Relapse and setbacks: why getting worse again isn't starting over
The most demoralising part of recovery is the second bad patch. It is also the most misread.
6 min readLiving with itAfter a crisis
The second bad patch is worse than the first.
Not usually in severity — often it is milder. Worse because of what it appears to mean. The first time, you did not know whether anything would help. The second time, you have already done the work, already had the months of feeling better, and it has come back anyway. That looks like proof the whole thing was a temporary reprieve.
It is the point at which a great many people stop taking the medication, stop going to the appointments, and stop telling anyone. Which is precisely backwards, and worth understanding properly.
What a setback actually indicates
Recovery from depression, anxiety and suicidal crisis is not a line going up. It is a sawtooth with an upward trend, and the teeth are not failures — they are the shape of the thing.
Two facts that get lost:
Getting worse again does not undo the gains. Whatever changed in your brain, your circumstances and your habits during the good stretch has not been deleted. The coping strategies still work. The relationships you repaired are still repaired. You are re-entering a bad patch with more equipment than you had last time, even when it does not feel that way.
The second episode is usually shorter. Because you recognise it earlier, because you already know what helps, and because the machinery for getting help is already in place — you have a GP who knows you, possibly a therapist, possibly a prescription. The first time, all of that had to be built from nothing while you were at your worst.
Why it feels like starting over
Because depression is, among other things, a memory problem.
When you are well you cannot properly recall what being unwell felt like, and when you are unwell you cannot recall being well. The good months do not feel like evidence — they feel like something that happened to a different person, or like a performance you were somehow getting away with.
This is a known feature of the illness, not an accurate assessment of your life. It is also the single strongest argument for having written something down while you were well.
Catching it earlier next time
The whole value of having been through it once is that you now know your own warning signs. Most people's are boringly consistent between episodes.
Common early ones — worth checking which are yours:
- Sleep going first, in either direction
- Cancelling things you were looking forward to
- Messages left unanswered for days
- Eating at strange hours, or not at all
- Drinking more
- The world getting quieter — less music, less conversation, less noise
- Rehearsing what people would say about you
Write yours down while you can still see them clearly. That is section one of a safety plan, and it is the section that buys you weeks.
What to do when you notice
Say it out loud to one person
The same day if possible. A setback that nobody else knows about grows quietly for months. "I think I'm slipping again" is the entire required sentence.
Go back early, not when it is undeniable
To the GP, the therapist, the crisis team. You do not need to be as bad as you were last time to be seen. "I've had this before and I can feel it starting" is one of the most useful things a clinician can hear, because it is the point at which intervention is cheapest.
Do not stop the medication because it stopped working
This is the most common and most damaging move. Stopping abruptly can produce withdrawal effects that look exactly like a rapid relapse, which then confirms the fear. If it is not working, that is a conversation with the prescriber about dose or a change — not a decision to make alone at 2am.
Reread your own plan
The version of you that wrote it knew things the current version cannot access. That is the whole point of having written it.
Cut the load, temporarily and deliberately
Fewer commitments, for a defined period, decided while you can still decide. Not as failure — as the same thing you would do with a physical injury.
The dangerous middle
One thing worth naming plainly, because it is counter-intuitive and it matters.
The riskiest period is often not the very bottom. It is the stretch on the way back up, when energy returns before hopelessness lifts — and the same is true after discharge from hospital, which is why the first days home are the highest-risk in the literature.
If you are starting to function again and still feel exactly as bleak, that is a point to tell someone, not a point to be reassured that you are improving because you managed to do the washing up.
What to say to yourself
Not affirmations. Two accurate statements:
"I have been here before and it ended." Not it got better forever. It ended. You have direct evidence for this, which is more than you had the first time.
"This is a bad patch, not the return of the permanent truth." Suicidal thinking arrives with tremendous certainty and presents itself as clarity — as finally seeing things as they are. That feeling is a symptom, and it lifts. It lifted before.
For the people around you
If someone you love is in a second or third episode, the useful thing is memory — theirs is not working.
"You were fine in the spring" is not a criticism when said gently; it is information they cannot currently reach. So is "last time this lasted about six weeks."
Do not treat a relapse as a personal failure on their part, and try not to sound disappointed. Both are extremely easy to convey without meaning to, and both make the next disclosure less likely.