Episodic mood illness represents a spectrum of conditions that are highly treatable yet often go misdiagnosed—it can take patients up to 9 years to get properly diagnosed, in fact. Much of the diagnostic challenge is posed by the varying presentations on opposite poles of the “mood spectrum”.
Let’s take a depressive episode, for example, as an individual’s first mood episode. If careful precision is not exercised by the clinician, they may be assumed to exhibit characteristic “Major Depressive Disorder”, and be prescribed an anti-depressant medication as a result. Unbeknownst to the patient, or the clinician for that matter, this depressive episode is only half the picture, and a manic or hypomanic episode is waiting in the wings somewhere in the future. It may even be the mistakenly prescribed antidepressant that triggers this new episode.
The broader point is that the presentation and symptoms of a given mood episode (depressive, manic, mixed, etc.) are only a part of the picture. Actually, it’s likely not more than 25% of the picture. The clinician will ideally also consider various other factors such as family history, age of onset, temperaments, and triggers.
Once the episodic nature of the mood disorder is established, the question typically then becomes, “What causes my mood episodes?”
The answer, of course, is yes.
Anything!—well, anything that induces a chemical change in your body can trigger a mood episode. Jetlag, too much sugar, not enough sugar, migraines, trauma, recreational drug use, changing clocks in springtime, seasonal and hormonal changes, and working the night shift—these are only a handful. The key however lies in:
- Avoiding medications known to exasperate mood episodes
- Building a relationship with your clinician over time so your unique triggers can be uncovered
- Practicing patience, as that uncovering process can take months or even years
Once you and your clinician have established a working hypothesis for your individual mood triggers, then you can develop a treatment plan broken in two categories: acute and maintenance. Acute treatment gets you well, while maintenance treatment keeps you well. I often ask my patients to imagine a house on the beach, each wave that breaks onto shore represents a mood episode. Our goal is to keep the house dry. Sometimes the wave is too big and the house gets wet, and our job is to remove the water from the living room, and rebuild stronger so when the next wave hits less water gets in. There’s no telling when the next wave will arrive, and that’s where the patience piece comes in, as well as an open line of communication between you and your provider.
Does all maintenance treatment necessarily involve medication?
The answer is a resounding no! This is where the individuality comes in—I was drawn to specialize in this area because of the individuality of mood disorders. No two people are alike, and there is no one size fits all approach. Some maintenance treatment includes medications, typically lower doses than for acute treatment. Other regimens prioritize non-pharmacological strategies, many of which have robust evidence tilting in their favor, such as light therapy, exercise, optimizing sleep hygiene, Vitamin D and Omega 3 supplementation. It all depends on the kind of waves coming in, how your house is built, how much water you’re willing to allow in, and what in your life tends to speed up, intensify, slow down, or diminish the waves.
What’s needed above all else is a clinician that is able and willing to go the extra mile in this regard. The therapeutic relationship provides the fertile ground necessary for long-term healing and stability.
(Also foundation repair if the house gets really wet.)
Ari Daniels is a Psychiatric Nurse Practitioner licensed in NY and NJ
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