Research paperRisk factors for recurrence in depression in the Lundby population, 1947–1997
Introduction
Depression is a common disorder in both women and men. Angst et al. (2002) found that 22.4% of women and 13.9% of men in community-based cohorts in Belgium, France, UK, Spain and the Netherlands had at least one episode of depression during their life time. In the Lundby Study, the cumulative risk of women becoming depressed was 30.7% and men 22.5% between the years 1972 and 1997 (Mattisson et al., 2005). Recurrence rates in depression are high. In a specialized care setting, up to 85% experienced a second episode of depression within 15 years (Mueller et al., 1999) and in a community-based setting, the Lundby Study, about 40% experienced a recurrence in depression during a 30–39-year follow up (Mattisson et al., 2007). Identifying the group with a more recurrent course of depression would be a cost-effective way to offer secondary preventive treatment (Hardeveld et al., 2010).
Several variables have been associated with an increased risk of first-time depression. The variables can be divided into groups of demographic, psychosocial, cognitive, personality, co-morbidity, biological and genetic risk factors. However, risk factors for first-time depression might not overlap with risk factors for a recurrent course. Demographic factors associated with first-time depression, e.g. gender, socioeconomic and marital status, have been found less likely to increase the risk of recurrence (Burcusa and Iacono, 2007). Although most studies show no difference between recurrence of depression in men and women, some studies (Kessing, 1998) have found female gender to be a risk factor for recurrence. There is some indication that psychosocial, cognitive and personality factors have an impact on both first onset and recurrence of depression (Hardeveld et al., 2010). Wainwright and Surtees (2002) investigated the relationship between childhood stressful life events and depression and found that parental divorce was a risk factor for both first-time depression and a recurrent course, whereas frightening events in childhood and physical abuse were solely associated with first-time depression. Some investigators have suggested that a low level of social support can be a risk factor for both first onset and recurrence in depression (Stice et al., 2004), but others have argued for a common underlying genetic vulnerability and no causal relationship between low social support and depression (Burcusa and Iacono, 2007). Rumination and negative cognitive styles have been found to be risk factors for both first onset and recurrence in depression (Iacoviello et al., 2006). Berlanga et al. (1999) found that neuroticism in an outpatient sample was a risk factor for recurrence in depression. Neuroticism is one of the ‘big five’ higher-order personality traits, and is defined as a tendency to act impulsively, feel hostile, experience negative emotions, deem situations as stressful, worry, fear the uncertain, and become easily fatigued (Ormel et al., 2004). Genetic factors such as a family history of mental illness, especially affective disorders, have been found to increase the risk of recurrence in depression (Burcusa and Iacono, 2007).
In a systematic review of the course of depression in community- and primary care-based surveys, Steinert et al. (2014) concluded that the risk factors for an unfavourable course, chronicity and recurrence, are variables inherent in the depressive disorder itself. In other words, variables describing the characteristics of the depressive disorder, as opposed to variables describing the afflicted individual and their life situation, have the greatest impact on the course of depression. The episode inherent variables that predict an unfavourable course of depression are onset age (Eaton et al., 2008), baseline severity of depression (Poutanen et al., 2007), dysthymia and overlying depression (Rhebergen et al., 2009), co-morbid mental disorders (Skodol et al., 2011), and number of episodes (Kessing et al., 2004).
The sub-type of a depressive episode could also be considered to be an inherent factor of the depressive disorder. However, studies on the courses of different depression subtypes have produced varied results. In a review on the course of endogenous depression, O′Leary (1996) concluded that most studies have shown that endogenous depression has a shorter time to remission, lower relapse risk, but a higher risk of late readmission than the non-endogenous depression subtypes. There was no clear consensus on whether the endogenous subtype had a more recurrent course or not. There are few long-term studies on depression subtypes and recurrence and chronicity (Gili et al., 2012). One long-term study (Angst et al., 2007) showed that melancholic depression had a higher rate of chronicity but not recurrence.
It has been implied that the course of depression is best studied in a general population sample, free from selection bias (Eaton et al., 2008). The Lundby Study is one of four well known large-scale community surveys of mental health (Hardeveld et al., 2013). The study started in 1947 and has been repeated three times since, in 1957, 1972 and 1997.
The aim of the current study is to identify risk factors associated with recurrence in depression among subjects in the Lundby Study, by comparing individuals who experienced a single episode of depression with those who had at least one recurrence during the follow-up. Factors investigated are gender, socioeconomic status, marital status, personality, heredity, age at first depressive episode, severity of first episode of depression, and presence of melancholic traits at first episode of depression.
Section snippets
The Lundby cohorts
The Lundby Study is based on two overlapping cohorts comprising a total of 3563 individuals. All residents of two adjoining parishes in the south of Sweden in 1947 and in 1957 were included. During the period 1947–1997, the Lundby area gradually developed from a rural area to a combined rural and suburban area. Most inhabitants of working age commuted to other cities in 1972/1997, while agriculture was the main source of income in 1947. About 50% of the Lundby population moved from the Lundby
Inherent factors and heredity
Of the factors investigated, melancholia at first onset has the greatest impact on the odds of suffering depression a second time. The odds ratio of recurrence if the subject was melancholic at onset is 3.52 (95% CI 1.62–7.66, p < 0.001). Degree of impairment at first onset is not a risk factor for recurrence, and recurrence in depression does not seem to be affected by heredity. The odds of recurrence in depression seem to decrease with age of onset, but a significant odds decrease can only be
Discussion
Risk factors associated with recurrent depression in the Lundby study were melancholic disorder and young age at first onset of depression and a premorbid nervous/tense personality. Demographic factors, heredity and degree of impairment at first onset were not found to be associated with recurrence in depression. In accordance with Steinert's (2014) conclusion on risk factors for recurrent depression, two of three risk factors found in this study are inherent in the first episode of depression:
Conclusion
Factors significantly associated with the risk of recurrence in depression in the Lundby Study are melancholic depression at first onset (regardless of the degree of impairment caused by the depression), young age at first onset, and a premorbid nervous/tense personality. Gender was not associated with the risk of recurrence in depression. These findings could justify a lengthier follow-up and treatment duration when melancholia is concerned. It may also be valuable to distinguish melancholia
Acknowledgements
The authors would especially like to thank the Lundby population. Furthermore, the authors would like to express their gratitude to Anna Lindgren, statistician at the Centre of Mathematical Sciences, Lund University, for aiding with the statistics, Anders Odensten who helped with the structuring of data and Leslie Walke for aiding with the language revision. At last the authors would like to thank The Ellen and Henrik Sjöbring Foundation, Skane University Hospital and the Faculty of Medicine,
Role of funding source
Funding for this study was granted from The Ellen and Henrik Sjöbring Foundation, Department of Psychiatry, Lund University. The funding sources had no role in either the study design, the collection, analysis and interpretation of data nor in the writing of the paper. Furthermore, they had no role in the decision to submit the paper for publication.
Linnéa Nöbbelin obtained her master’s degree in medicine at Lund University in 2015. She is currently a Ph.D. student under the supervision of Dr. Louise Brådvik. Her research is centered on the epidemiology of depressive disorders.
References (39)
- et al.
Risk for recurrence in depression
Clin. Psychol. Rev.
(2007) - et al.
"Mini-mental state". A practical method for grading the cognitive state of patients for the clinician
J. Psychiatr. Res.
(1975) - et al.
The course of depression in individuals at high and low cognitive risk for depression: a prospective study
J. Affect. Disord.
(2006) - et al.
Risk factors for depressive disorders in the Lundby cohort--a 50 year prospective clinical follow-up
J. Affect. Disord.
(2009) - et al.
First incidence depression in the Lundby Study: a comparison of the two time periods 1947–1972 and 1972–1997
J. Affect. Disord.
(2005) - et al.
The three-year naturalistic course of major depressive disorder, dysthymic disorder and double depression
J. Affect. Disord.
(2009) - et al.
The prospective long-term course of adult depression in general practice and the community. A systematic literature review
J. Affect. Disord.
(2014) - et al.
Childhood adversity, gender and depression over the life-course
J. Affect. Disord.
(2002) - et al.
Melancholia and atypical depression in the Zurich study: epidemiology, clinical characteristics, course, comorbidity and personality
Acta Psychiatr. Scand.
(2007) - et al.
Gender differences in depression. epidemiological findings from the European DEPRES I and II studies
Eur. Arch. Psychiatry Clin. Neurosci.
(2002)
Diagnostic and Statistical Manual of Mental Disorders
Personality and clinical predictors of recurrence of depression
Psychiatr. Serv.
Natural history of Diagnostic Interview Schedule/DSM-IV major depression. The Baltimore Epidemiologic Catchment Area follow-up
Arch. Gen. Psychiatry
Population-based study of first onset and chronicity in major depressive disorder
Arch. Gen. Psychiatry
Individual traits and morbidity in a Swedish rural population
Acta Psychiatr. Neurol. Scand. Suppl.
Resurrecting melancholia
Acta Psychiatr. Scand. Suppl.
Clinical patterns and treatment outcome in patients with melancholic, atypical and non-melancholic depressions
PLoS One
Socio-economic status, family disruption and residential stability in childhood: relation to onset, recurrence and remission of major depression
Psychol. Med.
A Prospective Study of the Incidence of Mental Disorders
Cited by (11)
The Epac2 coding gene (RAPGEF4) rs3769219 polymorphism is associated with protection against major depressive disorder in the Chinese Han population
2020, Neuroscience LettersCitation Excerpt :Depression is characterized by a high recurrence rate. Studies have shown that risk factors associated with recurrent depression include melancholic depression at first onset, young age at first onset, and premorbid nervous personality [44]. Alves et al. [45] found that excessive potentiation of adult neurogenesis and neuronal atrophy increased the susceptibility to behavioral deficits induced by stress re-exposure, while normalization of adult neurogenesis and enhancement of dendritic arborization reduced the risk of recurrent depression.
Incidence and recurrence of depression from adolescence to early adulthood: A longitudinal follow-up of the Mexican Adolescent Mental Health Survey
2020, Journal of Affective DisordersCitation Excerpt :Consistent with many prior studies showing a strong female preponderance of depression in adolescents after puberty (Essau et al., 2010; Galambos et al., 2004; Patton et al., 2008; Salk et al., 2016), we found that young females had higher incidence rates compared to males, but not so for recurrence. While female sex may be a predictor of onset, evidence that sex is a predictor of recurrence is inconsistent, mostly suggesting no (Hankin et al., 1998; Kovacs et al., 2003; Nöbbelin et al., 2018; Rao et al., 1995) or only slightly greater risk for females (1.0 to 1.2) in some populations (Bertschy et al., 2016). This is an important distinction for public planning and clinicians.
Psychological interventions for the prevention of depression relapse: systematic review and network meta-analysis
2023, Translational PsychiatryWhy Recurrent Depression Should Be Reconceptualized and Redefined
2023, Current Directions in Psychological Science
Linnéa Nöbbelin obtained her master’s degree in medicine at Lund University in 2015. She is currently a Ph.D. student under the supervision of Dr. Louise Brådvik. Her research is centered on the epidemiology of depressive disorders.
Dr. Louise Brådvik is an associate professor in psychiatry at Lund University and the project manager of the Lundby study. Her research is focused on suicide, addiction and the epidemiology of psychiatric diseases. She is a senior consultant.
Dr. Mats Bogren earned his Ph.D. in psychiatry at Lund University in 2009. His thesis was on the epidemiology of psychosis in the Lundby population. Other research interests are melancholia and the epidemiology of affective disorders. Dr. Bogren is currently working as a senior consultant at the psychiatric clinic at Skane University Hospital.
Dr. Cecilia Mattisson is an associate professor in psychiatry at Lund University. Her research is focused on depressive disorders, alcohol use disorders and epidemiology. Dr. Mattisson is currently working as a senior consultant at the psychiatric clinic at Skane University Hospital.