Is it possible to predict and prevent relapse in depression?

Research has revealed a unanimous recognition of the importance of relapse prevention but highlighted the lack of routine follow-up and evidence-based discussions with patients.

Women sat on steps looking deep in thought

Depression is a pervasive mental health condition, affecting 280 million people worldwide.

Alarming statistics reveal that even after receiving treatment for their initial depressive episode, nearly half of individuals will experience a relapse. The risk intensifies with each subsequent episode, reaching 90% after the third occurrence.(1)

Recognising the high prevalence of relapse in depression, and the limited guidance available to clinicians, a GP has embarked on a PhD to address the challenges surrounding relapse prediction and prevention in depression.

Dr Andrew Moriarty, a GP based in York and a PhD student at Hull York Medical School, aimed to understand whether it is possible to predict who is at risk of relapse of depression, and review the effectiveness of existing prevention interventions in primary care.

His project involved collaboration with Keele University, University College London, the University of Birmingham, the NIHR Complex Reviews Support Unit, the Cochrane Common Mental Disorders Group, the Cochrane Prognosis Methods Group, and the University of York’s Centre for Reviews and Dissemination.

His PhD was supervised by Professor Simon Gilbody, Professor of Psychological Medicine and Psychiatric Epidemiology and Professor Dean McMillan, Professor of Clinical Psychology at Hull York Medical School and Department of Health Sciences at the University of York, and Professor Carolyn Chew-Graham, Professor of General Practice Research at Keele University.

"Depression is so different for so many people. It is incredibly challenging to tackle such a complex problem, but it could make an enormous difference to people’s lives"
Dr Andrew Moriarty

Dr Moriarty, whose research is a funded by a prestigious NIHR Doctoral Research Fellowship, said, “Depression is such a common condition, but it is so different for so many people. It is complex to try to manage and is so individualised. This makes it challenging to consider how to develop evidence and guidance that can inform practice when everybody's circumstances are different.”

He continued, “The patient's views and expectations of managing depression are all so different as well. How do you address that in a way that is evidence based but also considers all those individual preferences? It is incredibly challenging to tackle such a complex problem, but it could make an enormous difference to people’s lives.”

A woman comforting a man looking upset

Patient power: Collaborating with lived experience of depression to shape research

Given the research's focus on individuals with depression, Dr Moriarty deemed it essential to involve people with lived experience of depression in the research.

A patient advisory group actively participated in the research, consisting of individuals with lived experience of depression who played a crucial role in shaping the study. Their involvement began prior to the PhD funding application and continued regularly throughout the PhD project, with their contributions extending to co-authoring a Cochrane blog post and an editorial for the British Journal of General Practice.

Emma, a member of the patient advisory group, said “I felt that I had relevant personal experience that could be used to help prevent the relapse of depression, and I wanted to use my experiences positively to contribute to the aim of the research.

“In the research study, I collaborated with Dr Moriarty and other individuals with personal experience of depression. Together, we provided input into the research design, including suggesting questions for research participants, advising on language and approach, and discussing the research findings. I also had the opportunity to co-write a Cochrane blog as part of my involvement. Overall, the experience was very positive for me.”

"Having patients involved in the research has been hugely beneficial; It has improved the quality of our research"
Dr Andrew Moriarty

Dr Moriarty said, “The patients have even contributed to the analysis and naming of themes. As a doctor, I sometimes unintentionally use clinical language or terms that are not patient-centred. The members of the patient advisory group have guided me in naming themes and generating meaningful concepts that resonate with people who have first-hand experience as patients.”

Dr Moriarty found their participation not only improved the research but also ensured appropriate approaches when engaging with participants, especially during qualitative interviews. The advisory group assisted in formulating relevant and meaningful questions that accurately captured the patient perspective.

Challenges in identifying and preventing depression relapse

The research began with a comprehensive Cochrane review, conducted in collaboration with the Cochrane Prognosis Methods Group. The review revealed a scarcity of reliable prediction models or tools for primary care settings, emphasising the need for further research.

Dr Moriarty then undertook the task of developing his own model in collaboration with Professor Richard Riley, Professor of Biostatistics and his team at the University of Birmingham, utilising data from primary care-based trials and incorporating routinely collected predictors available to GPs. However, the model's development indicated that reliably stratifying patients and predicting relapse remained challenging.

Dr Moriarty acknowledged that the difficulty in predicting the risk of relapse in depression in a primary care setting could be due to several reasons.

He explained, “This could be because it is an undifferentiated group of patients who do not have the same baseline. It might be that we are not able to measure the right things in primary care, and there might be other data that we are not routinely asking about that is important. It might be that the things we are measuring, we are not measuring in ways that are valid or meaningful.”

Dr Moriarty continued, “These should all be considered if we want to improve the ability to predict risk. Until we can do that more effectively, we need to focus on ensuring the longer-term ongoing care and support is better and more consistent and more evidence based.

"That involves thinking about how we can embed relapse prevention in primary care. It is quite a big ask. It is going to require policy change and resourcing, but it is potentially the way forward.”

"Until we can predict risk of depression relapse more effectively, we need to focus on evidence-based longer-term care and support"
Dr Andrew Moriarty

Dr Moriarty also conducted qualitative research, involving GPs and individuals with lived experiences of depression. This aspect aimed to explore perceptions of relapse, its discussion in clinical practice, and awareness of relapse prevention among patients and healthcare providers.

The findings revealed a unanimous recognition of the importance of relapse prevention but highlighted the lack of routine follow-up and evidence-based discussions with patients.

Dr Morarty said, “GPs and people with lived experience of depression both felt that support would best sit within primary care. However, currently there is not much guidance to help GPs to identify the people who are more likely to relapse, or availability of relapse prevention or treatments. It would need resourcing – with the current provision in primary care, it would not be feasible.”

Stethoscope

A springboard for change: Addressing the gaps in depression relapse prevention

Despite the research's efforts to develop prediction models and incorporate routinely collected data available to GPs, reliably stratifying patients and accurately predicting relapse remains a significant challenge.

The qualitative research also revealed a shared recognition among GPs and individuals with lived experiences of depression regarding the significance of relapse prevention.

However, there is currently a lack of guidance and resources available to GPs to identify individuals at a higher risk of relapse and provide effective prevention and treatment options.

Dr Moriarty’s research has garnered recognition, and he was awarded the joint Researcher of the Year at Hull York Medical School’s annual Postgraduate Research Conference in 2023. He is also presenting his research at the North American Primary Care Research Group (NAPCRG) Annual Meeting in San Francisco in late 2023.

As Dr Moriarty enters the final stages of writing his PhD thesis, he envisions a future where the impact of depression on disability and morbidity is effectively addressed, emphasising the importance of treating mental illness to prioritise overall health.

With the potential to make a substantial difference in people's lives, the research serves as a crucial step towards improving the understanding and management of depression and its relapse.

He said, “The impact of depression is huge in terms of disability and morbidity. If we want to consider what can be done to prioritise health in a way that is efficient for your health system, treating mental health problems effectively is a good place to start.”

For more information about this research, contact Dr Andrew Moriarty. Dr Moriarty is a member of the Centre for Health and Population Sciences.

References

(1) Kupfer DJ (1991) Long-term treatment of depression. J Clin Psychiatry 52(Suppl):28–34

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