A Bumpy Road: Dealing with Relapse

There may not ever be a last episode, but there are ways to fend off and mitigate the next one.

By Jodi Helmer

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.

“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…

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