Are you depressed again? How to spot a relapse.

How can we spot a recurrent depressive episode in Major Depressive Disorder?

In this series about recovery we’ve covered the 5 domains of recovery last week. They are managing your symptoms and increasing an active position in the existential, social, functional and physical areas of your life. We can think about recovery in terms of decreasing the burden of the illness and give meaning to what we’ve encountered in life and on the other hand we try to increase our wellness. Ashley from MentalHealth@Home wrote a terrific post about this distinction and why it is very important to always keep it in the back of your head. I’ve noticed that the two go well together but I need to keep a balance, one day I need to focus on managing the symptoms while another day I’m able to expand my overall well-being. These are communicating vessels and you need to keep the balance as the waves come.

 

Canva - Man Riding White Surfboard
How to keep your balance when the sea gets rough?

 

Today I’ll focus on prodromal symptoms, which are warning signs.

Why would we think about bad things in the future? Isn’t it easier to go on our marry way and try to forget or maybe just overcome a more difficult time? Maybe it will pass on its own when no attention is given. What we often see is that people with mental illnesses have a difficult time (when they are not that experienced yet) identifying if a possible relapse shows itself on the horizon. Like with all illnesses it is not a bad strategy to be aware of the onset, in order to be able to manage it in a better way. I’m not saying we are able to avoid all difficulties by looking at the horizon but at least we’ll have a hinge at what may come. And that, my friend, gives you some power to be in control of your own life. You move your position from a passive to a more active one. Doesn’t that feel better already?

What are the numbers of the recurrence in depression? Episodes are recurrent for most individuals with bipolar disorder and for 50% to 85% of those with major depressive disorder (MDD). More people are being treated for a recurrent episode than for first-time episodes and recurrence is associated with increased severity of episodes, increased duration of episodes, and shorter periods of wellness between episodes.

Not very much is known about the period before the onset of an acute depression, the prodromal phase. How can we look back and identify the onset of a new phase of depression and when is it needed to increase self-care and/or to reach out to your support team?

 

The prodromal stage.

The prodromal stage of an illness is usually considered a time period during which signs and symptoms of a particular disorder begin to be manifested. These early indications may be quantitatively or qualitatively different than symptoms evident during the acute stage of the illness. They may be fewer, less intense, or different than the symptoms that define the full-blown clinical manifestation of the illness. Prodromal phases of illness vary in duration and may last for only several minutes or hours to many weeks or months.

In the psychiatric field much effort is being placed on identifying the early warning signs of schizophrenia. It helps the person and their surroundings to seek help when help is needed and it can prevent a full blown psychotic outbreak. Each mental health crisis affects your overall health, your social contacts, your brain, it takes away the stability reached and can leave you with financial trouble, less self-esteem and even bigger problems than before the crisis. It takes things away. Although we can’t prevent all, we can learn to contain.

 

The four stages of relapse. [1].

 

1).“something’s not right”

What makes it may be difficult to intercept the early warning signs of depression is that sadness or a depressed mood is usually not the first sign. “Participants described initial negative, uncomfortable feelings that were vague and nondescript, such as fatigue and feeling overwhelmed. These early symptoms tended to be different, both quantitatively and qualitatively, than those used as standard criteria for diagnosing depression”. These symptoms can be attributed to external factors, rightfully so or not. In my experience we need to weigh the symptoms carefully: maybe you feel overwhelmed because a lot is happening right now. Maybe you’re tired because you’re undertaking a lot of things. The cause of worry can be the Corona virus, you’re not immune to life stressors. You’ll (I mean me) need to learn to feel what is normal for you and what is not in the stage of recovery that you are in.

Things can be looked at the other way too. Participants also described expending energy to put up a front. They stated that they behaved normally, although they were feeling stressed, exhausted, and unwell. One subject said “Well, there’s a certain amount of guilt associated when you feel a little bit phony because you are acting [like] the normal person, your normal state, but you’re not feeling the same”.

So things come down to be the Sherlock in your own life and to be honest with yourself without losing reality. Does my thinking affect my mood? Do I tend to worry more? Is there a valid reason for worry? What can I do in the moment to make it better? What areas are slipping away? Can you contain this area by self-care or by asking for help, by sharing your worries? Are these ‘new’ symptoms or are they still present? It is important to note that after this stage a depression didn’t need to occur.

 

2) “something’s really wrong”

After the initial period of not feeling well, participants described more standard, focused symptoms including alterations in sleep and appetite, lack of energy, changes in cognition, withdrawal and isolation, general anxiety, and suicidal ideation. These symptoms were all linked to one general outcome, the inability to experience congruence, harmony, or synchrony with the environment. This experience, which we labeled as “desynchrony,” was disturbing to all participants. They described being on different schedules than those around them, experiencing differences in sleepwake cycles, having reduced cognitive clarity to match their everyday tasks, and functioning and feeling out of tune with others. These symptoms often led to avoidance of interpersonal interactions.

One participant described it as follows: The first symptom I experienced was I just started waking up early. You know, wake up at two in the morning, wide awake-not to where you’re going to go back to sleep again-and you start worrying about the next day, and then, if you’re not sleeping, you worry about not sleeping. It’s a vicious cycle.

Individuals who had supportive others (see also 4. Getting connected), including family, friends, or professionals, who were able to point out their symptoms at this stage and encourage helping behavior, tended to report a greater degree of control over their emerging episodes.

 

3) “the crash”

Each of the focus-group members experienced “pivotal symptoms,” which generally encompassed difficulties with sleep, cognition, interpersonal relationships, and safety. These pivotal symptoms announced the onset of acute depression.

“And my mental acuity also went. I worked as a health care professional and it just scared the bee-gee-bees out of me, the lack of concentration I had at work. I knew I could make a mistake that could really hurt someone.”

 

4) “getting connected”

Or the need to seek help. All described a critical need at this stage to find a person who would listen to them, someone who could provide feedback about their status and assistance with active intervention. This was usually a family member, a friend, or a therapist who was able to validate the symptoms. This is not the final stage after depression has occurred in my mind, but this is woven into the whole prodromal phase maybe of every illness.

Getting connected, having someone listen, and having symptoms validated as depression appear to be important elements of symptom relief.

 

What are your thoughts on relapse?

Research sought to explore the issues involved in coming to grips with an illness identity over time. Understanding the need to reconstruct and reinterpret one’s past in terms of the current situation– constructing a theory of the nature of depression as life-long and establishing modes of coping– can help to clarify the work involved in identifying and labeling symptoms of recurrent depression. To understand your warning signs is a very individual process as your journey on the recovery path is too.

 

What are your findings with recurrent depression? Do you recognize some symptoms that can function as a warning sign? Do you have a plan in action when you notice such symptoms? Do you try to differentiate between ‘normal’ or ‘residual’ signs or am I minimizing here? I find it difficult to keep the balance between ‘living with it’ and ‘the step to take action’. I find that this article shed some light on how symptoms can be viewed but I also feel that I need to have more experience in that field.

 

Canva - Surfer Surfing with his Surfer Dog
Learn to read the weather conditions and take help on board.

 

 

 

Resources and additional reading.

 

MentalHealth@Home; Mental health treatment versus wellness promotion. 

 

[1] https://deepblue.lib.umich.edu/bitstream/handle/2027.42/75396/h0080234.pdf?sequence=1&isAllowed=y

[1] This is a very small study, N= 16 (!) Still I like to think about the findings that are being presented. While subjects were asked to recall information retrospectively, the consistency of responses from all participants, including those with bipolar diagnoses, was striking.

 

24 thoughts on “Are you depressed again? How to spot a relapse.

  1. Sleep used to be a key early warning sign for me that things weren’t right. My current meds knock me out at night, though, so I tend to sleep pretty well regardless of how I’m doing.

    Liked by 1 person

      1. When my sleep does get affected now I wake up earlier. I almost never have problems falling asleep as long as I’ve had my meds, although that was an issue in the past.

        Liked by 1 person

    1. All my family members are estranged, one of my friends is, one friend is depressed and out of contact, the others are really difficult to get in contact with. Things just conspired to leave me alone with everything :\. Damn it’s hard. Now I’ll be even more alone with things shutting down, so I need to just put myself 100% first and focus on survival, doing things which keep me going.

      Liked by 1 person

      1. I’m just on a cycle where it gets so pitiful, that just finding a way to motivate myself to get up early again, and do basic tasks feels satisfying and is so much more preferable to being lethargic and in bed or wasting time. But it gets me no closer to having the real important things done, which just overwhelm me now, so I go fall backwards again.

        Liked by 1 person

      2. I think people with mental health struggles can have already some understanding what works for them in a difficult situation. We are possible in the advantage here that we don’t have to think about what anymore but we need to adjust the what is needed for us *now*?
        Survival will be the first step indeed.

        Liked by 1 person

  2. Now that I went through the ketamine for pain, I’m blown away by how much I’m feeling better mentally. I have struggled with depression at times in my life (thought about death 24/7 last winter) and didn’t realize I was depressed while battling all the pain and fatigue of the past 6 months. I knew I was bummed, who wouldn’t be, but I feel an immense change in my thinking. I still feel low grade pain, but my brain literally can’t ruminate on it after the ketamine and I’m motivated to do things, I feel so hopeful and excited about life……haha terrible timing with the virus…..but at least I feel like going outside again! I will be meeting the CBT therapist at the pain clinic this week and am super excited to talk about ways to keep this good thing going! Great post, my eyes have been opened to the many forms depression can take and I am on the outlook for symptoms.

    Liked by 1 person

    1. You’re such a sweetheart and I wish you all the best with the ketamine-therapy and the CBT. It is really a big difference when depression and its colleagues leaves the building. I’m on the look out to for symptoms but I’m also learning to accept what is normal without panicking.
      While I’m doing that …. in sweeps Corona!
      🙄🙄🙄
      Life, it never gets boring.

      Liked by 1 person

  3. So true! I’m relatively new to relapses well since I was diagnosed anyway up until then there was no name for my crappy feelings. I am learning to recognise relapse signs with my therapist. It can still catch me off guard time to time though! I also find it’s worse when it catches me off guard because I start to kick myself for being complacent! Xx

    Liked by 1 person

    1. I recognize your feelings. It is a balance between prevention, acceptation and healing.
      It catches me off guard too and I did blame myself. Now I try to stay calm and act when I can and do what I think is right for me. I hope I can still learn how to live with it better. Thank you for commenting and for sharing your story. It helps me tremendously to read that others are on ‘their recovery way’ too.

      Like

  4. It’s somewhat paradoxical that the relapse experience is so individual and yet there are recognizable stages. Still, I’m grateful that the stages exist, because it gives us more time to take action if we spot the warning signs. It’s also nice to see the stages explained in order so that if someone I know is starting down that path, I have more information to figure out what the appropriate support action is.

    Liked by 1 person

    1. Yes that was my thinking too. Mental health is so very unique to the person but still we have a need to some guidance. I think it can take a while to know yourself so well that you can recognize some signs at the spot as you are so close to them of course. Having some sort of idea or guidance can form some help to see the bigger picture.

      Liked by 1 person

  5. I know when I’m starting to get tetchy, irritated by small things and other people; I start feeling so angry and that maybe I’ll snap. But I’ve got a great family and 2 good friends I can connect with immediately so I can try to nip it in the bud — increase my meds slightly and try to get some sleep in now and again – cos lack of sleep doesn’t help my mood 😦

    Liked by 1 person

    1. I get irritated too but I don’t notice it, my surroundings do! I start to snap at people and everything bores and annoys me at the same time. Sleep is some holy medicine, works for everybody but definitely in the mood department. Good that you have people close to you to help you navigate, I believe that having some people that close can be of great value. I agree with your answer for 100%!

      Liked by 1 person

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