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.
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).“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.
Resources and additional reading.
MentalHealth@Home; Mental health treatment versus wellness promotion.
 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.