Where someone is liable to a return of the Affective illnesses [ clinical depression, endogenous depression, puerperal depression, manic-depression, bipolar mood illness etc ] then they may have to face up to the fatc that in phases of these illness their insight into the illness will be lost, and they may go into a misbelieving , mistrusting attitude to help and treatment.

If they come to realise this then there are steps they should take to reduce the residual consequnces of being ill in this kind of way for their future relationships.

Employment will not always make allowance for the uncertainty about future recurrence.
Close companions, friends, and family also will need to be reassured that what they may have had to do - act in the seeming opposition to what the suffereer says they want during their worse times of illness, will be accepted as necessary when the sufferer is well again, and those people will not be subject to reproach and recrimination.

There are steps to be taken towards damage limitatation, against a future illness phase, that should be taken and made known to those needing to know, beforehand.

Firstly if the sufferer can develop some 'self employable skill in relatively short supply which is 'transportable' , if a job is lost than a return to the skill in other circumstances will be possible - the current employment scene may have been forfeited, but the type of skill developed will enable rejoining employment.

Work that can be dropped, and picked up again should be sought rather than looking for a career with momentum, in one particular situation.

Then there is help to be got from advanced statements - one of which published in the Royal College house journal is appended next.

Where another illness may wreck financial and work relationships and reputation, it is necessary for suffere to think about and to build up a plan B for after a future recovery, erecting a buffer reserve, of eventual forgiveness, and of salted away ungetattable [ ungetattable for sufferer, but available to companion or dependent and protected for their usage ] money, so that life can go on for personal and work companions and dependents, without the sufferer; and not be destroyed by the time in the illness.

It may be possible to have an agreement for a waking up power of attorney given as an advanced declaration.

Maybe to a trust control involving more than one controlling person.

The Mental incapavcity Act will be helpful.

The current Royal College of Psychiatry House journal Bulletin gives space to an appreciation of carers experience and also has this

from a self-declared user who has phases of sevee depression when insight might be lost.

I heard of advance directives being used in psychiatry at a MIND study day.

The example was very much a directive, prohibiting the use of antidepressant drugs and electroconvulsive therapy (ECT). I have sufficient trust in my psychiatrist to feel that he should make such decisions on my behalf if required. I therefore felt a directive unnecessary.

Recently, however, I was admitted, deeply depressed, to a different ward than usual. Alone in my room, I refused to come out. I was therefore not given my drugs. As a result, I became very agitated in the night. It could have been avoided had my drugs been given.
Transferred to my usual ward, my named nurse said 'We know you will stay in your room and need everything brought to you, but will start to come out as you feel better'. I made no request for relatives to be informed.

When my sister visited, she was shocked to discover that I had been in hospital for 5 days before anyone was aware of my admission.

Once well, I reflected on these events, then produced a paper in consultation with my professional carers, not entitled 'advance directive' but 'notes on care'. It contains basic information about me, and relevant telephone numbers. I give details of relatives who should be informed of my admission even if I am saying I do not want anyone to know.

I give instructions for my own safety, for instance my car keys must be taken from me, remembering I sometimes carry a spare set in my handbag. When this is done I get angry and frustrated, but when well I am convinced my instructions were correct. I also warn that if I have been feeling suicidal I might have an accumulation of drugs in my car. I describe my self-isolating behaviour. I make no prohibitions regarding treatment, though I do mention ECT. I have had ECT but find the treatment unpleasant, even frightening.
I state that if it is considered when I am not able to make my own decision, my psychiatrist and my sister should decide. I trust my consultant to take into account my antipathy.

My community psychiatric nurse, named nurse and consultant have copies of the directive.

I include the request that a copy be given to the staff on any other ward to which I am admitted.

I have had a very positive reaction from my professional carers.

My named nurse wishes that other patients would do likewise.

It leaves me confident that, in the event of my becoming ill again, matters will be dealt with in the manner I would have wished when well and able to make considered and reflective judgements about my care.