ANN ARBOR—The initial stage of a major depression, which recurs in 50 percent to 85 percent of all patients who experience a first episode, is like a stealth bomber. It seems to fly under a patient’s radar in the guise of vaguely negative, uncomfortable emotions that patients don’t at first identify as warning signs of depression.

Instead—even though they have experienced major depression before—patients deny what they glimpse on their psychic screens, attribute their fatigue and stress to external demands, and put on a front to conceal their distress, according to a study from the University of Michigan School of Nursing.

“It is important for patients and their families to learn how to recognize the early warning signs of an oncoming depression because early intervention can prevent or minimize relapse or recurrence,” said Bonnie M. Hagerty, assistant professor of nursing. “There is some evidence that the ‘prodromes’ or early symptoms of depression, while they vary from patient to patient, are fairly consistent within each patient.

“Also, research suggests that patients generally experience at least one psychiatric symptom prior to the onset of depressed mood—generalized anxiety, perhaps, or sadness, irritability, impaired work, decreased initiative, loss of interest, fatigue or insomnia.”

Hagerty’s study of the early warning signs and subsequent course of major depression is reported in the April issue of the Journal of Orthopsychiatry. Hagerty and her colleagues conducted a series of focus group sessions over the course of a year with 16 people who had experienced more than one episode of depression.

The U-M researchers identified four consistent themes in the onset stages of depression:

• Something’s Not Right: The duration of this stage varied from days to months, both within and between study participants, but generally the participants said they denied the symptoms, blamed their negative feelings on stress, the weather or other external difficulties, and expended considerable energy putting up a front even though they felt unwell.

“The ‘something’s not right’ feelings the participants described tended to be different—much vaguer and more diffuse than those used as standard criteria for diagnosing depression,” Hagerty said. “Also the symptoms sometimes disappeared for a while, then recurred.

“Patients should try to monitor themselves when they feel that something is not right, and acknowledge the possibility that depression may be setting in so they can catch it in time before they spiral down.”

• Something’s Really Wrong: At this point, the participants’ symptoms became more standard and focused. Their sleeping and eating patterns changed and their energy and the ability to concentrate evaporated. Participants also said they withdrew from others, became anxious and had thoughts of suicide.

“The participants described feeling desynchronized, out of harmony or out of tune with their surroundings. They had different daily schedules, different sleep-wake cycles, reduced ability to think clearly and efficiently.

“Participants who took action at this point—who sought therapy or were able to provide some sort of self-help—felt more control over their emerging depressions and were often able to relieve and shorten the episodes.”

• The Crash: One to three specific or pivotal symptoms develop, signaling the beginning of an acute episode of depression to all participants. “Each participant experienced these pivotal symptoms, which usually encompassed difficulties with sleep, cognition, personal relationships and physical safety,” Hagerty said.
• Getting Connected: Getting connected meant seeking help from a family member, friend, or therapist. “This is a critical stage. All the participants felt an intense need to find a person who would listen to them and provide feedback and beneficial assistance. Uncertainty about forthcoming care or disappointment about the quality of care could contribute to the severity and duration of the depressive episode. We can’t emphasize enough how important it is for mental health professionals to listen to symptoms, show concern and provide encouragement.”

Hagerty’s colleagues on the study were Reg A. Williams, associate professor of nursing, and Michelle Liken, U-M doctoral candidate in nursing. 

More information:

• Bonnie M. Hagerty
• Reg A. Williams
• [email protected]