Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Combine clear risk communication and supported treatment choice with an individual relapse plan that specifies early signs, practical responses, medication arrangements and routes to timely care.
Shared decision making is a continuing process of choosing care together, using clinical evidence and the person's own priorities. The clinician should explain the decision to be made, what options exist and how their likely consequences relate to this person's life. Someone may place particular weight on avoiding sedation, maintaining sexual function, preserving sleep or reducing the chance of another admission. A meaningful discussion makes those priorities visible rather than treating acceptance of the clinician's first recommendation as proof that a shared decision occurred.
Risk communication should make comparisons understandable. NICE NG197 recommends absolute risk rather than relative risk, natural frequencies rather than percentages, the same denominator for comparisons and a stated time period when relevant. If suitable personalised estimates are unavailable, explain the uncertainty and continue the conversation. Decision aids can help organise options and values, but they do not replace clinical discussion. Use information in accessible formats, provide time where the clinical situation allows, and ask the person to explain their understanding in their own words so that misunderstandings can be corrected.
Several clinically reasonable options have different benefits, adverse effects or practical demands, making the person's priorities important to the choice.
The person nods but cannot explain the plan, suggesting that language, information load, distress or power imbalance may have prevented meaningful participation.
A repeatable change precedes previous episodes, such as shortening sleep before mania or increasing withdrawal before depressive relapse.
Ongoing low mood, avoidance, interpersonal strain, physical illness or housing problems may persist after substantial improvement and increase relapse risk.
The person and supporters know symptoms to watch for but do not know whom to contact, what action is permitted or who will respond outside routine hours.
Asking the person to describe the plan reveals whether it was explained clearly and should feel like a check on communication rather than an examination.
A warning sign becomes useful when linked to what the person will do, how soon, and which clinician or service will respond.
Improvised concealed medication can cause harm and violate autonomy; any exceptional covert-administration process requires its own lawful assessment, documented safeguards and review.
Symptoms after reducing an antidepressant need assessment of timing, nature and dose changes rather than automatic classification as recurrence of the original illness.
Presenting relative risk alone in a way that obscures the absolute chance and time frame of benefit or harm.
Equating a patient's treatment refusal with lack of capacity instead of exploring understanding, support needs and reasons.
Writing a relapse checklist without a contact route, response threshold or clear responsibility for acting on concerns.
Allowing an agreed crisis plan to be interpreted as permission for relatives to invent dose increases or conceal medicines.
Stopping effective preventive treatment abruptly without a discussion of withdrawal, relapse risk and follow-up.
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A clinician is comparing two relapse-prevention options whose outcomes were measured over one year. Which explanation most closely follows NICE advice on communicating numerical risk during shared decision making?
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 7 Sept 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes
Relapse prevention begins by reconstructing the person's previous pattern. What changed first, what did the person or supporters notice, which circumstances preceded deterioration and what response helped? Warning signs may include disrupted sleep, withdrawal, increased spending, irritability, suspiciousness or rumination, but their value depends on the individual's history. A written plan should connect each useful signal with an action, a time frame and a named contact. Include the person's coping methods, practical supports, preferred response in crisis and the responsibilities of primary and secondary care.
NICE CG185 recommends jointly developing a bipolar risk-management plan that covers personal triggers, early symptoms, coping strategies, contact arrangements and, where appropriate, a protocol for additional medicine or dose increases. Such a protocol must be explicit and authorised by the prescriber, with clear limits and review arrangements. It is not permission for a relative to improvise extra doses or hide medicine in food. Covert administration is a separate legally safeguarded process: for example, NICE SC1 requires capacity assessment, a best-interests meeting involving the prescriber, pharmacist, care staff and family or advocate, a recorded plan and regular review for adult care-home residents. It must not be used when the resident has capacity to decide about treatment.
For depression, relapse risk is higher with recurrent or severe episodes, residual symptoms, unhelpful coping patterns and continuing social or physical-health difficulties. NICE NG222 recommends a shared discussion of continuing antidepressants, psychological treatment or both according to the person's history and preference. For people at higher risk after remission with medication alone, options include continuing the effective antidepressant dose, group CBT or mindfulness-based cognitive therapy, or their combination. Group CBT or MBCT for relapse prevention usually comprises eight sessions over two to three months, with possible additional sessions during the following year. A plan should also address enduring problems such as loneliness, housing stress or disrupted routines.