Relapse in Major Depressive Disorder

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What is Major Depressive Disorder?
Major Depressive Disorder (MDD) is a condition with variations in clinical symptoms that

leads to alterations in mood, thoughts and concentration, psychomotor symptoms, and disturbances in neurovegetative functions such as appetite and sleep. It is currently one of the most common mental disorders which affects around 4% of the world population. There has been research on several risk factors, but it is important to keep in mind the discrimination between correlation and causation. Some of these risk factors include adverse childhood experiences, stressful environmental events, and even gender, with women being currently described as more at risk for its onset, and personality traits such as Eysenck’s “neuroticism”, which means a predisposition to greater emotional difficulties during stressful situations. The DSM-5 describes the diagnostic criteria for MDD as having the following symptoms (with at least one of depressed mood or loss of interest) in a 2 week period, which can be accounted for subjectively or through observations by others:

1. Depressed mood for nearly all day and nearly each day
2. Markedly lower interest in activities nearly every day
3. Significant change in weight
4. Sleep disturbances such as insomnia or hypersomnia nearly everyday
5. Psychomotor agitation or retardation nearly everyday
6. Fatigue nearly every day
7. Feelings of worthlessness or guilt nearly everyday
8. Decreased ability to concentrate and tendency towards indecisiveness nearlyeveryday
9. Recurrent suicidal ideation

These symptoms must cause distress in different areas of functioning and they should not be attributable to another disorder or condition. It’s onset can be seen in adulthood, or as early-onset in childhood or adolescence. In these cases there is the danger of life-long multiple recurrences.

What is MDD Relapse
Research has shown that 60% of patients are vulnerable to a depression relapse. It involves

MDD symptoms coming back after remission, which is a period of at least 2 months where the patient no longer meets the criteria. The percentage increases the more episodes you suffer from during your life, reaching a 90% chance of relapse in patients who have had 3 episodes.

In addition, MDD is highly undertreated, with only 50% of patients that have gone through a time-limited treatment responding to it, while the other half remain affected by the symptoms. Therefore, there must be additional treatment measures and there must be a greater emphasis on predicting and preventing relapse. This is clearly an important issue that causes an undeniable burden on the patients, and which must therefore be studied intensively.

Predicting and Preventing MDD Relapse
There are 2 main relapse prevention strategies: antidepressant medication continuation

(ADMc) and psychological relapse prevention strategies. The pharmacological approach has been shown to reduce chances of relapse by around 50%-70%, but they often bring with them many undesirable side effects. For example, Selective Serotonin Reuptake Inhibitors (SSRI) have shown good results, but their long-term use includes disturbances in mood, such as apathy, sleep, and sexual behaviors. Other pharmacological approaches may even cause more alarming effects, such as

Tricyclic Antidepressants, which are no longer widely used because of its side effects affecting cardiac conduction and anticholinergic effects. Because of this, non-pharmacological strategies may be preferred by patients.

The psychological relapse prevention strategies include Mindfulness-based cognitive therapy (MBCT). This strategy differs from other psychological strategies such as cognitive behavioral therapy because, although they also have shown benefits for reducing relapse, they often aren’t specifically aimed at MDD and they were not designed with the specific purpose of preventing relapse, unlike MBCT. This strategy emphasizes the fact that even though negative patterns may reoccur the patient can learn to disengage from them and avoid the rumination that could often cause the relapse. It includes a group treatment, which means it can be applied to larger groups of patients, and at home practices of meditation, which has shown an association between mean duration of mediation and a reduced likelihood of relapse. A pragmatic long term study was done by Williem Kuyken in the UK, which showed that MBCT could lead to a protective effect against relapse similar to that of antidepressants. This therefore suggests that there could be an alternative for patients who do not seek to use antidepressants in the long term.

Other important factors include predicting MDD relapse, as well as early interventions. With early interventions patients have a greater chance of improving their symptoms, which allows them to become autonomous again and build relationships with others, which could protect against a relapse. Additionally, for the prediction of MDD there has been the development of computer-aided diagnostic systems, such as that developed by Alice Othmani and Assaad Oussama Zegnina. They created a system for relapse prediction based on audiovisual cues that discriminate between healthy patients from depressed patients, analyzing the correlation of a subject to their deep representation model of depression. With the analysis of many factors extracted from clinical interviews, if there is a high correlation there is the alert of a possible relapse. More information on their system can be found in the references of this article.

Conclusion
Major Depressive Disorder is a condition which can affect a subject’s entire life due to its

possibility of relapse. Even though there are existing strategies that help mitigate the likelihood of relapse, more attention and research should be dedicated to its prediction and prevention.

By Giulia Dacco Coppi

giulia.daccocoppi01@icatt.

References

Crane, C., Crane, R. S., Eames, C., Fennell, M. J. V., Silverton, S., Williams, J. M., &

Barnhofer, T. (2014). The effects of amount of home meditation practice in mindfulness based cognitive therapy on hazard of relapse to depression in the staying well after Depression trial. Behaviour Research and Therapy, 63, 17–24. https://doi.org/10.1016/j.brat.2014.08.015

DSM-5-TR diagnostic criteria for a major depressive episode. UpToDate. (n.d.). https://www.uptodate.com/contents/image?imageKey=PSYCH%2F89994

Fava, M., & Kendler, K. S. (n.d.). Major depressive disorder: Neuron – cell press. 50 Neuron. https://www.cell.com/fulltext/S0896-6273(00)00112-4

Mulder, R. (2015). Depression relapse: Importance of a long-term perspective. The Lancet, 386(9988), 10–12. https://doi.org/10.1016/s0140-6736(14)62448-x