Research report
Onset of remission and relapse in depression: Testing operational criteria through course description in a second Dublin cohort of first-admission participants

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Abstract

Background

This paper extends previous work describing course in depression using a recommended operational model that defines remission onset and relapse. We test whether a similar course pattern would emerge using this model in a new cohort of depressed participants.

Methods

We recruited a cohort of 86 participants, first-time inpatients, with DSM-IV major depression. Outcome was assessed prospectively over a 13-month minimum follow-up period. Remission onset was defined as a Ham-D score < 8 for two consecutive weeks; relapse as a Ham-D score > 16 for two consecutive weeks and meeting DSM-IV criteria for major depressive disorder.

Results

The cumulative probability of remission onset was 0.62 (SE = 0.05) and 0.80 (SE = 0.05) at 3 and 6 months following study entry. The relapse risk was 0.28 (SE = 0.05) at 6 months post remission onset; 53% of those relapsing did so in the first 2 months post remission onset. Predictors of longer times to remission onset included: longer illness length, higher anxiety scores and unemployment; higher anxiety scores predicted relapse. The course pattern is similar to that reported previously.

Limitations

These findings apply to inpatients only. Course was not rated blind to all of the participants' baseline data.

Conclusions

Defining remission onset and relapse using this model is associated with a replicable course pattern. A singular clinical advantage of the model is the identification of those participants at highest risk of relapse 2 months post remission onset.

Introduction

The criteria for defining an endpoint for treatment in major depression have yet to be established clearly (Keller, 2003). Unsurprisingly, a range of approaches have been adopted to report course in clinical trials of treatment in depression, resulting in confusion as to how course has been conceptualised and reported (Prien et al., 1991). A significant advance for researchers and clinicians alike has been the introduction of operational criteria for defining course in depression based on a conceptual framework of remission, relapse, recovery and recurrence (Frank et al., 1991). In clinical practice, on both sides of the Atlantic, remission is now recognised as a key objective of treatment in depressive illness (Anderson et al., 2000, American Psychiatric Association, 2000).

This focus has been on improvement in symptoms — which may risk overlooking other aspects of “wellness” including psychosocial function and patho-physiological changes (Keller, 2003). Nevertheless, in the absence of a universally accepted definition for remission (Keller, 2003), a focus on symptoms may be a useful place to start. Accordingly when we previously undertook to study the effect of personality on illness course (remission onset and relapse) of a cohort of depressed participants hospitalised for the first time, we adopted Frank et al. (1991) proposed operational model of course based on the Hamilton Rating Scale for Depression (Ham-D, Hamilton, 1960).

Relative to course description as defined using different models or criteria (Keller et al., 1984, Keller and Shapiro, 1984, Keitner et al., 1991, Shea et al., 1992, Ramana et al., 1995, Alexopoulos et al., 1996), we found two key differences using this model (O'Leary et al., 2000). Compared to these studies, the cumulative probability of remission onset was higher at 3 and 6 months following study entry and the cumulative probability of relapse was higher in the 6 months post remission onset. These differences, we hypothesised, were due to the relatively short time interval to define remission onset as stipulated in the Frank et al. (1991) Ham-D model (2 weeks) compared to the longer duration criteria specified in other studies (Prien and Kupfer, 1986, Shea et al., 1992).

We considered that this pattern of results might have, if replicated, two important clinical implications. As nearly two thirds of participants were in remission onset at 3 months, this course pattern could possibly identify the clinically important residual third of participants at increased risk of non-remission. This would be supported by replication of the factors predictive of longer times to remission onset and relapse identified in our previous cohort (O'Leary et al., 2000). Intriguingly the course pattern included the finding that more than half of those participants who experienced a relapse did so in the first 2 months after remission onset — identifying a subgroup of participants at high risk of early relapse.

Subsequently we have recruited a second cohort of participants admitted consecutively for the first time with a major depressive disorder, primarily with a view to assessing the effect of personality on course and describing course using the same Ham-D model as before (LagendijkM-C 2003.). Given the importance of this model's potential clinical implications as cited above and the infrequency of any recent published naturalistic studies describing remission onset and relapse specifically using this model, we test in this paper whether a pattern of course (and predictors thereof) similar to that of our previous Dublin cohort, emerged.

Section snippets

Entry criteria

The study entry criteria were: (i) age at entry from 18 to 65 years; (ii) DSM-IV criteria for major depressive disorder — single or recurrent (American Psychiatric Association, 1994); (iii) first lifetime admission for major depressive disorder; (iv) a rating of 17 or more on the Hamilton Depression Rating Scale, 17-item (Ham-D, Hamilton, 1960); and (v) informed consent from the participant and their treating consultant psychiatrist. Participants were excluded if they had a previous history of

Socio-demographic and clinical details

Eighty six of 100 consecutive participants referred for interview were recruited to the study. Of those excluded, 13 had been admitted previously for depression; one had a co-morbid alcohol dependency syndrome. Nearly all participants (93%) were admitted to St. Patrick's hospital. Just over half (53.5%) were referred by their General Practitioner; 30.3% and 8.1% were referred by their consultant psychiatrist or from an accident and emergency department.

Socio-demographically, just over half

Discussion

Previously we adopted Frank et al. (1991) Ham-D based model to describe course of a consecutive series of 100 first-admission depressed participants admitted to two adjacent Dublin hospitals and followed prospectively for 18 months (O'Leary et al., 2000). In this paper we aimed to test whether the course outcome findings were replicable particularly as there are few if any published naturalistic studies that adopt a definition of remission onset with a duration criterion of only 2 weeks.

Important

Role of funding source

St. Patrick's hospital, Dublin and Trinity College, Dublin, funded this study through research grants. The funding bodies had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Conflict of interest

All authors declare that there are no conflicts of interest.

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  • Cited by (0)

    1

    Present address: Department of Psychology, University of Birmingham, United Kingdom.

    2

    Present address: Sligo, Ireland.

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