Relapse after recovery from unipolar depression: A critical review.

Abstract

Studies of relapse after recovery from unipolar depression are reviewed. Methodological deficiencies identified include (a) inadequate definitions of recovery and relapse; (b) incomplete descriptions of the samples; (c) inadequate inclusion and exclusion criteria; and (d) inadequate data analyses that do not take into account the changing composition of samples over follow-up. Despite the methodological problems, it is tentatively concluded that relapse after recovery from unipolar depression is frequent but less likely to occur the longer a person stays well and that relapse is more likely with a history of depressive episodes, recent stress, lack of social support, or persistent neuroendocrine dysregulation after recovery. Demographic variables that have consistently failed to demonstrate an association with relapse include gender, marital status, and socioeconomic status. Prevention of relapse with maintenance therapy is discussed, and recommendations for research on relapse are proposed.The widespread risk, high prevalence, and frequent recurrence of depression have resulted in a considerable amount of research on the sociological, environmental, personal, and neurochemical variables associated with the onset and maintenance of depression, recovery from depression, and relapse after recovery. The present article focuses on relapse. In general, relapse refers to a deterioration in health after a period of recovery from illness. In contrast, onset refers to illness that interrupts a period of health that was not preceded by an episode of the same illness. In practice, this distinction is not always easily made, a problem that we discuss later in the article.Previous reviewers have addressed specific aspects of research on relapse. Lavori, Keller, and Klerman (1984) discussed various statistical approaches used to report data on relapse in affective disorders, and Zis and Goodwin (1979) outlined some of the methodological problems that could account for the large differences in reported rates of relapse in depression. The present review is broader than either of these. First, we will comment on the importance of research on relapse. Second, we will discuss some conceptual and methodological issues. Third, we will critically review the research data. Last, we will present some recommendations for research. The Importance of Research on RelapseFrom a practical point of view, studies of relapse have an important advantage over studies of first onset in that the former can be conducted more readily within a prospective, longitudinal framework. Subjects at risk for relapse are identified and

Risk for recurrence in depression

“…Several researchers have found that an increased Hamilton score, reflecting the presence of a large number of symptoms and/or several severe symptoms, predicts recurrent episodes in adult inpatient samples (e.g., Belsher & Costello, 1988;O'Leary et al, 2000;Ramana et al, 1995). However, there have been a few exceptions, including two studies of children and adolescents which found that severity of depression, as indicated by an extracted Hamilton score, does not predict later recurrent episodes (Birmaher et al, 2004;Rao et al, 1995).…”

“…The importance of adult SLEs has been highlighted in many other studies (Belsher & Costello, 1988). For example, one study followed 67 individuals with recurrent depression following successful treatment for depression (i.e., psychotherapy and/or medication).…”

“…Kessler and Magee (1993) found that lack of a close relationship to an adult while still a child was predictive of depression recurrence; however, this does not mean that social support in adulthood is not protective, since this was not investigated. Meanwhile Paykel and colleagues (1996) also did not find that social support was protective against relapse, although their sample was restricted to those with severe episodes of depression; it may be the case that social support is less able to protect against more severe (Belsher & Costello, 1988;Birmaher et al, 2002); however, this is but one specific facet of social support (Spotts et al, 2004).Finally, twin studies of depression and social support have yielded conflicting results. Some studies have found that some forms of social support exert a direct influence on risk for recurrence, while other forms of social support are influenced themselves by recurrence (e.g., Wade & Kendler, 2000); other research has shown that there is common genetic vulnerability to both recurrence and social support, and that this is the factor driving their relationship (Bergeman, Plomin, Pederson, & McClearn, 1991;Wade & Kendler, 2000).…”

“…It is also usually highly recurrent, with at least 50% of those who recover from a first episode of depression having one or more additional episodes in their lifetime, and approximately 80% of those with a history of two episodes having another recurrence (American Psychiatric Association, 2000;Kupfer, Frank, & Wamhoff, 1996;Post, 1992). Once a first episode has occurred, recurrent episodes will usually begin within five years of the initial episode (Belsher & Costello, 1988;Lewinsohn, Clarke, Seeley, & Rohde, 1994), and, on average, individuals with a history of depression will have five (Kessler & Walters, 1998) to nine (Kessler, Zhao, Blazer, & Swartz, 1997) separate depressive episodes in their lifetime.Due to the fact that depression can be so recurrent, it can have significant personal and public health consequences. For example, one meta-analysis found that the suicide rate among those with depression is approximately twenty times higher than the rate for the general population (Harris & Barraclough, 1997).…”

“…Furthermore, they found that there was no association between childhood SLEs and recurrence of depression, if chronic interpersonal stress in adulthood was absent. They did not investigate, however, whether chronic interpersonal stress in adulthood was sufficient to increase liability to recurrence of depression, in the absence of childhood stressful life events.The importance of adult SLEs has been highlighted in many other studies (Belsher & Costello, 1988). For example, one study followed 67 individuals with recurrent depression following successful treatment for depression (i.e., psychotherapy and/or medication).…”