How to Make a Staying-Well Plan: Catching Early Warning Signs Before a Relapse

Staying-well plan vs. safety plan

A safety plan is for the worst hour. A staying-well plan is for the other 8,000 hours a year.

One is a list of steps for when suicidal thoughts or a crisis build. The other is a description of what ordinary, stable life looks like for you, what tends to pull you away from it, and what you and the people around you will do when the first signs show up. Many people need both. In most weeks, only the staying-well plan gets used.

Does writing it down help?

The idea has been tested most in bipolar disorder. In a 1999 trial published in the BMJ, people with bipolar disorder who had 7 to 12 sessions with a psychologist to learn their own early warning signs of mania, and how to get treatment quickly, went longer before their next manic episode, had fewer manic episodes over 18 months, and functioned better at work and socially. It made no difference to depressive episodes. A 2007 Cochrane review of randomized trials, including this one, found that early warning sign interventions added to usual care lengthened the time before the next episode, reduced the share of people admitted to hospital, and improved functioning. The reviewers noted two limits: only six of the eleven trials reported the main outcome, and the early warning sign work was delivered alongside other psychological treatment, so it is not clear how much of the benefit came from it alone. A 2021 analysis of 39 trials reached a similar conclusion: structured therapies added to medication were associated with fewer recurrences in bipolar disorder. These were plans built with a clinician, not worksheets filled in alone, which is one more reason to bring yours to an appointment.

For recurrent depression, one of the best-studied psychological approaches to staying well is mindfulness-based cognitive therapy (MBCT). A 2016 analysis of individual data from nine trials, covering 1,258 people whose depression had lifted fully or partly, found that MBCT reduced the risk of relapse over 60 weeks compared with not receiving it, including compared with other active treatments such as antidepressants. MBCT is a structured course taught by trained MBCT teachers, not a worksheet, but part of what it teaches is the same skill: noticing the early shift and responding on purpose instead of drifting.

The reason to put it on paper is that the early signs of a relapse are easy to see in hindsight and hard to see while they are happening, because they look like ordinary life. Skipping one night of sleep or canceling one plan is nothing. The third night and the third canceled plan is a pattern, and a pattern you agreed in advance to act on is much harder to explain away.

What goes in it

1. Your baseline: what a steady day looks like

Write down the handful of things that are true when you are doing well. Keep it concrete: roughly when you sleep and wake, whether you eat regular meals, how much you move, who you talk to in a normal week, how you take your medication if you take any, and what you do that is just for you.

This list does two jobs. It is the routine to protect, and it is the ruler you measure the early signs against.

2. Triggers: what tends to knock you off

Triggers are events or situations that have come before a bad stretch in the past. Common ones include losing sleep, conflict with someone close, anniversaries of a loss, money or job stress, drinking or using more than usual, travel across time zones, stopping or changing a medication, and the weeks after a hospital stay.

You cannot avoid most of them. Knowing them means you can raise your guard when one arrives, instead of being surprised two weeks later.

3. Early warning signs: how slipping starts for you

These are yours, and they are usually small. Ask the people who have seen you get unwell what they noticed first. Common early signs people report include:

• Sleeping noticeably less, or much more, for several nights
• Pulling away from people, not answering messages
• Skipping meals, or eating in a way that is unusual for you
• Irritability out of proportion to what is happening
• Thoughts speeding up, talking faster, starting many things at once
• Losing interest in things that usually hold your attention
• Hopeless or self-critical thoughts creeping back in
• Missing medication doses, or deciding you no longer need them

Rank them if you can. The sign that always comes first is the one worth watching most closely.

4. The agreed actions: what happens when a sign shows up

For each early sign, decide in advance what you will do and what the people around you may do. Keep it to one or two actions per sign. Examples:

• Two nights of poor sleep: protect the next night, cut caffeine and alcohol, and message my prescriber if it reaches three.
• Three days of not answering messages: my sister can call, and I have agreed to pick up.
• Missed doses for more than a day or two: I call my prescriber before restarting, because some medications, such as lamotrigine, have to be restarted at a lower dose after a break of several days.
• Hopeless thoughts returning: I open my safety plan and book the next available appointment.

Then decide the line where this plan hands off to the safety plan. For many people it is any return of thoughts of suicide, or any day when the early signs stack up and the agreed actions did not help. If anyone is in immediate danger, do not work through either plan first: call 911. For thoughts of suicide or a crisis that is building, call or text 988, the Suicide & Crisis Lifeline.

Protecting the baseline

The baseline in part one is not a wish list. Most of it is ordinary advice that applies whatever the diagnosis. Enough sleep supports mood and attention, and going to bed and getting up at the same time every day helps you get it. Physical activity is associated with a lower risk of developing depression, and in trials exercise has reduced symptoms in people who already have it, although most of those trials had a high risk of bias. Staying in touch with friends or family who can offer emotional support and practical help is part of NIMH’s basic self-care advice. Alcohol interacts with many psychiatric medications, and with some it can increase feelings of depression or hopelessness. None of it replaces treatment.

If you take medication, the staying-well plan is the place to write down what it is, why you take it, and what you agreed with your prescriber about stopping or changing it. Feeling well is when stopping is most tempting. In a 2021 trial of adults in UK primary care who felt well enough to stop their antidepressant, 56% of those whose medication was tapered off had a relapse within a year, compared with 39% of those who kept taking it. NIMH advises people with bipolar disorder not to stop medication without talking to their health care provider first.

Sharing it

A staying-well plan you keep to yourself only works if you can see your own early signs, which is exactly what gets harder as an episode starts. Share the early signs and the agreed actions with one or two people who see you often, and agree on what you want from them. A partner who knows that “three days of no messages” is a sign, and has permission to act on it, is doing part of the plan’s job.

If you are working with a therapist or prescriber, bring the plan to an appointment. They can help you sharpen it, and they will have seen patterns in your history that you may not have.

If you want to go further and put your treatment wishes in writing for a future crisis, that is what a psychiatric advance directive is for.