Why Depression Comes Back: Understanding the Remission-Relapse Cycle

Reclaiming your mental wellness back from depression is difficult and energy-consuming. While it may take some time to find the right combination of treatments, activities, and therapeutic techniques that work, most people will eventually find relief.

After reaching this stage, it may seem like depression is “cured.” For around 50 to 60% of people, it is. However, for many, depression is a recurrent disorder with periods of remission and relapse, similar to asthma, diabetes, or lupus [1].

This can be a difficult message to hear, but knowledge is power. By recognising and understanding the recurring nature of depression, you are in a much better position to manage your condition.

Looking after your mental health will never be a one-and-done deal. Instead, it is a responsibility that you will have throughout your lifetime. It’s a tough path, but you never have to go down it alone. Depression treatments, support from loved ones, and guidance from medical professionals are resources that can support you along the way.

What Is Depression Relapse?

After going through several cycles of recurring depression, I finally understood my pattern. If I wanted to feel better, I would have to keep managing my stressors. Knowing that I can be healthy again motivates me when a relapse eventually happens. - Anonymous

After treatment, depression symptoms can go away. Even going through a difficult period doesn’t bring them back. When this happens, depression is considered to be in remission. However, it is common for a depressive episode to reoccur, or relapse, after months or even years of being symptom free.

The mental health community defines depression relapse as the re-emergence of symptoms, such as irritability, a sense of worthlessness, or pervasive low mood, after a period of emotional health.

While people with recurrent depression can go through periods of emotional stability in between depressive episodes, this is not the same as the cycles associated with bipolar disorder. Although, in isolation, depressive episodes in the two conditions can look very similar.

What Is the Difference Between Recurrent Depression and Bipolar Disorder?

People with both recurrent depression and bipolar disorder can experience depressive episodes. The major difference is that people with bipolar disorder also experience at least one period of extreme emotional highs, known as mania or hypomania.

Bipolar depressive episodes require different treatments than the depressive episodes of recurrent depression, so accurate diagnosis is key. Just one episode of hypomania or mania is enough to eliminate recurrent depression as a diagnosis.

If you have ever experienced any combination of the following symptoms of bipolar disorder, consult your doctor:

• Sense of euphoria or invincibility
• An increase in risk-taking behaviours
• Incessant talking, pressured speech patterns
• Racing thoughts
• Insomnia and reduced need for sleep [2]

Does Everyone Relapse and Why Does It Happen?

While the causes of depression relapse aren’t clear, it is very common. Sometimes, relapse arises after facing a series of difficult situations. Other times, it occurs out of nowhere, right when everything seemed to be going so well.

Half of people with major depressive disorder will experience more than one episode in their lifetime. After experiencing two episodes, the majority of people will have at least one more relapse. Episodes tend to occur several years apart but may last for weeks or months.

Researchers are still uncovering the science behind depression relapses. There is some evidence that some personality traits, like neuroticism and dependency, can increase the likelihood of recurrence. Neuropsychologists are also investigating other possible factors, like hormonal fluctuations, genetics, and sleep quality.

Sometimes, the triggers for relapse are easier to identify. A stressful life event, like a job loss, the death of a loved one, or an illness can increase the risk of relapse. Managing stress with less helpful coping mechanisms, such as alcohol or drugs, can also cause a relapse.

Since the causes of relapse are both within and outside of our control, it is not easy to say what particular factor causes it. For many people with clinical depression, the chance of relapse is not a question of if, but when. It’s not because they have done anything wrong. It's just the nature of depression as a recurring disease.

Even so, relapse can unleash complicated feelings of guilt and hopelessness. If you’ve noticed your depression is coming back, take it easy on yourself. Tough times are inevitable and difficult to predict. For this reason, relapse management is just as important as prevention.

How Can We Manage and Prevent Relapse?

Since relapse is so common, most psychologists recommend creating and following a relapse prevention plan immediately after depression treatment. How this looks will depend on several factors, including:

• How many previous relapses you’ve had
• Your response to antidepressant treatment

Generally, people should continue any successful treatment approach for a minimum of 6 months after remission. In the case of selective serotonin reuptake inhibitors (SSRIs) and other prescription antidepressants, a psychiatrist may adapt the dose by tapering it over time [3].

Mental health self-care activities like a daily mindfulness meditation practice and a sleep hygiene routine can also reduce the risk of relapse.

The relapse prevention plan includes monitoring therapeutic activities to help identify depressive symptoms in the early stages. For example, writing down any worrisome behaviour changes, such as sudden changes to sleeping or eating patterns, and tracking their duration.

If symptoms like loss of interest, low mood, and intense feelings of worthlessness or guilt persist for more than 14 days, it could indicate a relapse.

Relapse prevention plans include steps to take should depressive symptoms return [4].

Here are a few common actions:

• Schedule a therapy/ psychiatry appointment
• Lower stressors by delegating tasks, scaling down projects, or delaying significant changes if possible
• Call/meet up with a friend or loved one
• Cut back on alcohol and overprocessed foods
• Try a few evidence-based journaling prompts[5]

• What emotion did I feel most today? Where in my body do I feel my emotions?

• What actions have I done in the past that improved my mood? Can I do any of these actions today?

• Re-introduce effective depression treatments into your daily routine. Keep evidence-based treatments on-hand, such as a therapy lamp in the case of seasonal depression.
• Start daily tDCS sessions with the Flow headset. Flow is a medically approved brain stimulation device that you can safely use at home under the supervision of a qualified Health Practitioner to reduce depressive symptoms. You can order the Flow headset and have it delivered directly to your door. If you always have a Flow headset on hand, you can start treatment sessions as soon as depressive symptoms re-emerge [6].

Relapse isn’t a personal failure, but rather an inevitable part of the recovery journey. Having a robust relapse prevention plan in place is the best way to keep depression in check.