The Critical Role of Remission in Major Depressive Disorder (MDD)

by Aspasia Venieri

THE PHASES OF MAJOR DEPRESSIVE DISORDER :

The psychiatric guide of disorders DSM-5, further to the basic criteria for major depression (MDD), it suggests that mental health practitioners also monitor the following:

• Single or Recurrent Episode

• Severity: Mild, Moderate, Severe

• In Partial or In Full Remission

• With: anxious distress, mixed features, melancholic features, atypical features, mood-congruent psychotic features, mood-incongruent psychotic features, catatonia, peripartum onset or seasonal pattern. .

(American Psychiatric Association,2013)

THE PHASES OF MDD DESCRIBED IN DSM -5:

Major Depressive Episode: (MDE) Lasts from 2 weeks to several years.

Remission: A period of minimum 2 months, that can extend to years, with no symptoms or few mild ones between MDEs.

Partial Remission: The period after the end of a MDE when few or mild symptoms remain that do not fulfill the criteria of a MDE, or a period of less than 2 months where the remaining symptoms are not significant.

Full Remission: A period of 2 months after the end of a MDE where no significant symptoms are apparent.

Recovery:

It can start 3 months after onset for 2/5 cases and within 1 year for 4/5 of cases. The more recent the onset of the MDD, the higher the probability for recovery.

Factors that inhibit recovery: chronicity of the disorder, duration of MDEs, existence of psychotic features, anxiety, comorbid personality disorders and symptom severity.

Recurrence: Risk factors for the development of a new MDE: The severity of previous MDE, younger age, several episodes and residual symptoms during remission.

(American Psychiatric Association,2013)

SYMPTOMATIC vs FUNCTIONAL REMISSION

Symptomatic Remission:

Refers to the decrease of the intensity and/or number of symptoms from a MDE. It is the most common type of remission measured and targeted in literature.

It is usually measured via a score of ≤ 7 at the HAMD-17 questionnaire or the Clinical Global Impression Severity Scale (CGI-S) with a score ≤ 3.

Yet, different time criteria are used in literature to define Remission.

Functional Remission:

It is measured with SOFAS score >30 from DSM IV. It assesses the capacity of the individual for the following:

Pursuing full/part-time job, education, retraining, housewife etc.

Independent living status, maintaining an apartment without another party's financial or other type of support

Some significant social relationships outside family

Recovery:

• There have been different definitions for recovery in literature:

A time period ≥ 4 months of stable remission

A combination of symptomatic & functional remission

(Spellmann et al., 2017)

SYMPTOM PROFILES OF MDD PHASES

In a 3-year randomized clinical trial, Conradi, Ormel and De Jonge (2012), examined 267 clients between 18-70 years old, who suffered from depression in the last 12 months. They noted the following symptoms apparent in the different phases of MDD:

Core Symptoms:

Depressed mood & Diminished interest

Other Symptoms:

1.Cognitive problems

2.Sleeping problems

3.Lack of energy

4.Worthlessness /guilt

5.Eating problems

6.Psychomotor problems (least prevalent)

7.Recurrent thoughts of death (least prevalent)

Mean duration of phases :

Relapses: 11 weeks

Recurrences: 14 weeks

Remissions: 4 weeks

Recoveries: 67 weeks

Duration of symptoms in Relapse & Recurrence:

The psychomotor problems lasted much longer in the Recovery phase (46% of the time), and less in Recurrence (26% of the time).

All other symptoms had a similar duration.

Duration of individual symptoms in Remission & Recovery:

• Core symptoms: 53 vs 15%

• Cognitive problems: 60 vs 41%

• Death ideations: 13 vs 10%

Severity of overall symptomatology: 3.33 vs 1.85

Core symptoms were more prevalent in Remission vs the initial & final phases of Recovery. Moreover, in Remission, they had higher severity than in the last phase of Recovery.

(Conradi, Ormel & De Jonge, 2012)

Important Differences in the Phases of Depression

Remissions ≠ Recoveries:

Differ significantly in duration, symptom severity and symptom ranking. Remissions have 3.3 symptoms in average when a Depressive episode has ≥ 5 according to DSM IV.

Relapses ~Recurrences :

Have similar duration, rank of symptoms and level of severity. Only psychomotor problems differ in prevalence without any apparent reason. Otherwise, these phases only differ in timing.

Residual symptoms are important triggers of Major Depressive Episodes” (p.643)

Interesting Differences

In the final phase of Recovery, clients displayed lower levels of the core symptoms and of all the symptoms combined; whereas, in Remission, those levels were high.

The authors suggest that maybe a Recurrence that follows a Recovery phase is provoked by a new stressful event vs the “dormant symptoms” that are reenacted with a Relapse.

(Conradi, Ormel & De Jonge, 2012)

COGNITIVE DEFICITS THAT REMAIN IN REMISSION AFFECT FUNCTIONING & QUALITY OF LIFE

Cognitive deficits may be present during:

• 85-94% of the activation of a MDE

• 39-44% of a remission period

Cognitive deficits in Depression involve:

• Negatively biased emotional processing (cognitive distortions) and perception (dysfunctional attitudes), which also affect attention as well as episodic & working memory.

• Decreased sensitivity to positive feedback and learning related to rewards.

• Executive Functions and Psychomotor speed malfunction.

Cognitive function during remission is affected negatively by the number of previous episodes.

Improving cognitive functioning in MDD is positively related to achieving Functional Remission and decreasing risk for Relapse.

Even after treatment with the newer antidepressants, cognitive deficits are the most common residual symptoms when the affective symptoms are alleviated.

Combination of pharmacotherapy with Cognitive Therapy proves more effective vs either method on its own, according to the modern cognitive neuropsychological model of depression.

(Gonda et al., 2015)

CELL GENESIS & DENDRITIC PLASTICITY IN THE BRAIN DURING DEPRESSION

During Depression, there is slow cytogenesis and fast dendritic alteration of the neurons in the brain.

Prolonged exposure to stress develops depression and deregulates neuroplasticity in the brain.

These alterations develop first anxiety and then depressive behaviors and cognitive disabilities.

Use of Antidepressants

Antidepressants act therapeutically on cell abnormalities and dendritic atrophy; yet, neurogenesis takes 4-6 weeks, so the AD’s effect can only be monitored then.

They restore dendritic neuronal morphology which is associated with fast remission

Moreover, they develop new neurons and cells, which help to maintain Remission and proceed to long term Recovery.

(Mateus-Pinheiro et al., 2013)

REFLECTIONS

Mental health practitioners should pay attention on the following aspects, when treating clients that may suffer from MDD, which is one of the most common disorders:

• In academic literature, one should pay attention to the definition given in each journal when Remission or Recovery in MDD are mentioned, in order to be able to compare similar constructs: Symptomatic vs Functional Remission, and Remission vs Recovery.

• Remission is not a symptom free phase. It should be the target when treating depression to begin with. The residual symptoms should be identified and treated on time, because they are the triggers of the next MDE.

• The core symptoms (depressed mood & Diminished interest) along with Cognitive deficits should be the first symptoms targeted for treatment in the remission phase to attain a more long-lasting Recovery, in a faster way.

• Symptomatic and Functional Remission should both be targeted for a client’s well being & Recovery.

• It is useful to know how antidepressants prescribed by a psychiatrist act, and psychoeducate the clients on what to expect, and why cognitive behavior therapy complements the benefits of medication.

• In Recurrent Episodes of depression, new sources of stress should be identified for treatment.

• Understand how decreased cell genesis and dendrite atrophies (this is a cognitive malfunction), first develop anxiety, and at a later stage manifest depressive behaviors and cognitions. This could also explain why there is so high comorbidity in these two disorders.

• More research is needed in order to establish valid and consensual criteria for Remission and Recovery.

• People manifest MDD with a variety of symptoms and comorbidities. Thus, more research is needed in order to identify the symptoms’ profiles during the different phases of MDD that have different specifiers.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Conradi, H. J., Ormel, J., & De Jonge, P. (2012). Symptom profiles of DSM-IV-defined remission, recovery, and recurrence of depression: The role of the core symptoms. Depression and Anxiety, 29: 638-645.

Gonda, X., Pompili, M., Serafini, G., Carvalho, A.F., Rihmer, Z. (2015). The role of cognitive disfunction in the symptoms and remission from depression. Annals of General Psychiatry 14: 27.

Mateus-Pinheiro, A., Patricio, P., Bessa, J. M., Sousa, N., Pinto, L. (2013). Cell genesis and dendritic plasticity: A neuroplastic pas de deux in the onset and remission from depression. Molecular Psychiatry 18: 748-750.

Spellmann, I., Schennach, R., Seemüller, F., Meyer, S., Musil, R., Jäger, M., … Ising, M. (2017). Validity of remission and recovery criteria for schizophrenia and major depression: Comparison of the results of two one-year follow up naturalistic studies. European Archives of Psychiatry & Clinical Neuroscience. 267 (4): 303-313.

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