crisis plan to follow in an emergency.

A good plan includes

• Addresses of walk-in crisis centres or emergency rooms
• Care team and crisis line numbers, including 988 and any local mobile crisis team
• Early warning signs and what helps
• Past crises, suicide attempts or substance use
• Preferred hospital or crisis centre
• What makes things worse, and what calms
• Who to call, and who looks after kids or pets
• Whether local police have CIT-trained officers

NAMI suggests going over the plan with your loved one, and with their doctor if they are comfortable. Keep copies in several places, such as a kitchen drawer, the glove compartment, your phone, your bedside table or your wallet.

NAMI also suggests keeping a copy in a room at home that has a lock and a phone.

If your loved one won’t work on a plan with you, NAMI says you can make one on your own. Write down the numbers, places and steps you would need.

Keep the invitation open. A calm moment later, perhaps after a hard week has passed, may be a better time to try again.

A psychiatric advance directive (PAD) is written by the person while they are well, setting out their preferences for care if they later become too unwell to decide. Planning ahead can make a big difference to their experience of care.

You can call or text 988, or chat at chat.988lifeline.org. Trained counsellors answer. It’s free and confidential.

Good to know

• You can reach out if you’re worried about someone else
• Spanish speakers can press 2, or text AYUDA to 988
• Veterans and service members can press 1 or text 838255

SAMHSA’s crisis framework says everyone in a mental health crisis should have someone to talk to, someone to respond, and somewhere to go. Mobile crisis teams are the “someone to respond”: behavioural health professionals who come to the person.

They can offer on-the-spot support and calming, and help get the person to care if needed. NAMI notes they aren’t yet available everywhere, so find out now whether your area has one.

Walk-in crisis clinics and psychiatric urgent care centres offer immediate attention in a less intensive setting than a hospital. They can recommend a hospital stay when it is needed.

Some areas also have crisis stabilisation units, short-stay observation beds and crisis respite homes, which can help someone settle and connect with ongoing support.

Find A Helpline lists free, confidential helplines around the world at findahelpline.com. In an emergency, call your local emergency number.

Tell the dispatcher your loved one is having a mental health crisis, and share their history or diagnosis. If responders don’t know it is a mental health crisis, they can’t handle it in the right way.

When you call

• Ask if a CIT-trained officer or mobile crisis team can come
• Say it’s a mental health crisis
• Share the diagnosis, any weapons in the home, and what calms them

NAMI suggests saying “This is a mental health crisis,” offering any helpful information, and then stepping out of the way. Staying calm is the best way to help everyone stay safe. Yelling or getting too close to an officer can make things more tense.

Try to

• Keep your hands visible
• Speak slowly and clearly
• Tell them what has calmed your loved one before

• Take someone who wants to go to hospital there
• In some situations, take a person for an involuntary mental health evaluation. The laws differ from state to state.
• Check on someone you can’t reach. Call the police non-emergency number and ask for a welfare check.

A well-trained CIT officer can often calm a person down and help them agree to go to hospital voluntarily.

When it may be needed

• A suicide attempt
• Assault or threats toward another person
• Hearing voices, paranoia or confusion that feels unsafe
• Drug or alcohol use during a crisis

People are usually registered first, with questions about insurance and medical history. Staff then check how urgently care is needed, and a mental health assessment helps decide on a plan and a referral for care afterwards.

If the person and their doctor agree a hospital stay would help, they are admitted voluntarily. If someone is very unwell, refuses care and is considered a danger to themselves or others, an involuntary stay may be possible.

An involuntary stay is usually short, often up to about three days. Keeping someone longer usually needs a court hearing. The rules are set by each state, so ask the care team or your local NAMI affiliate how it works where you live.

Before someone leaves hospital, a social worker or case manager should help make a discharge plan. Family members should be involved if the person is coming home or will need a lot of support.

Questions to ask

• When is the first follow-up appointment?
• Who do we call if things get worse?
• What warning signs should we watch for?
• Is a day programme or step-down service an option?

Partial or day hospital programmes offer care and monitoring during the day for someone who is unwell but not in danger, so they can sleep at home. They can also be a step between hospital and full return home.