Propagation of major depressive disorder: Relationship between first episode symptoms and recurrence
Introduction
Major depressive disorder (MDD) is a prevalent and chronic disorder. The re-establishment of MDD following a diagnosis-free period, or recurrence, is one of several forms of chronicity. Estimates indicate that 60–80% of adults who experience one episode will undergo at least one recurrence, with the majority of recurrences occurring within the first 5 years (Frank et al., 1990). Women may be particularly vulnerable to recurrence (Mueller et al., 1999). Likewise, estimates among community and clinical samples of adolescents indicate that 33% to 70% experience recurrences within several years (Kovacs et al., 1984a, Lewinsohn et al., 1998).
Clearly, many depressed individuals can anticipate future episodes of the disorder. Nevertheless, a sizable group of individuals who experience one episode never suffer from a second. Are such individuals different from the remainder of depressed individuals who are plagued with recurrent episodes? Perhaps phenomenological differences exist between the depressive experiences of recurrent and nonrecurrent cases of MDD. If so, then it may be possible to identify them as risk factors for recurrence.
Certain characteristics related to depressive episodes have been identified as predictors of recurrence. The strongest predictor of future MDD is a prior history of the disorder, and previous episodes may relate to recurrence in several ways. For instance, previous findings suggest that the probability of recurrence increases with the severity of the initial episode, as well as with earlier onset age (Lewinsohn et al., 2000). Incomplete recovery from episodes has also been identified as a risk factor for recurrence (Judd et al., 2000).
The goal of the present study is to enhance understanding of risk factors for recurrence by examining whether MDD symptoms and related clinical characteristics predict recurrence. To this end, we examine first episode symptoms in a community sample of adolescents and young adults with recurrent and nonrecurrent MDD. To our knowledge, this is the first study to investigate the predictive ability of full syndrome symptoms for MDD recurrence among adolescents and young adults.
Other studies have investigated the predictive ability of subsyndromal depressive symptoms for MDD onset, reporting that up to seven of the nine DSM MDD criteria are subsyndromal risk factors for MDD onset (Dryman and Eaton, 1991, Eaton et al., 1995, Hadjiyannakis et al., 2005). When the presence of other symptoms, however, only depressed mood has uniquely contributed to the prediction of later MDD (Hadjiyannakis et al., 2005). Based on this finding, as well as the centrality of depressed mood to MDD, we predict that the presence of depressed mood during the first episode will increase risk for recurrence.
In addition to depressed mood, sleep disturbance may also have a special relation to MDD onset. Current and lifetime histories of insomnia have predicted new MDD onset even controlling for history of other depressive symptoms (Ford and Kamerow, 1989). In a separate investigation, insomnia preceded onset of recurrent MDD by several weeks, and also preceded onset of other MDD symptoms (Perlis et al., 1997). Thus, sleep disturbance appears to distinguish (a) first episode MDD onset from no onset and (b) recurrent MDD from nonrecurrence. Findings from a series of psychophysiological sleep studies provide data that may help interpret these findings. Consistent with the findings reported above, depressed persons differ from nondepressed controls on electroencephalographic sleep measures (Kupfer and Thase, 1983). Moreover, recurrent MDD is associated with greater disturbances of sleep continuity, rapid eye movement sleep, and diminished slow wave sleep than clinically comparable single episode MDD (Thase et al., 1995). This is the case both during depressive states and during periods of MDD remission (Jindal et al., 2002), which suggests that sleep disturbances may be a temporally stable characteristic that distinguishes among never depressed, single episode MDD, and recurrent MDD group. These findings support the hypothesis that recurrent MDD is associated with a more severe neurophysiological substrate (e.g., dysfunctional serotonergic system) than single episode MDD. Based on these findings, we predict that the presence of sleep disturbance (i.e., insomnia or hypersomnia) in the first depressive episode will increase risk for recurrence.
In sum, we hypothesize that individuals who display first episode depressed mood or sleep disturbance will be more likely to experience a recurrent episode. The present study differs from previous studies in that we focus on full syndrome, as opposed to subsyndromal, depressive symptoms in the prediction of MDD recurrence. Of note, full syndrome and subsyndrome condition reflect the same symptoms, just different numbers of or impairment associated with them. Distinction of the two is important, however, because identification of full syndrome depressive symptoms, which increase risk for recurrence, may alert clinicians to certain MDD presentations that may benefit from treatment approaches that focus heavily on prevention of future depression.
Section snippets
Subjects
Participants were randomly selected from nine senior high schools representative of urban and rural districts in western Oregon. A total of 1,709 adolescents completed the initial (T1) assessments, with an overall participation rate of 61%. Approximately half of the T1 panel sample was female (53.7%), with an average age of 16.6 (S.D. = 1.2). A total of 8.9% were nonwhite; 71.3% were living with two parents, and 53% were living with two biological parents; and 12.3% had repeated a grade in
Results
Of 487 participants who experienced at least one MDD episode, 263 (162 women) cases were nonrecurrent. The 224 participants (172 women) who experienced multiple episodes will be referred to as “recurrent cases.” The percentage subjects endorsing each symptom during the first MDD episode is displayed in the second column of Table 1. For the total sample, the mean number of symptoms at episode 1 was 17.2 (S.D. = 4.3, range = 6–32), out of a total of 35. Mean age of onset at episode 1 was 16.9 years
Discussion
MDD is a highly recurrent disorder. Previous findings suggested that depressed mood and sleep disturbances may predict MDD recurrence. The results of the present study indicate that certain symptoms of first episode MDD may indeed distinguish those who experience a single episode from those who recur, although predictions regarding depressed mood and sleep disturbance received only partial support. Among DSM-III-R symptoms, greater frequencies of two MDD criteria (depressed mood and increased
Acknowledgments
This research was supported in part by National Institute of Mental Health awards MH40501 and MH50522, and by the John Simon Guggenheim Foundation.
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