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Wednesday, January 30, 2008

Risk Factors for Recurrence in Depression

On Vicarious Therapy there was an important question raised: Early Medical Intervention for Major Depression. I kept thinking about it, the answer is: I don't know.
Here is the problem:

Now, six plus years into this MDE I'm still searching for something that will help me, but I believe I at least FINALLY, in the psychiatrist I see, have the knowledgeable and completely supportive help I needed all along.

I often wonder, had I received help at 18 or 19, instead of 36, would I be better today? Would I be struggling so hard to find something to help me?

That is why I got interested in a long article in Clinical Psychology Research about Risk of Recurrence in Depression.

Some facts about Recurrent Depression:

  • 50% of patients who recover from their first episode will have one or more additional episodes in their lifetime.

  • 80% of patients with a history of two episodes will have another recurrence during their life

  • On average , patients with a history of depression will have five to nine separate depressive episodes in their lifetime

  • 90% of those with recurrent depression report "very much" impairment, limiting work productivity and social interactions.

This review article considered studies that were identified through literature searches. The focus is on psychological and clinical risk factors not on biological measures.
Depression in this review can be a diagnosis by DSM or ICD criteria but also a score above a cutt-off on the BDI or Hamilton. Especially this last method of defining depression is very controversial, a high score on one of these severity scales doesn't always imply the existence of a depression.
They studied risk factors for recurrence these are different from risk factors for first episode depression.

Causes of recurrence

  • Female gender is not a significant risk factor for recurrence

  • Age at first onset (younger age) and lifetime number of depressive episodes (more numbers of episodes) appear to be related to increased risk of recurrence , although further research disentangling these variables is necessary

  • A severe first episode as indicated by a severe symptom picture is also a risk factor

  • Longer duration of first depressive episode is not a risk factor

  • In adults co morbidity is also associated with higher risk of recurrence. Co morbidity such as dysthymia, alcohol or drug abuse, anxiety disorders

  • Transmission of genetic risk from parents to children is a risk factor of recurrence.

  • Negative cognitive styles is a risk factor for recurrence.

  • High levels of neuroticism are a risk for recurrence

  • Stressful life events are risk factors for recurrence

  • In women social support is a protective factor against recurrent episodes of depression

  • Studies on psychosocial scarring and personality scarring due to depressive episode have largely been negative

The Scar Hypothesis of Depression
People who have recovered from an episode of clinical depression have an elevated risk for developing a new episode of depression compared with those not previously depressed. One possible explanation for this finding is that depression may leave ‘scars’—enduring psychological changes resulting from depression.
This hypothesis has been refuted several times.The role of personality in depression [of moderate duration and severity] is more consistent with the vulnerability model than with the scar hypothesis. See also Depression fails to scar personality - introversion, neurotism and dependency tend to predispose individuals to depression rather than result from depression - Brief Article

This is the conclusion of the authors in their abstract:
Our review suggests that recurrent depression reflects an underlying vulnerability that is largely genetic in nature and that may predispose those high in the vulnerability not only to recurrent depressive episodes, but also to the significant psychosocial risk factors that often accompany recurrent depression.

The problem with risk factors is the casual relationship with the depression. Is the depression the cause for these risk factors having an effect or are these risk factors of significant influence on the course of the disease. The only solution to this question is a large prospective study with adolescents at risk followed over a long period of time compared to adolescents without risk (genetic risk).
Nevertheless the authors did a large and comprehensive review of the subject, their conclusions are well-founded by the data. This review doesn't answer the question posed by the author of Vicarious Therapy. To my knowledge there is no evidence of early intervention and course of recurrent of depression. Anyone else?

Related post on this blog:
Risk Factors for Psychiatric Disorders
BURCUSA, S., IACONO, W. (2007). Risk for recurrence in depression. Clinical Psychology Review, 27(8), 959-985. DOI: 10.1016/j.cpr.2007.02.005


The Shrink said...

I know of no robust evidence for early intervention impacting on relapse frequency/intensity of all F33.x Recurrent depressive disorder, over time.

We do know that animal models show high catecholamine levels are neurotoxic. Thus severe depression and the high adrenalin state that this generates will cause neuronal cell loss which may have clinical significance.

This would let us postulate that early intervention could be neuroprotective.

Although there're no studies I've read evidencing longditudinal outcome differences from early intervention I'd love to see that looked at.

Dr. Shock said...

Yes or some kind of kindle phenomenon comparable to bipolar disorder. More episodes increasing the probability of recurrence with hardly any trigger compared to the first episodes.

Daniel Carlat said...

Dr. Shock, I love your site. Discovered it recently, I like your hard-headed approach to evaluating the research and not taking things for granted. I just added you to my blogroll a The Carlat Psychiatry Blog.

Dr. Shock said...

Thanks, found your blog months ago, it is very good. I am a bit slow in keeping my blogroll in sync.
You're on it.