Depression: protecting against the next episode
Depression has a habit of returning. Knowing what preceded this one, what your own early signs look like, and having a plan you would actually follow when unwell is part of the treatment.
People come to therapy for depression wanting the current episode to lift, which is entirely reasonable. What they are often not told is that depression has a habit of returning, and that a good course of treatment does two jobs: it lifts this one, and it makes the next one less likely, shorter, or easier to catch early. I want to describe the second job, because it is the part that lasts.
Why it returns
An episode of depression leaves a groove. The loop that maintained it, less activity, lower mood, less activity, is a path the mind has walked before and can find again quickly. The situations that preceded it, a loss, a period of overload, a particular kind of stress, tend to recur in a life. And the early signs of a low, which were missed the first time because nobody knew to look for them, are easy to miss again.
None of this means another episode is inevitable. It means that knowing your own pattern is protective, and that building the protection while you are well, or getting well, is far easier than trying to build it once the low has taken hold.
What preceded this one
Part of the later work in CBT for depression is going back over the run-up to this episode, to find the sequence rather than to assign blame. What was happening in the months before? What changed? Was there a loss, a birth, a job, an ending, a slow accumulation of demand? What got dropped first: the exercise, the friends, the sleep? Most episodes, examined this way, turn out to have a run-up that was visible in retrospect and invisible at the time.
Your own early signs
Everyone's low has a signature, and it is rarely the textbook one. For one person the first sign is stopping replying to messages. For another it is a particular kind of tiredness on waking, or cancelling plans, or the shower becoming a task, or a specific way of talking to themselves that only appears when it is coming. These signs appear days or weeks before the mood itself is obviously low, and they are the point at which acting is easiest.
We write them down. It sounds simple, and it is one of the most useful documents to come out of the work, because it turns a vague dread of relapse into a short, concrete list that you or someone close to you can check against.
A plan you would actually follow
Most relapse plans are written by a well person for a well person. Exercise more, see friends, eat properly, get outside. All sensible, and all impossible on the day the plan is needed, because the low has removed exactly the energy the plan assumes.
So we build the plan for the person you are when unwell. "Walk to the end of the road" rather than "go for a run". "Send one message to one person" rather than "see friends". The smallest steps, the ones that are possible on a bad week, because the feeling follows the doing and the doing has to be small enough to start. And a named person, told in advance, who can say "I think it might be coming" without it feeling like an accusation.
Medication and other care
If you take antidepressants, the question of how long to stay on them is between you and your GP, and therapy sits alongside whichever way that goes. If a previous episode involved a specialist service, we note who to contact and when. The plan joins up with the rest of your care rather than running separately.
What the plan does
Most people describe the plan as steadying rather than frightening. It converts "what if it comes back?" into "here is what I do if it starts", which is a question with an answer. And an early sign becomes a cue to act, with the action already decided, rather than the beginning of the end.
How the work runs
A typical course of CBT for depression runs 12 to 20 weekly sessions, and the protection work usually comes in the second half, once the current episode has begun to lift and there is energy to think about the future. We track mood with a short weekly measure throughout, because depression is unreliable at noticing its own improvement, and the numbers often see it first.
If this is not your first episode and you would like it to be your last, there is more on how I treat depression, and relapse prevention is built into the course.