Elsevier

Clinical Psychology Review

Volume 31, Issue 8, December 2011, Pages 1349-1360
Clinical Psychology Review

Relapse and recurrence prevention in depression: Current research and future prospects

https://doi.org/10.1016/j.cpr.2011.09.003Get rights and content

Abstract

There is a growing body of literature which indicates that acute phases of psychotherapy are often ineffective in preventing relapse and recurrence in major depression. As a result, there is a need to develop and evaluate therapeutic approaches which aim to reduce the risk of relapse. This article provides a review of the empirical studies which have tested the prophylactic effects of therapy (cognitive-behavioral, mindfulness-based, and interpersonal psychotherapy) targeting relapse and recurrence in major depression. For definitional clarity, relapse is defined here as a return to full depressive symptomatology before an individual has reached a full recovery, whereas recurrence in defined as the onset of a new depressive episode after a full recovery has been achieved. Psychotherapeutic efforts to prevent relapse and recurrence in depression have been effective to varying degrees, and a number of variables appear to moderate the success of these approaches. A consistent finding has been that preventive cognitive-behavioral and mindfulness-based therapies are most effective for patients with three or more previous depressive episodes, and alternative explanations for this finding are discussed. It is noted, however, that a number of methodological limitations exist within this field of research, and so a set of hypotheses that may guide future studies in this area is provided.

Highlights

► We review relapse and recurrence prevention efforts in depression. ► Highlight the limitations of this research (e.g., lack of definitional consensus). ► Psychotherapy seems to work for those with a more extensive history of depression. ► We provide a set of guiding hypothesis for future research.

Introduction

Recent data have led to the suggestion that cognitive-behavioral therapy might reduce the risk of relapse or recurrence relative to pharmacotherapy (Dobson et al., 2008, Hollon et al., 2006). Several studies that employ naturalistic follow-up procedures after the cessation of acute phase cognitive therapy indicate that anywhere from 6.9% (Shapiro et al., 1995) to 83% (Jarrett et al., 2000) of individuals who have recovered from a depressive episode will go on to experience a subsequent new episode of depression. According to a recent meta-analysis (Vittengl, Clark, Dunn, & Jarrett, 2007), the mean proportion of patients who experience relapse or recurrence after receiving acute phase cognitive therapy was 29% in the first year and 54% in the second year. Although acute cognitive therapy did significantly better than its pharmacotherapeutic counterpart in reducing relapse and recurrence rates, these figures are still a concern when the burden of depression and the toll it takes on the lives of its sufferers are considered.

As Vittengl et al. (2007) point out, relapse/recurrence rates vary considerably across studies, and it is likely that a number of moderators of these rates are involved. Recently, Bockting, Spinhoven, Koeter, Wouters, and Schene (2006) reported that risk factors for relapse/recurrence included a high number of previous episodes, more residual depressive symptomatology and psychopathology, and finally, more daily hassles. In a 5.5 year follow up of this study, Bockting et al. (2009) also reported that in addition to a high number of previous episodes and residual depressive symptoms, two potentially modifiable predictors of recurrence in remitted recurrently depressed patients included a more avoidant way to deal with problems and a lower capacity to ‘refocus on positive matters’.

Burcusa and Iacono (2007) discuss a number of theories which have been offered as explanation for recurrence, which are reviewed below. One of the hypotheses the authors forward is that “individuals at high risk for multiple episodes possess the necessary characteristics to make them prone to recurrent depression, and such characteristics exist even before their first episode” (p. 974). As such, these authors suggest that vulnerability to depression in general is a non-specific premorbid marker of depression. If this argument is valid, recurrence can therefore be thought of as an almost inevitable sequel of the disorder. Alternatively, the increasing vulnerability for relapse with episodes might be caused by ‘scarring’ as a result of previous episodes. One aspect of the scar hypothesis is related to the idea of “kindling”, which is the proposition that less stress is required to provoke each subsequent episode (Monroe and Harkness, 2005, Post and Weiss, 1995). There is indeed some evidence for the kindling hypothesis (Bockting, Spinhoven, Koeter, Wouters, Visser, et al., 2006, Kendler et al., 2000, Lewinsohn et al., 2000, ten Doesschate et al., 2010). Another explanation for the increasing vulnerability with increasing episodes is the stress generation hypothesis (Hammen, 1991), which presumes that there is an increase in the generation of stressful events with more episodes, and that these events in turn increase the risk of recurrence. This hypothesis might hold especially for interpersonal stress (Hammen, 1991). However, instead of scarring as a result of previous episodes, premorbid characteristics might also be responsible for the generation of stress in recurrent depression. Indeed, Holahan, Moos, Holahan, Brennan, and Schutte (2005) found that avoidant coping might play a role in the generation of stress, and thus might be linked to future depressive symptoms. An avoidant problem-solving style resulted in a higher number of daily hassles and life events which are linked to depressive symptoms.

Another rendition of the scar hypothesis, namely the differential activation hypothesis, was forwarded by Teasdale in his revised cognitive model of depression (Teasdale, 1988). According to this hypothesis, depressive thinking results from repeated associations between the depressed state and negative thinking patterns. The strengthening of these associations with repeated episodes is assumed to contribute to an increased risk of recurrence following each subsequent episode. There is some empirical evidence for this presumed heightened cognitive reactivity as a potential causal risk factor for recurrence (Lau, Segal, & Williams, 2004).

The chronic nature of depression and the relative failure of acute psychotherapy to prevent its relapse dictate that efforts with the primary aim of relapse prevention should be liberally employed to stave off this disorder (Bieling & Antony, 2003). A number of published studies have focused exclusively on stand-alone treatments which have the goal of relapse prevention. Given the methodological and operational variability that exists in this literature, the meta-analytical approach (cf. Guidi et al., 2010, Vittengl et al., 2007) might paint a somewhat misleading picture of the data. Limitations of meta-analyses include, but are not limited to, publication bias (otherwise known as file drawer effect), magnification of study bias, and subjective selection (Eysenck, 1994, Moncrieff, 1998). Given such criticisms, this paper provides a qualitative review of relapse prevention programs in depression that takes this variability into account, and provides a set of possible mechanisms for their success or failure. It is also our aim to present a set of guiding hypotheses that may direct future research regarding relapse prevention. Before such a task can be appropriately accomplished, however, the definitions for commonly used terms throughout are provided.

Section snippets

Definitions of relapse and recurrence

While the goal of relapse prevention programs is to reduce the reoccurrence of depressive disorders, different conceptions of this idea exist. Indeed, different researchers use the term “relapse” as a general concept to capture all reoccurrences of depression, when more precise definitions may be required. The current review uses the Frank et al. (1991) definitions of remission, recovery, relapse and recurrence. These researchers define partial remission to mean a brief period in which the

Search strategy and study selection

A comprehensive literature review was conducted in order identify all studies that examine relapse prevention and recurrence in depression. The databases PsychINFO and PubMed were searched using keywords such as “relapse”, “recurrence”, “prevention”, “depression”, “cognition”, “mindfulness”, “interpersonal”, and “therapy”. Studies adhering to the following criteria were included in this review: a) the use of adult participants (i.e., 18 and over), b) studies employing a form of psychotherapy,

Psychosocial interventions for the prevention of depression relapse

What follows is a review of those studies which employed a form of psychotherapy as an explicit intervention to maintain the gains made during the acute phase of therapy, and to prevent or forestall a depression relapse. As mentioned above, these studies represent stand-alone procedures which directly target relapse and recurrence. The major intervention models used to date in this fashion include cognitive therapy, mindfulness-based cognitive therapy, and interpersonal therapy, each is

Prevention efforts in cognitive therapy

Cognitive therapy (CT) was first developed as a treatment for patients who currently met diagnostic criteria for Major Depression (Beck, Rush, Shaw, & Emery, 1979), and most of the trials of CT focus on outcomes during the acute phase of treatment. It has also been recognized, however, that acute phase CT has enduring effects (Vittengl et al., 2007), which in some instances have been shown to be as potent as even a continued course of antidepressant medication. In this section, however, the use

Prevention efforts with mindfulness-based cognitive therapy

Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2002) was developed as an explicit intervention to reduce relapse and recurrence in depression. The model which underpins MBCT posits that a key aspect of the vulnerability to relapse into depression is not the content of negative thinking, but rather the process. This approach builds on the pioneering work of Kabat-Zinn, 1990, Kabat-Zinn, 1994 which helped patients with chronic health problems to develop awareness skills

Prevention efforts in interpersonal therapy

A few studies have applied Interpersonal Therapy (IPT; Klerman, Weissman, Rounsaville, & Chevron, 1984) as a preventative measure in depression. In an early trial, Frank et al. (1990) examined the efficacy of various treatments in preventing recurrence in depression. The researchers randomly allocated 128 patients with recurrent unipolar depression to one of five groups: medication clinic and active ADM (imipramine), combined psychotherapy (a version of IPT) and ADM, medication clinic and pill

Possible mechanisms of change in relapse prevention

Given the relative scarcity of relapse prevention research in depression, attempts to understand the mechanisms of change must be considered tentative at best. In this section, we highlight some of the emergent patterns from the extant research, and hypothesize about potential mechanisms of change.

A consistent finding has been that the prevention effectiveness of CT and MBCT is moderated by the number of episodes experienced prior to therapy (Bockting, Spinhoven, Koeter, Wouters and Schene, 2006

Conclusions and future directions

Even when it is effective, acute phase therapy does not protect many individuals with depression from experiencing future episodes of the disorder. Although there is evidence that many forms of psychotherapy can reduce the chronicity of depression, most of the studies to date have examined the prophylactic benefits of preventative cognitive therapy. There are a number of more recent studies which indicate that mindfulness-based cognitive therapy (MBCT) and interpersonal therapy (IPT) offer some

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