The Course of Depression

The following information explains the Course of Depression.  It also includes a link to the Hamilton Rating Scale for Depression.

The Course of Depression

Episode

The initial episode often, but not always, follows a significant precipitating event, for example a job loss, relationship discourse or some type of trigger. The course of depression can vary based on individual factors and influencers. Episodes may occur in clusters or could be isolated and separated by many years. Episodes may become increasingly frequent and more severe with age.

Untreated, a major depressive episode may last, on average, about four months. Some people only experience a single depressive episode and thereafter are symptom free. However, many people who experience one major depressive episode will go on to experience multiple major depressive episodes. Consider the following:

  • 50% of patients who have a single episode and recover can be expected to have one or more episodes in their lifetime[i]
  • 80% of those with a history of two episodes will have another recurrence[ii]

Response

After the initial episode, an individual who seeks treatment may have a response or partial response with symptomatic relief. Symptoms begin to improve in response to medication. A response is defined as a greater than 50% reduction in the Hamilton Rating Scale for Depression (HAM-D). Some patients may still exhibit significant depressive symptoms.

Remission

The next step in the course of depression is remission. Remission is defined as an attainment of asymptomatic status (normal). Achieving remission would enable patients to return to their job, engage with their children, and resume normal activities.

Recovery

Recovery is defined as asymptomatic status for six consecutive months or longer. Mental health consumers are given hope of reaching some level of normal life with the possibility of recovering.

In the past, clinicians settled for patients feeling better or having a partial response to medication. Now, remission is the standard of care in depression.[iii] Similar to other diseases, failure to achieve full remission may result in risks for future episodes, and increased severity including morbidity and mortality.[iv]

Relapse

Relapse occurs when patients have a return of the same episode and symptoms reappear prior to a complete recovery.   Often patients discontinue their medication when they start feeling better. It is important for health care professionals to counsel patients on the necessity of adhering to the prescribed regimen.

A person may relapse prior to reaching the recovery phase, requiring a new medication or combination therapy. Keep in mind two out of three patients will not adequately respond to antidepressant monotherapy.[v] Additionally, depression is a chronic and recurring disorder often requiring medication throughout patients’ lives.

Recurrence

If a person fully recovers from a major depressive episode, and subsequently has a new episode this is called a recurrence.  Clinicians struggle to assist patients in maintaining normalcy, since the course of depression often includes recurrence.  Studies have shown in patients who have had two episodes of depression, the risk of another recurrence is 80%.

[i] See episode…

[i]Kupfer, DJ.; Frank, E.; Wamhoff, J. Mood disorders: Update on prevention of recurrence. In: Mundt, C.;Goldstein, MJ., editors. Interpersonal factors in the origin and course of affective disorders. London,England: Gaskell/Royal College of Psychiatrists; 1996. p. 289-302.

[ii]IBID

[iii]Depression Guideline Panel No. 5. AHCPR.

iv] American Psychiatric Association; 2000.

[v] Gaynes BN, Rush AJ, Trivedi M, Wisniewski SR, Balasubramani GK, Spencer DC, Petersen T, Klinkman M, Warden D, Schneider RK, Castro DB, Golden RN. A direct comparison of presenting characteristics of depressed outpatients from primary vs. specialty care settings: preliminary findings from the STAR*D clinical trial. Gen Hosp Psychiatry. 2005 Mar-Apr;27(2):87-96.