The Doctor Is In: Disappointments along the course of depression

The Doctor Is In is an occasional series where JHU Press authors discuss the latest developments and news in health and medicine.

Guest post by Susan J. Noonan, M.D., M.P.H.

Many people find that the symptoms of major depression or bipolar depression come and go in a pattern that is unique to them and fairly unpredictable, even with treatment. You may have an episode now but then no symptoms for a few months or years.  When this happens it is called a relapsing and remitting condition. You can gain some control over this by paying attention, responding to your Triggers and Warning Signs, and following your Relapse Prevention Plan. Triggers are events that cause you distress and may lead to an increase in your symptoms; Warning Signs are distinct changes from your baseline that precede an episode of depression or mania; a Relapse Prevention Plan is a day-to-day approach to help you identify, monitor, and respond to changes in your symptoms. These are tools that I discuss in my new book, Managing Your Depression: What You Can Do to Feel Better, published by the Johns Hopkins University Press. But it can be frustrating to plan your life when you wonder what is coming next around the corner, if or when. Do not allow the possibility of symptoms returning control your life.

When you are doing well, the prior symptoms of depression are vague and distant and it seems as though they will never return. You feel strong. If the symptoms do come back, they hit you like a brick wall. Returning depression is a disappointment because your expectations for life were set by your recent experience of doing well. Your memory of the recent past is fresh, while your memory of the prior episode(s) has faded; you may have little recall of the symptoms as an illness. It then becomes easy to fall into a pattern of self-blame, failure, or shame, where you feel responsible for your current situation. What did I do/not do to bring this on? Do not allow this mindset to take over. You are experiencing the natural ebb and flow of the disease. Many factors account for the return of symptoms. When you are in the midst of depression, it is very hard to remember that things will eventually change for the better. Disappointments like this make you feel as if time stands still, and you have no patience for these symptoms that interfere with living your life – you want things to change NOW! Try to remember that it takes time.

So, how do you handle the disappointment that comes when you have been doing well and then have a return of symptoms? First, you have to remind yourself that depression is an illness, and that part of this illness includes a fluctuation in symptoms over time, just like now. Second, you have to remove any self-blame from your mind. Even if you have been vigilant about following the basics of mental health and your Relapse Prevention Plan, you often cannot control a flare up of this or any other illness. Remind yourself that it is not your fault.

Next, go back to the basics of mental health and self-care. Take all medications as prescribed, avoid alcohol and street drugs. Follow the basics of diet/nutrition, sleep, and exercise, maintain a daily routine and structure, and avoid isolation by keeping up with your social contacts. Get up and be active – don’t stay in bed all day. Follow your Relapse Prevention Plan so that you are doing what you need to do to identify and respond to changes in your symptoms. Use CBT (Cognitive Behavior Therapy) exercises to help reframe distortions in your thinking. Take time for some positive experiences in your life: do something that brings you pleasure or used to bring you pleasure. Also, it often helps to reach out to others by volunteering your time. This gives you a different perspective on your own situation and your current disappointment.

And remind yourself that this episode will pass.

noonanSusan J. Noonan, M.D., M.P.H., is a physician and certified Peer Specialist who works as a consultant at Massachusetts General Hospital. She is the author of Managing Your Depression: What You Can Do to Feel Better, published by JHU Press.