The five year outcome of major depression: Effects of baseline variables and type of treatment

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Abstract

Background

Depression is commonly a relapsing or chronic disorder. Long-term outcome is therefore important. We report on the outcome of major depression five years after receiving treatment with medication or psychotherapy.

Methods

472 patients were treated in three consecutive randomised controlled trials in one clinical research centre. 298 were followed up at five years. Of these, 106 patients were treated with medications, while the remaining 192 were given psychotherapy. The a priori outcome measure was mood symptoms in the two years prior to the assessment.

Results

The majority (56%) of patients had no depressive symptoms in the prior two years. One third (32%) had fluctuating depression, while 12% were chronic depressed. Predictors of outcome were few; baseline severity, suicidality, personality pathology, and type of treatment. Those receiving medication did somewhat worse, even when adjusted for this group's higher depression severity, suicidality and personality pathology at baseline.

Conclusions

Long-term depressive symptoms are common after evidence-based treatment, although over half the patients appear to recover. Psychotherapy may be superior to medication in reducing the level of symptoms in the longer term. Personality remains one of the few baseline predictors of long-term outcome.

Introduction

Depression is a common disorder characterised by high relapse rates (Spijker et al., 2002; Mulder et al., 2009), substantial residual symptomatology, and in at least 10% of cases, a chronic course (Eaton et al., 2008). Some clinicians have advocated managing depression as a chronic disease requiring long-term treatment (Andrews, 2001). However, there is a lack of data on the long-term effects of treatment, leaving a major gap in evidence for the clinical practice of psychiatry (Uher and Pavlova, 2016).

This paper reports on the five year follow up of 298 patients who were treated in three randomised controlled trials (RCTS) conducted by a Clinical Research Unit in Christchurch, New Zealand. The studies were undertaken sequentially by the same core group of clinicians. Patients were recruited using similar methods in each study. Randomisation used the same block randomisation design. One study used antidepressants, comparing fluoxetine and nortriptyline, while the other two studies compared evidence-based psychotherapies; Cognitive Behavioural Therapy (CBT) with Interpersonal Therapy (IPT), and CBT with Schema Therapy (ST). All patients were interviewed with the SCID, a structured clinical interview at baseline, and similar measures were repeated throughout treatment and follow up. The five year outcome interviews were carried out by the same small group of clinicians and researchers.

The paper reports on the five year outcome of patients across three studies.

The aims were:

  • 1)

    To study the course of depression in the three to five years after initial treatment.

  • 2)

    To determine whether the original treatment a patient received influenced the course of illness.

  • 3)

    To determine whether baseline demographic features or clinical characteristics of the depression, comorbidity or personality predicted the long-term outcome of the depression.

Section snippets

Trial design

All three studies were single centre RCTs with two parallel arms and equal randomisation of eligible participants to each treatment.

Participants

Patients were 18 years or over meeting DSM-IV criteria for a non-psychotic major depressive episode as the principal diagnosis (Apa, 1994). Patients were recruited from a variety of sources including mental health outpatient clinics, general practitioners and psychiatric emergency services. No advertising for patients was undertaken. Participants were required to

Results

A total of 472 patients were enrolled in the three studies at baseline. At five years, 298 (63%) were able to be re-assessed. The individual study retention rates were as follow: fluoxetine versus nortriptyline 106/195 (54%), CBT compared to IPT 117/177 (66%), and CBT compared to ST 75/100 (75%)

Discussion

Overall patients who had received treatment for MD did reasonably well three to five years after their treated episodes. The majority (54%) had no significant depressive symptoms between three and five years and no relapse of their depressive episode. Around one third (32%) had fluctuating mood symptoms while the remaining 12% had chronic symptoms of depression. There were several baseline predictors of outcome based on univariate comparison. These included depression severity (measured using

Conclusion

There are three conclusions:

  • 1)

    Around half the patients treated for major depression will continue to suffer significant mood symptoms in the long term, and around 10% of patients will remain chronically depressed

  • 2)

    Psychotherapy may be superior to medication in reducing the level of symptoms over the longer term. However, studies or meta-analysis comparing drug treatment and psychotherapy need to be interpreted with caution since the patient groups may not be the same. In the current study, patients

CRediT authorship contribution statement

Roger T. Mulder: Conceptualization, Project administration, Investigation, Methodology, Resources, Writing – original draft. Chris MA. Frampton: Data curation, Formal analysis, Software. Jenny Jordan: Investigation, Methodology, Resources, Writing – review & editing. Suzanne E. Luty: Investigation, Methodology, Resources, Writing – review & editing. Virginia VW. McIntosh: Investigation, Methodology, Resources, Writing – review & editing. Janet D. Carter: Investigation, Methodology, Resources,

Declaration of competing interest

Roger Mulder has received support for travel to education meetings from Servier and Lundbeck, speaker fees from Servier, and committee fees from Janssen. Chris Frampton, Jenny Jordan, Suzanne Luty, Virginia McIntosh, and Janet Carter have no conflicts of interest to declare.

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