C. Steven Richards1 and Lee M. Cohen2
1Department of Psychological Sciences, Texas Tech University, Lubbock, TX, USA
2Department of Psychology, College of Liberal Arts, The University of Mississippi, University, MS, USA
In 1978, Richards and Perri noted, in the context of a treatment maintenance study, that psychosocial treatment effects often do not last (Richards & Perri, 1978). Unfortunately, four decades later, this is still the case. Hence, depression is an excellent example of the complex challenges faced when working with individuals to prevent relapse and recurrence (Richards & Perri, 2010a). Further, it often presents along with many health conditions and diseases (Richards & O'Hara, 2014a). In fact, depressive comorbidity is so frequently observed in healthcare settings that healthcare providers from all backgrounds need to have some understanding of this disorder as well as the impact it has on the primary medical concern for which their patients are seeking treatment (Richards & O'Hara, 2014b). In this entry, examples of depressive relapse and recurrence, concurrent with serious health conditions, are presented. Implications of this research and scholarship, as well as recommendations for preventing and reducing depressive relapse, are also discussed.
Depression is a chronically relapsing and recurring condition (American Psychiatric Association [APA], 2013). It is also quite prevalent, with approximately 7–10% of the adult population in the United States and other industrialized countries experiencing depression or a closely related mood disorder at a given point in time (Gotlib & Hammen, 2015; Kessler & Ustun, 2008). For the purpose of this entry, the term “depression” will be used as the general equivalent for major depressive disorder, as defined in the DSM‐5 (APA, 2013). This said, it is important to note that this use of the term “depression” is not universal. In fact, some investigators use “depression” to indicate diagnostically subthreshold symptoms and signs, such as elevated symptom levels on a self‐report measure, rather than the interview‐based observational assessments that are the base of DSM‐5 diagnoses. In research settings, mingling the concepts of self‐reported “subthreshold depressive symptoms,” “depression,” and interview‐based “major depressive disorder” is somewhat controversial (e.g., see discussions in APA, DSM‐5, 2013; Gotlib & Hammen, 2015; Richards & Perri, 2002; Watson & O'Hara, 2017).
In summary, depression is a serious and debilitating disorder, with negative implications for day‐to‐day functioning, disruptions in close relationships at work and at home, deterioration in chronic health conditions and diseases, and an overall negative impact on morbidity and mortality (Kessler, Scott, Shahly, & Zaslavsky, 2014). Indeed, most large national and international surveys, such as those conducted by the US National Institute of Mental Health and the World Health Organization, have indicated that serious clinical depression, such as major depressive disorder, is always high on the list of causes for day‐to‐day disruptions in functioning and increased disability (Gotlib & Hammen, 2015; Kessler & Ustun, 2008). Moreover, there is a large literature associating depression, and depressive relapse, with a variety of chronic health conditions and diseases. Therefore, it is important that depressive relapse is assessed over time, and when necessary, treated in health contexts in accordance with approved clinical interventions.
Frank, Kupfer, Reynolds, and their colleagues have conducted a very ambitious series of randomized controlled trials examining relapse prevention for depression (e.g., Frank et al., 1990; Reynolds et al., 2006). These studies include long‐term follow‐ups and comparison of treatment maintenance interventions. Specifically, after successful completion of treatment (often 12–20 weeks), Frank and her colleagues compared various combinations of a psychosocial intervention and an antidepressant medication. The psychosocial intervention studied during both acute treatment and maintenance therapy was interpersonal psychotherapy (IPT) for depression, which is a brief form of psychotherapy that focuses on an array of interpersonal issues and skills (see Weissman, Markowitz, & Klerman, 2017 for a review of IPT). The antidepressant medications used across these studies were FDA‐approved antidepressant medications (e.g., imipramine [Tofranil], a tricyclic antidepressant medication, or a selective serotonin reuptake inhibitor [SSRI] such as paroxetine [Paxil]). A review of this group's extensive body of research along with other relevant studies on IPT is available in O'Hara, Schiller, and Stuart (2010).
Several conclusions can be drawn from this important work, which utilized various combinations of IPT and antidepressant medications as relapse‐prevention strategies for depressed adults. First, the continuation of maintenance treatment for depression following successful acute treatment, with IPT, antidepressant medications, or both, usually leads to reductions in the rate of depressive relapse and recurrence over multiyear follow‐ups (e.g., Frank et al., 1990, 2007; Reynolds et al., 1999, 2006). For example, the Reynolds et al. study (1999) with depressed older adults found that 90% of the participants relapsed across a 3‐year follow‐up in the maintenance group that received a placebo during follow‐up. However, only 20% of participants relapsed in the maintenance group that received IPT and antidepressant medication during follow‐up. Adding to this impressive finding is the fact that it was with older adults, a population that often has chronic health conditions. This is an extremely important finding (however, compare with Reynolds et al., 2006, with even older‐old adults, over 70 years of age, where the maintenance effect of long‐term IPT was not particularly powerful). Second, there is support for maintenance IPT as a stand‐alone relapse‐prevention strategy among adult women, which is important, as some women may be reluctant to take long‐term antidepressants due to pregnancy or postpartum breastfeeding (Frank et al., 2007). Since depression and depressive relapse are highly prevalent, and frequently comorbid with other health concerns, approaches to reducing depressive relapse are very important.
Third, given findings from several randomized controlled trials and/or more naturalistic, low‐cost intervention trials in point‐of‐healthcare clinics with depressed postpartum women, IPT interventions in the acute phase of depression treatment, and/or during maintenance treatment, appear to be helpful for depressive relapse prevention with women caring for young children (e.g., Nylen et al., 2010; O'Hara, Stuart, Gorman, & Wenzel, 2000; Serge, Brock, & O'Hara, 2015). Therefore, even in economically challenged and underserved populations, IPT apparently has potential as both an acute and maintenance treatment for depression (e.g., Serge et al., 2015).
In addition to the promising research examining the effectiveness of IPT, there is also an extensive research literature evaluating the benefits of cognitive behavior therapy (CBT), or more cognitively focused cognitive therapy (CT), as a relapse‐prevention strategy in depressed adults. As with the treatment maintenance and depressive relapse‐prevention research with IPT, the studies with CBT and CT have often been quite promising in support of this approach (e.g., for studies see Hollon, DeRubeis, et al., 2005; Jarrett et al., 2001; for a review see Hollon, Stewart, & Strunk, 2005). In summary, there are few, if any, evidence‐based psychotherapy for depression approaches with as much evaluation using large randomized controlled trials as CBT and CT. Overall, this well‐researched psychosocial intervention has also shown strong potential as a relapse‐prevention strategy for depressed adults.
Finally, there has also been encouraging research investigations of mindfulness‐based versions of CT (and CBT) in the area of depressive relapse prevention. Recent meta‐analytic reviews of this research indicate considerable potential for mindfulness‐based therapy for relapse prevention of depression. For example, a meta‐analysis of over 1,200 individuals with recurrent depression, collected across nine research trials, suggested that patients receiving mindfulness‐based interventions (sometimes combined with antidepressant medication) showed less depressive relapse by about 23% compared with patients who were continued on antidepressant medication but who did not receive the mindfulness therapy (Kuyken et al., 2016). Researchers, scholarly reviewers, and clinicians who work with individuals diagnosed with depression typically consider a 23% reduction in depressive relapse to be an important clinical finding (Gotlib & Hammen, 2015; Richards & Perri, 2010a).
These studies on mindfulness‐based interventions were also typically conducted considering the constraints of real‐world conditions, such as the use of time‐limited psychological treatment. Specifically, the study designs compared 8 weeks of a mindfulness version of CT with “usual care,” where “usual care” primarily consisted of antidepressant medication treatment and did not include an evidence‐based psychotherapy. Therefore, this research by Kuyken et al. (2016) offers hope that mindfulness‐based therapies, as with the more traditional CT and CBT therapies developed before them, may help depressed patients significantly decrease depressive relapse rates.
There are many potential examples of depression and depressive relapse in the health context. Moreover, this research and clinical literature is expanding rapidly, attracting increased attention from investigators, editors, and clinicians. For example, a recent “special section” of the Journal of Consulting and Clinical Psychology (Davila & Safren, 2017) focused on “sexual and gender minority health.” For instance, an ambitious study presented in this special section, by Choi, Batchelder, Ehlinger, Safren, and O'Cleirigh (2017), illustrates recent work on depression and depressive relapse in the context of important health behaviors. The investigators used network analysis to investigate the comorbidity of depression, PTSD, and sexual risk behaviors in the context of sexual minority men who had histories of trauma. Their sample included 296 sexual minority men who were HIV negative and living in urban environments. The findings suggested that comorbid depression and PTSD, and relapse for either disorder, were strongly related to increases in sexual risk behaviors, which in turn are often related to significant health problems and diseases (Choi et al., 2017).
Another example is a recent study by Desautels, avard, Ivers, Savard, and Caplette‐Gingras (2018), which evaluated treatment options in anticipation of enhancing relapse prevention, among depressed cancer patients. This study compared the efficacy of treating breast cancer patients that had considerable depressive symptoms with either CT or bright light therapy. The design was a randomized controlled trial, with 62 breast cancer patients, and it included pre‐, post‐, and 6‐month follow‐up assessments. Although caution is warranted because of the relatively small sample of 62 participants, CT appeared to be efficacious for this group of cancer patients, compared with a wait list control group. The bright light therapy showed some promise for briefly reducing depressive symptoms among these patients, but it was not as consistently efficacious as CT across all depression measures or at the follow‐up assessments. Moreover, bright light therapy appeared to be more vulnerable, than CT, to the enrolled patients having experiences with depressive relapse during follow‐up. Extensions of this treatment approach to larger and more diverse cancer patient samples, and with longer follow‐up assessments, could prove interesting. This bright light therapy approach may be particularly helpful in circumstances where the well‐tested approaches of CT or CBT are not available, or not acceptable, to cancer patients.
Finally, some of the recent research that is relevant to depressive relapse investigates depression and other important health‐related behaviors in the context of longitudinal research in the natural environment, rather than the randomized controlled trials that were highlighted earlier. An interesting example is the study by Trucco, Villafuerte, Hussong, Burmeister, and Zucker (2018). These investigators explored the longitudinal pathways to alcohol use and abuse among 426 adolescents who had genetic risk factors for addiction (e.g., their biological father had been charged with drunk driving and met diagnostic criteria for alcohol use disorder), which the researchers predicted would be moderated by depression and depressive relapse during the last wave of the study (adolescents aged 15–17 years). Thus, they predicted that depression would be related to more substance use and would essentially facilitate the expression of the genetic risk factors. Trucco et al. (2018) also predicted that ineffective coping methods for stress would be a moderator, related to greater substance use. It was found that ongoing depression (or depressive relapse), along with ineffective coping methods, appears to be a pathway that allows genetic risk factors to influence substance use and abuse. This study also represents some of the research trends toward excellence in clinical health psychology and behavioral medicine, noted in other entries in this volume. These trends include use of a large sample (N = 426, plus a comparison sample), which was followed longitudinally over many years (ages 3–17, in 5 waves), using multimodal and diverse measures (multi‐method and multi‐source) that included biological and psychological variables.
Treatment effects often do not last. Patients and their healthcare providers are frequently surprised, and disappointed, that the psychological improvements and associated health benefits that may occur during, and soon after, acute psychological treatment will disappear over longer periods of time. Depression and depressive relapse are clear examples of this problem. Without evidence‐based care, along with thorough attention to empirically supported relapse‐prevention strategies, most depressed patients will experience relapse or recurrence within a few years of treatment completion. Clinical depression, such as major depressive disorder, is a chronic and relapsing condition. Recent studies suggest that depressive relapse can be reduced, even in high‐risk populations such as older adults, through a combination of evidence‐based therapies such as IPT, CBT, and antidepressant medication, along with maintenance follow‐up care that can last several years.
In sum, four implications can be culled from this entry and the much broader research literature on depression and relapse in health contexts. Noted below are also a few of the specific relapse‐prevention strategies for depression that are supported by empirical research (see Gotlib & Hammen, 2015; Hollon, Stewart, et al., 2005; Richards & Perri, 2010a, for reviews of this literature):
C. Steven Richards, PhD, is a professor of psychological sciences at Texas Tech University. His research interests include depression, clinical health psychology and behavioral medicine, comorbidity of health problems and psychopathology, self‐control, and relapse prevention for depression. He has held 15 administrative positions during his faculty appointments at Texas Tech University, Syracuse University, and the University of Missouri–Columbia. Dr. Richards earned his PhD in clinical psychology at the State University of New York at Stony Brook (now Stony Brook University).
Lee M. Cohen, PhD, is dean of the College of Liberal Arts and professor in the Department of Psychology at the University of Mississippi. Dr. Cohen came to the University of Mississippi from Texas Tech University, where he served in a number of administrative roles including the director of the nationally accredited doctoral program in clinical psychology and the chair of the Department of Psychological Sciences. As a faculty member, he received several university‐wide awards for his teaching and academic achievement. As a researcher, he received more than $1.5 million from funding agencies, including the US Department of Health and Human Services, the National Science Foundation, and the National Institutes of Health/National Institute on Drug Abuse. His research program examines the behavioral and physiological mechanisms that contribute to nicotine use, and he worked to develop optimal smoking cessation treatments. Dr. Cohen is a fellow of the American Psychological Association and the Society of Behavioral Medicine. He received his PhD in clinical psychology from Oklahoma State University.