Recurrent Depressive Disorder

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Recurrent Depressive Disorder

THC Editorial Team December 29, 2020
Moonlight on Mount Lafayette, New Hampshire, 1873, William Trost Richards, The Metropolitan Museum of Art (article on recurrent depressive disorder)
Moonlight on Mount Lafayette, New Hampshire, 1873, William Trost Richards, The Metropolitan Museum of Art

Contents

What Is Recurrent Depressive Disorder?

Recurrent depressive disorder is a type of clinical depression. Rather than having one episode of depression, whether short or long, a person with recurrent depressive disorder will experience additional episodes of depression after periods of time without symptoms.1 These episodes can be considered as mild, moderate, or severe and with or without psychosis, depending on the number of symptoms and how much these symptoms impact an individual’s life.

Although not included in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (5th edition; DSM-5), recurrent depressive disorder is listed in the World Health Organization’s International Classification of Diseases (11th edition; ICD-11). This is not a type of bipolar depression. In fact, according to the ICD-11, to be diagnosed with recurrent depressive disorder, the affected individual cannot have a period of increased energy, hypomania, or mania during the time in between depressive episodes.2 The period in between episodes is simply without symptoms of depression.

Those who have had an episode of depression are 50% more likely to have a recurrence.3 Additionally, individuals with recurrent depressive disorder who have had two episodes are 80% more likely to have a third.

What Are the Symptoms of Recurrent Depressive Disorder?

Symptoms of recurrent depressive disorder are similar to those of any type of depression except that the individual will be free from symptoms for weeks or even years at a time before experiencing another episode.

Symptoms include the following:4

  • persistent feelings of sadness or emptiness
  • loss of interest in activities
  • difficulty concentrating or making decisions
  • irritability or anger
  • changes in appetite or weight
  • fatigue or lack of energy
  • feelings of worthlessness or excessive guilt
  • changes in sleep patterns
  • anxiety or restlessness
  • unexplained physical pains or gastrointestinal disturbances
  • suicidal thoughts or attempts

The degree to which these symptoms affect an individual’s ability to function determines if an episode is considered to be mild, moderate, or severe. For example, a mild episode may be irritating and annoying, whereas a severe episode may prevent a person from engaging in daily activities. In severe cases, psychosis may or may not be present.

It is important to note that with each subsequent depressive episode, an individual has an increased risk of developing suicidal thoughts or of attempting suicide.5

Types of Recurrent Depressive Disorder

There are two types of recurrent depressive disorder. The most common, recurrent major depression, involves episodes that meet the diagnostic criteria for major depressive disorder (listed above), followed by months or years of remission before the occurrence of the next episode.

The second type of recurrent depressive disorder—which is listed in DSM-5—is recurrent brief depression. Researchers have found that some individuals may experience short-term severe depressive episodes that last for 2 to 7 days.6 This type of recurrent depression frequently occurs together with major depressive disorder or persistent depressive disorder.

Causes and Risk Factors of Recurrent Depressive Disorder

Although no specific cause of recurrent depressive disorder has been established, researchers believe that it can be related to genetics, hormones, and brain chemistry.3 Additionally, those who have depression have been shown to have physiological differences in their brains compared to those without depression.

Because there is such a high recurrence rate for depressive disorders, extensive research has been done in this area. While many risk factors have been studied to determine if an individual will experience a recurrence of depressive episodes, studies have identified only a few that may show an indication for recurrent depression:3

  • severity of first depressive episode
  • comorbid conditions, such as major depression, dysthymia (i.e., persistent mild depression), and anxiety
  • proneness to psychological distress (i.e., a tendency for anxiety, depression, self-doubt, and other negative feelings)
  • stressful life events
  • family history of mental illness, especially depression

Some studies have found that those who abuse drugs, have been discriminated against, or were abused as children may have a higher risk for developing recurrent depressive disorder.7

How Is Recurrent Depressive Disorder Diagnosed?

According to the ICD-11, to be diagnosed with recurrent depressive disorder, all of the following conditions must be met:

  • at least one previous depressive episode that lasted for at least 2 weeks
  • at least five current depressive symptoms that have lasted at least 2 weeks
  • at least 2 months with no depressive symptoms in between episodes
  • no increase in energy levels or evidence of mania or hypomania

Treatments for Recurrent Depressive Disorder

As with most other types of depression, the most common and effective treatment includes a combination of medication and psychotherapy while the individual is experiencing an active depressive episode. This treatment may last for months or at least until the symptoms become more manageable. Once the episode of recurrent depression is considered to be in remission, psychotherapy may be stopped, and the affected individual may remain on medication to prevent another occurrence.

Pharmacological Maintenance Therapy

Following a depressive episode, it is generally recommended that medication therapy be continued for at least 1 year after the individual notices improvement to prevent a recurrence.8 However, individuals who have a history of concurrent depressive episodes after the discontinuation of medication may need pharmacological intervention for years, if not for life.9

Prolonged Psychotherapy

Although psychotherapy is typically discontinued when the individual notices improvement, some research shows that continuing, especially with cognitive behavioral therapy, can help prevent recurrent depressive episodes from occurring.10

Electroconvulsive Therapy

Electroconvulsive therapy, or shock therapy, may be used as a last resort for those who show no response to multiple efforts at medication and psychotherapy. Although this treatment can be very effective, it can also be disruptive to a person’s life, at least initially. Subsequent electroconvulsive treatments to maintain gains are not recommended. Instead, the use of certain medications following initial shock therapy has been shown to be effective in reducing relapse.11,12

References

  1. Mental Health UK. (n.d.). Types of depression. Retrieved September 1,2020, from
    https://mentalhealth-uk.org/help-and-information/conditions/depression/types-of-depression/
  2. Maj, M. (2015). Mood disorders in ICD-11. European Psychiatry, 30(Suppl. 1), 98.
    https://doi.org/10.1016/S0924-9338(15)30080-8
  3. Burcusa, S. L., &Iacono, W. G. (2007). Risk for recurrence in depression. Clinical psychology review, 27(8), 959–985.
    https://doi.org/10.1016/j.cpr.2007.02.005
  4. Mayo Clinic. (n.d.). Depression (major depressive disorder). Retrieved September 1, 2020, from
    https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007
  5. Pompili, M., Innamorati, M., Raja, M., Falcone, I., Ducci, G., Angeletti, G., Lester, D., Girardi, P., Tatarelli, R., & De Pisa, E. (2008). Suicide risk in depression and bipolar disorder: Do impulsiveness-aggressiveness and pharmacotherapy predict suicidal intent? Neuropsychiatric Disease and Treatment, 4(1), 247–255.
    https://doi.org/10.2147/ndt.s2192
  6. McIntosh, A. M., & Goodwin, G. M. (2010). Mood disorder. In E. C. Johnson, S. M. Lawrie, M. Sharpe, D. C. Owens, &A. M. McIntosh (Eds.), Companion to psychiatric studies (8th ed.).
  7. Suija, K., Aluoja, A., Kalda, R., &Maaroos, H.-I. (2011). Factors associated with recurrent depression: A prospective study in family practice. Family Practice, 28(1), 22–28.
    https://doi.org/10.1093/fampra/cmq076
  8. Paykel, E.S. (2001). Continuation and maintenance therapy in depression. British Medical Bulletin March, 57(1), 145–159.
    https://doi.org/10.1093/bmb/57.1.145
  9. Pringsheim, T., Kelly, M., &Barbui, C. (2016, February). Stopping antidepressants following depression. BMJ, 352.
    https://doi.org/10.1136/bmj.i220
  10. Fava, G. A., Rafanelli, C., Grandi, S., Conti, S., &Belluardo, P. (1998). Prevention of recurrent depression with cognitive behavioral therapy: Preliminary findings. Archives of General Psychiatry, 55(9), 816–820.
    https://doi.org/10.1001/archpsyc.55.9.816
  11. Preventing recurrent depression: Long-term treatment for major depressive disorder. (2007). Primary Care Companion to the Journal of Clinical Psychiatry, 9(3), 214–223.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1911177/
  12. Hermida, A. P., Glass, O. M., Shafi, H., & McDonald, W. M. (2018, September). Electroconvulsive therapy in depression: Current practice and future direction. Psychiatric Clinics of North America, 41(3), 341–353.
    https://doi.org/10.1016/j.psc.2018.04.001

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