May 19, 2021

By Mark D. Rego, MD

One of the most common experiences I’ve had as a psychiatrist is someone telling me how bad they have been feeling in a way that is identical to a conversation I’ve had with them before. For example, “Doctor, I am always tired but can’t sleep; I’ve stopped doing needle point, which I love; I cry for little things, even at Hallmark commercials. Only my grandchildren cheer me up, but then I can’t wait for them to go home.” I flip back in their chart and see that one year ago (give or take a couple of weeks) they told me the exact same thing.

What’s important here is how people’s symptoms tend to be the same in the early part of each episode of illness. Some will be textbook problems like trouble sleeping, but others are unique to the person, like the loss of interest in needle point. This brief list of symptoms are your early warning signs. You may have more or less of them as time goes on, but through the course of illness, your early warning signs will be the same types of symptoms, and you’ll likely even use the same words to describe them.

I go over the early warning sign list with all my patients so that, together, we can establish an early warning system. The purpose of the system is to contact me (or someone else who could do it for you, like a parent or friend) so we can begin work on preventing the relapse right away.


Why the Warning Sign System Works

The reasons for a relapse of your illness are many, but a few stand out. The most common are: changes in medication, stopping or decreasing therapy, and a life stressor or loss. But as illnesses progress, and after you’ve had a couple of episodes, there is less and less of a reason for a relapse. It may just happen by itself (although hopefully not if your medication regimen has been working).

A warning sign system is priceless because our job as a treatment team (sometimes including another person like a spouse, parent or friend) is to prevent episodes. It is like having a secret passcode to your illness that we can use whenever it is about to resurface.

The early warning sign system works because it will usually be weeks or months before these early symptoms turn into a full-blown episode. When early warning signs appear, we, the treatment team, know that a problem is coming. If you build your early warning signs list correctly, it will rarely be wrong. This gives you time to act in heading off a recurrence of illness. A medication adjustment, a change or initiation of therapy, or perhaps some change in the daily life of the patient. There are many options, but they work best — very well, in fact — when done early.


How to Build Your Own Warning Sign System

So, how do you assemble a truly useful early warning sign system? The best place to begin is your first episode or the first time you went for help. At that time, the memory of how things developed was fresh. So, answers to questions like, “What was the first thing you noticed that was different?” or “When do you think it all began?” may be in the chart. But if this is not available, no worries. You just have to have a conversation with your clinician about the first things you notice when an episode begins.

Sleep is typically on the list for all disorders. Usually less sleep, but sometimes more. Then your clinician should go through the symptoms for mood, anxiety, obsessions, psychosis or whatever your condition may be. Additionally, think about a typical day, and see what were the first things you noticed that were changing. Patients with depression commonly lose an interest; people with anxiety may feel the need to avoid some trigger; people with psychosis might notice a change in thinking about the world. In each case, it will be personal to you. This becomes a code language between you and your clinician.

I have had calls that say, “Doctor, I am crying at TV shows and did nothing all weekend,” or “I can’t go over that bridge on my way to work. I have to take the long way,” or “I am home and feel afraid to go out, but I don’t know what I am afraid of.” The first person had a history of depression, the second had panic disorder and the third had psychosis. In each case, we had discussed early warning signs and they were reporting to me as planned. For each of them, we had already discussed what to do, so we could start right away.

Lastly, designating a third member of your treatment team can ensure the success of a warning sign system. There are things that this third person (a partner, friend, family member; any person who knows you well) will see that neither you nor your clinician will know about and can be invaluable in heading off an episode.

An early warning sign system is free and effective and, if you have a working team, it can work to prevent relapses. In my opinion, no person living with mental illness should be without it.


Dr. Mark D. Rego is a psychiatrist with 30 years of experience in. He spent 25 years in practice. He is now doing his own research, teaching psychiatry at Yale and is writing a book about the effects of modern life on mental illness. His website is

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