Elsevier

Clinical Psychology Review

Volume 27, Issue 8, December 2007, Pages 959-985
Clinical Psychology Review

Risk for recurrence in depression

https://doi.org/10.1016/j.cpr.2007.02.005Get rights and content

Abstract

Depression is a highly recurrent disorder with significant personal and public health consequences. Prevention of recurrence would be extremely desirable, and thus researchers have begun to identify risk factors that are specific to recurrence, which may be different from risk factors for first onset of depression. Methodological issues in this area of research are briefly reviewed (e.g., the various definitions of “recurrence” and “depression”), followed by a review of studies on specific risk factors, including demographic variables (gender, socio-economic status, and marital status), clinical variables (age at first onset, number of prior episodes, severity of first/index episode, and comorbid psychopathology), family history of psychopathology, and psychosocial and psychological variables (level of psychosocial functioning, cognitions, personality, social support, and stressful life events). In addition, scar theories are evaluated for their potential to explain how these variables and recurrent depression are linked. 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.

Section snippets

Definitions and methodological issues

Due to the fact that several different approaches have been taken to define both “depression” and “recurrence,” it is important to understand how these terms have been defined and what the methodological implications are of the different approaches adopted by investigators when studying recurrent depression.

Demographics

Considerable research on risk factors for recurrent depression has focused on demographic variables. These include gender, socio-economic status, and marital status. Generally, these variables have been considered risk factors for recurrence when they are more likely to be present in those with multiple episodes of depression, as opposed to those with only one episode or those with no history of depression.

Clinical picture and family history

Several clinical features of depression have been investigated to see if they explain risk for recurrence. These factors include age at onset of the first episode, lifetime number of depressive episodes, severity of first episode, presence of comorbid psychopathology, and family history of depression and other mental illness. Research in this area has not investigated the impact of DSM- or ICD-defined depressive subtypes, such as the melancholic subtype, on risk for recurrence, although this

Cognitions

Negative cognitive styles have long been implicated as a risk factor for the onset of depression. For example, it has been posited that individuals who attribute global, stable, and internal causes to stressful life events are more likely to become depressed than are those that attribute the causes to temporary, stable, and external influences (Abramson, Seligman, & Teasdale, 1978). Similarly, Beck hypothesized that those with dysfunctional beliefs and resulting negative cognitive biases would

Scar theories: an explanatory mechanism for elevated recurrence risk

Due to the greater rates of depression in those who have a history of depression compared to those who have no such history, it must be the case that either the depression itself somehow increases the vulnerability to become depressed again, or that individuals at high risk for multiple episodes already possessed the necessary characteristics to make them prone to depression even before their first episode. Scar theories focus on the former of these suppositions and are all similar in that they

Summary and conclusions

Depression is a very common mental illness that is highly recurrent in individuals. In addition, it is a disorder with substantial personal and public health consequences. Thus, there is great interest in the development of strategies that might reduce the recurrence of depression. Important to the development of preventive interventions is a basic understanding of the factors that predict and contribute to recurrence. However, research in this area is rife with methodological variability.

References (120)

  • D.N. Klein et al.

    Age of onset in chronic major depression: Relations to demographic and clinical variables, family history, and treatment response

    Journal of Affective Disorders

    (1999)
  • M. Kovacs

    Gender and the course of major depressive disorder through adolescence in clinically referred youngsters

    Journal of the American Academy of Child and Adolescent Psychiatry

    (2001)
  • M. Kovacs et al.

    Developmental changes in the phenomenology of depression in girls compared to boys from childhood onward

    Journal of Affective Disorders

    (2003)
  • D.J. Kupfer et al.

    The interaction of drug- and psycho-therapy in the long-term treatment of depression

    Journal of Affective Disorders

    (2001)
  • P.M. Lewinsohn et al.

    Major depression in community adolescents: Age at onset, episode duration, and time to recurrence

    Journal of the Academy of Child and Adolescent Psychiatry

    (1994)
  • P.B. Mitchell et al.

    Severity of stressful life events in first and subsequent episodes of depression: The relevance of depressive subtype

    Journal of Affective Disorders

    (2003)
  • D. O'Leary et al.

    Remission onset and relapse in depression: An 18-month prospective study of course for 100 first admission patients

    Journal of Affective Disorders

    (2000)
  • U. Rao et al.

    Continuity of depression during the transition to adulthood: A 5-year longitudinal study of young women

    Journal of the American Academy of Child and Adolescent Psychiatry

    (1999)
  • U. Rao et al.

    Unipolar depression in adolescents: Clinical outcome in adulthood

    Journal of the American Academy of Child and Adolescent Psychiatry

    (1995)
  • Z.V. Segal et al.

    Challenges in preventing relapse in major depression: Report of a National Institute of Mental Health Workshop on state of the science of relapse prevention in major depression

    Journal of Affective Disorders

    (2003)
  • L.Y. Abramson et al.

    Learned helplessness in humans: Critiques and reformulation

    Journal of Abnormal Psychology

    (1978)
  • L.B. Alloy et al.

    Prospective incidence of first onsets and recurrences of depression in individuals at high and low cognitive risk for depression

    Journal of Abnormal Psychology

    (2006)
  • J.E. Alpert

    Improving depression outcome: New concepts, strategies and technologies

    Journal of Psychopharmacology

    (2006)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (1980)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (1987)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (1994)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (2000)
  • A. Beck et al.

    Cognitive therapy of depression

    (1979)
  • A.T. Beck

    Beck depression inventory — II

    (1996)
  • G. Belsher et al.

    Relapse after recovery from unipolar depression: A critical review

    Psychological Bulletin

    (1988)
  • C.S. Bergeman et al.

    Genetic mediation of the relationship between social support and psychological well-being

    Psychology and Aging

    (1991)
  • C. Berlanga et al.

    Personality and clinical predictors of recurrence of depression

    Psychiatric Services

    (1999)
  • B. Birmaher et al.

    Course and outcome of child and adolescent major depressive disorder

    Child and Adolescent Psychiatric Clinics of North America

    (2002)
  • R.C. Bland et al.

    Recurrent and nonrecurrent depression

    Archives of General Psychiatry

    (1986)
  • C.L. Bockting et al.

    Preventing relapse/recurrence in recurrent depression with cognitive therapy: A randomized controlled trial

    Journal of Consulting and Clinical Psychology

    (2005)
  • T.S. Brugha et al.

    Predicting the short-term outcome of first episodes and recurrences of clinical depression: A prospective study of life events, difficulties, and social support networks

    Journal of Clinical Psychiatry

    (1997)
  • S.L. Burcusa et al.

    Adolescent twins discordant for major depressive disorder: Shared familial liability to externalizing and other internalizing disorders

    Journal of Child Psychology and Psychiatry

    (2003)
  • J.N. Butcher et al.

    Abnormal psychology

    (2004)
  • A. Caspi et al.

    Influence of life stress on depression: Moderation by a polymorphism in the 5-HTT gene

    Science

    (2003)
  • W. Coryell et al.

    Predictors of relapse into major depressive disorder in a nonclinical population

    American Journal of Psychiatry

    (1991)
  • A. Deister et al.

    Predicting the long-term outcome of affective disorders

    Acta Psychiatrica Scandinavica

    (1993)
  • R.A. Depue et al.

    Neurobehavioral aspects of affective disorders

    Annual Review of Psychology

    (1989)
  • D.J.A. Dozois

    The psychometric characteristics of the Hamilton Depression Inventory

    Journal of Personality Assessment

    (2003)
  • M.W. Enns et al.

    Personality dimensions and depression: Review and commentary

    Canadian Journal of Psychiatry

    (1997)
  • A. Fanous et al.

    Neuroticism, major depression and gender: A population-based twin study

    Psychological Medicine

    (2002)
  • J.P. Feighner et al.

    Diagnostic criteria for use in psychiatric research

    Archives of General Psychiatry

    (1972)
  • E. Fombonne et al.

    The Maudsley long-term follow-up of child and adolescent depression: I. Psychiatric outcomes in adulthood

    British Journal of Psychiatry

    (2001)
  • E. Fombonne et al.

    The Maudsley long-term follow-up of child and adolescent depression: II. Suicidality, criminality, and social dysfunction in adulthood

    British Journal of Psychiatry

    (2001)
  • E. Frank et al.

    Conceptualization and rationale for consensus definitions of terms in major depressive disorder

    Archives of General Psychiatry

    (1991)
  • D.E. Giles et al.

    Clinical predictors of recurrence in depression

    American Journal of Psychiatry

    (1989)
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