A comprehensive model of predictors of persistence and recurrence in adults with major depression: Results from a national 3-year prospective study
Introduction
Major depression is a leading source of disease burden (Hollon et al., 2005, Lopez et al., 2006) characterized by complex patterns of recurrence and persistence (Hasin et al., 2005, Kessler et al., 2003, Mueller et al., 1999, Solomon et al., 1997). Persistence and recurrence are common among patients with major depression (Frank et al., 1990, Keller et al., 1983, Mueller et al., 1999). Persistence may be defined by a prolonged time to recovery from an index episode and recurrence by the occurrence of a new episode in a remitted case (Skodol et al., 2011). Identifying predictors of persistence and recurrence in patients with a major depressive episode (MDE) is an important challenge for clinicians and researchers.
Prior research has implicated several risk factors for MDE persistence or recurrence. They include severity of major depression (Sargeant et al., 1990, Skodol et al., 2011, Spijker et al., 2010, Steinert et al., 2014), number of lifetime MDEs (Skodol et al., 2011, Spijker et al., 2010, Steinert et al., 2014), co-occurring Axis I (Hoertel et al., 2013a, Hoertel et al., 2013b, Hoertel et al., 2013c, Keller et al., 1982, Keller et al., 1992, Klein et al., 2006, Manetti et al., 2014, Steinert et al., 2014) and Axis II disorders (Grilo et al., 2005, Skodol et al., 2011), history of suicide attempts (Avery and Winokur, 1978), family history of depression (Patten et al., 2010), concurrent physical health problems and psychosocial difficulties (Lam et al., 2009), early age at onset of first MDE (Hoertel et al., 2013a, Klein et al., 1999), stressful live events (Wang et al., 2012), female gender, older age and being divorced or widowed (Colman et al., 2011, Dowrick et al., 2011, Fava et al., 2007, Gilman et al., 2013, Hardeveld et al., 2013a, Hardeveld et al., 2013b, Kornstein et al., 2000, Lam et al., 2009, Patten et al., 2012, ten Doesschate et al., 2010, Wang et al., 2012).
The diversity of these predictors and their frequent co-occurrence suggest the need to develop more powerful statistical approaches. Several integrative predictive models of MDE persistence or recurrence have been examined (Brugha et al., 1997, Dowrick et al., 2011, ten Doesschate et al., 2010, Wang et al., 2014, Fandiño-Losada et al., 2016). However, most of these models have been based on samples of convenience and used relatively small sample sizes. In addition, because MDE often co-occurs with other mental disorders (Kessler et al., 2003, Kessler et al., 2005, Manetti et al., 2014), recent theories have proposed a meta-structure of psychiatric diagnoses that organizes disorders into broad dimensions of psychopathology (i.e., internalizing and externalizing dimensions) (Blanco et al., 2013, Eaton et al., 2012, Hoertel et al., 2015a, Hoertel et al., 2015b, Kotov et al., 2011, Krueger et al., 1998, Krueger and Markon, 2006). Applying this dimensional approach to model disorder comorbidity in a comprehensive model of MDE persistence or recurrence could help clarify whether broad psychopathological liabilities or individual Axis I or Axis II disorders predict persistence or recurrence of MDE.
This report proposes a comprehensive model of the 3-year risk of persistence or recurrence of MDE using a longitudinal nationally representative study, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). We used structural equation modeling to examine simultaneously the effects of four broad groups of clinical factors previously identified as potential predictors of persistence and recurrence of MDE: 1) severity of depressive illness, 2) severity of mental and physical comorbidity, 3) sociodemographic characteristics and 4) treatment-seeking behavior. With this model, we aimed to ascertain readily identifiable characteristics to help clinicians recognize adults with MDE who are at increased risk for recurrent or chronic MDE.
Section snippets
Sample
Data were drawn from the wave 1 and wave 2 of the NESARC, a nationally representative face-to-face survey of the US adult population, conducted in 2001–2002 (Wave 1) and 2004–2005 (Wave 2) by the National Institute on Alcoholism and Alcohol Abuse (NIAAA) (Grant et al., 2003). The target population included the civilian noninstitutionalized population, aged 18 years and older, residing in the United States. The overall response rate at Wave 1 was 81% and the cumulative response rate at Wave 2
Clinical characteristics assessed at wave 1 and the 3-year risk of MDE persistence and recurrence
Among participants with a 12-month DSM-IV diagnosis of MDE at Wave 1 (n = 2587), 15.7% (SE = 0.8, N = 418) had a chronic MDE and 20.7% (SE = 0.9, n = 526) had a new MDE during a 3-year follow-up period. Binary logistic models showed that increased risk of MDE persistence was significantly associated with all comorbid mental disorders (except for alcohol and drug use disorders and histrionic and antisocial personality disorders), lower mental and physical component summary scores, all symptoms
Discussion
In a large, nationally representative cohort of US adults, we sought to build a comprehensive model of MDE persistence and recurrence that integrates information across a wide range of clinical domains to estimate their relative impact. About 36% of individuals with an MDE at Wave 1 had either a persistent or a recurrent MDE at 3-year follow-up. Risk of persistence or recurrence of MDE was not determined by a single factor, but rather by the combined effects of multiple risk factors. Most
Funding/support
This study was supported by NIH grants MH076051 and MH082773 (Drs. Blanco, Olfson, Oquendo and Wall) and the New York State Psychiatric Institute (Drs. Hoertel, Blanco, Olfson, Oquendo and Wall) and a fellowship grant from Public Health Expertise (Dr. Hoertel). The sponsors had no additional role in the design and conduct of the study; collection, management, analysis and interpretation of the data; and preparation, review or approval of the manuscript.
Role of the funding source
The funding sources had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Additional information
The National Epidemiologic Survey on Alcohol and Related Conditions was sponsored by the National Institute on Alcohol Abuse and Alcoholism and funded, in part, by the Intramural Program, NIAAA, National Institutes of Health. The original data set for the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) is available from the National Institute on Alcohol Abuse and Alcoholism (http://www.niaaa.nih.gov).
Contributors
NH, CB and FL designed the study. NH and MW undertook statistical analyses. NH and CB wrote the first draft of the manuscript. MAO, MW, MO, BF, SF, HP, CL, and FL reviewed the draft. All authors contributed to and have approved the final manuscript.
Conflicts of interest
Dr. Blanco holds stock in Sanofi, Eli Lilly, Inc and General Electric. Dr. Oquendo receives royalties for the commercial use of the C-SSRS and her family owns stock in Bristol Myers Squibb. Dr. Falissard has been consultant for E. Lilly, BMS, Servier, SANOFI, GSK, HRA, Roche, Boeringer Ingelheim, Bayer, Almirall, Allergan, Stallergene, Genzyme, Pierre Fabre, Astrazeneca, Novartis, Janssen, Astellas, Biotronik, Daiichi-Sankyo, Gilead, MSD, Lundbeck, Stallergene, Actelion, UCB, Otsuka, Grunenthal
Disclaimer
The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of any of the sponsoring organizations, agencies, or the US government.
References (78)
- et al.
A preliminary investigation of the long-term outcome of the unified protocol for transdiagnostic treatment of emotional disorders
Compr. Psychiatry
(2014) - et al.
Reliability of the alcohol and drug modules of the alcohol use disorder and associated disabilities interview schedule–Alcohol/Drug-Revised (AUDADIS-ADR): an international comparison
Drug Alcohol Depend.
(1997) - et al.
The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV): reliability of alcohol consumption, tobacco use, family history of depression and psychiatric diagnostic modules in a general population sample
Drug Alcohol Depend.
(2003) - et al.
The Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS): reliability of alcohol and drug modules in a general population sample
Drug Alcohol Depend.
(1995) - et al.
Recurrence of major depressive disorder across different treatment settings: results from the NESDA study
J. Affect Disord.
(2013) - et al.
The Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS): reliability of alcohol and drug modules in a clinical sample
Drug Alcohol Depend.
(1997) - et al.
Evidence for a two-stage model of dependence using the NESARC and its implications for genetic association studies
Drug Alcohol Depend.
(2008) - et al.
Subthreshold bipolar disorder in a U.S. national representative sample: prevalence, correlates and perspectives for psychiatric nosography
J. Affect Disord.
(2013) - et al.
Why does the lifetime prevalence of major depressive disorder in the elderly appear to be lower than in younger adults? Results from a national representative sample
J. Affect Disord.
(2013) - et al.
Poor longitudinal continuity of care is associated with an increased mortality rate among patients with mental disorders: results from the french national health insurance reimbursement database
Eur. Psychiatry
(2014)
A dimensional liability model of age differences in mental disorder prevalence: evidence from a national sample
J. Psychiatr. Res.
Predictors of relapse in patients with major depressive disorder in a 52-week, fixed dose, double blind, randomized trial of selegiline transdermal system (STS)
J. Affect Disord.
Age of onset in chronic major depression: relation to demographic and clinical variables, family history, and treatment response
J. Affect Disord.
Gender differences in chronic major and double depression
J. Affect Disord.
Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults
III. Pharmacother. J. Affect Disord.
Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data
Lancet
Relationship between psychiatric disorders and sexually transmitted diseases in a nationally representative sample
J. Psychosom. Res.
Comorbidity of late-life depression in the United States: a population-based study
Am. J. Geriatr. Psychiatry
Depressive episode characteristics and subsequent recurrence risk
J. Affect Disord.
The prospective long-term course of adult depression in general practice and the community. a systematic literature review
J. Affect Disord.
Design of the Coordinated Anxiety Learning and Management (CALM) study: innovations in collaborative care for anxiety disorders
Gen. Hosp. Psychiatry
Suicide, attempted suicide, and relapse rates in depression
Arch. Gen. Psychiatry
Mapping common psychiatric disorders: structure and predictive validity in the national epidemiologic survey on alcohol and related conditions
JAMA psychiatry
Epidemiology of major depression with atypical features: results from the national Epidemiologic Survey on Alcohol and Related Conditions (NESARC)
J. Clin. Psychiatry
Examining heterotypic continuity of psychopathology: a prospective national study
Psychol. Med.
Barriers to seeking treatment for major depression
Depress Anxiety
Predicting the short-term outcome of first episodes and recurrences of clinical depression: a prospective study of life events, difficulties, and social support networks
J. Clin. Psychiatry
The Spanish Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS): reliability and concordance with clinical diagnoses in a Hispanic population
J. Stud. Alcohol Drugs
The clinician's illusion
Arch. Gen. Psychiatry
Predictors of long-term prognosis of depression
CMAJ
Predicting long-term recovery from depression in community settings in Western Europe: evidence from ODIN
Soc. Psychiatry Psychiatr. Epidemiol.
An invariant dimensional liability model of gender differences in mental disorder prevalence: evidence from a national sample
J. Abnorm Psychol.
Path analysis of the chronicity of depression using the comprehensive developmental model framework
Nord. J. Psychiatry
The concept of recovery in major depression
Psychol. Med.
Three-year outcomes for maintenance therapies in recurrent depression
Arch. Gen. Psychiatry
A bright side, facet analysis of histrionic personality disorder: the relationship between the HDS Colourful factor and the NEO-PI-R facets in a large adult sample
J. Soc. Psychol.
Psychosocial stressors and the prognosis of major depression: a test of Axis IV
Psychol. Med.
Sociodemographic and psychopathologic predictors of first incidence of DSM-IV substance use, mood and anxiety disorders: results from the Wave 2 national epidemiologic survey on alcohol and related conditions
Mol. Psychiatry
Two-year prospective naturalistic study of remission from major depressive disorder as a function of personality disorder comorbidity
J. Consult Clin. Psychol.
Cited by (41)
The impact of fibroid treatments on quality of life and mental health: a systematic review
2024, Fertility and SterilityThe effect of symptomatology and mental wellbeing on quality of life in people with acoustic neuroma
2023, Journal of Clinical NeuroscienceHow chronic are depressive and anxiety disorders? 9-year general population study using narrow and broad course outcomes
2022, Journal of Affective DisordersPredicting 3-year persistent or recurrent major depressive episode using machine learning techniques
2022, Psychiatry Research Communications