Predicting and preventing relapse of depression in primary care

INTRODUCTION

Depression is now the leading cause of disability worldwide.¹ The majority of people with depression are managed in primary care.² There has been a shift in the understanding of depression as a discrete or episodic illness to being considered a long-term relapsing-remitting condition with possibly incomplete recovery between episodes for some patients. The literature draws a distinction between relapse (the re-emergence of depressive symptoms following some level of remission, but preceding full recovery) and recurrence (the onset of a new episode of depression following recovery), recurrence rates being lower than relapse rates.³ This dichotomy may be more important to researchers and clinicians than it is to patients, who are likely to be less concerned with terminology and more concerned by the risk of ‘becoming unwell again’ and what can be done to reduce this risk.

After treatment of the first episode of depression, approximately half of all patients will relapse, and this risk increases for every subsequent episode (70% and 90% after a second and third episode respectively).⁴ A recent study of a cohort of patients who had received psychosocial treatment through the Improving Access to Psychological Therapies (IAPT) service in England showed that, of those who relapse, the majority (79%) do so within the first 6 months.⁵

There is also evidence to suggest that the severity of depression and resistance to treatment increases with each successive episode,⁶ so there are potential benefits of providing on-going care following remission, perhaps after the first episode, to prevent relapse and improve overall disease trajectory. This editorial examines the current evidence around relapse prevention in primary care before discussing the case for improved risk-stratification of patients and the …