Depressive illnesses often have a relapsing course. A person experiencing the first episode of depression has a 50% likelihood of experiencing another. Of those, 70% will experience a third, with the majority experiencing a further episode.¹

This poses questions for both underwriters and claims managers. Underwriters will be looking to gauge the risk of further episodes, while claims managers will want to ensure that claimants get the best interventions to maintain their future well‑being.

In essence, both are looking for answers to these key questions: Which factors that predict relapse are present, and what interventions has the person engaged with to minimise their risk of relapsing?

Predictors of Relapse

While there may be a technical difference between “relapse” and “recurrence,” for all practical purposes they can be thought of as the same thing. Predictors of relapse include:^2,3

• Number of prior episodes
• Severity of initial episode
• Residual symptoms after treatment
• Unhelpful coping styles
• Physical health or social/environmental stressors
• Co‑existing mental health disorders
• Time since the last episode (risk decreases as the time increases).

Interventions may have little impact on some of these factors, but for others, the course of action that follows recovery can influence an individual’s likelihood of relapse.

The National Institute for Clinical Excellence (NICE) recently released new guidelines for health professionals on the management of depression in adults. Based on a detailed examination of the evidence, the guidelines offer advice on relapse prevention across a number of different scenarios.

The guidance stresses the importance of collaborative decision making, while acknowledging that significant variation in practice and care is not always optimal.⁴

Evidence-Based Recommendations in the NICE Report

• Scenario 1 – Depression remitted with an antidepressant medication.
  According to the guidelines, continuing with medication at an effective dose for two years reduces an individual’s risk of relapse by 50%, whilst abrupt cessation increases the risk of relapse and withdrawal symptoms. Potential long-term problems associated with antidepressants – e.g. increased bleeding risk, effects on sexual function and difficulty stopping – need to be considered when making this decision.
  
  Regular reviews (at least every six months) with monitoring of mood, side-effects and factors that may affect the risk of relapse are required.
  
  Detailed recommendations concerning the process of stopping medications were made but the precise indications, beyond personal choice or impact of side-effects, were not forthcoming.
• Scenario 2 – Depression remitted, and the person wants to engage with psychotherapy either alone (so medication can be stopped) or in combination with medication.
  Evidence for the impact of Cognitive Behavioural Therapy (CBT) (particularly group) or Mindfulness-Based Cognitive Therapy (MBCT) is strongest, both alone and combined with antidepressants. It is important that therapy specifically covers “relapse prevention skills” and that top‑up sessions are provided over the course of a year.
• Scenario 3 – Depression remitted with psychological interventions alone.
  A relatively brief intervention is recommended that includes reviewing situations and behaviours that rendered the person vulnerable, what had been learnt during or helped by the therapy, and how these strategies might be employed in the future. The importance of identifying warning signs and early intervention is also stressed.
• Scenario 4 – Depression remitted with a combination of medication and psychological intervention.
  The guidance recommends that a discussion should be undertaken in the spirit of shared decision making about continuing either or both of these treatments. The outcome depends upon the person’s clinical needs and preferences.
  
  The evidence concerning the cost-effectiveness of these interventions was less clear cut. Medication can be relatively cheap with routine reviews provided in primary care, whilst psychological interventions require high intensity involvement from a professional over a prolonged period. The use of group work can offset these costs.⁵

While the NICE guidelines are still in draft form, they represent a rigorous, up-to-date analysis of the current evidence. For example, it has often been assumed that stopping medication was a positive step. While this may be the case, the evidence shows the reverse can sometimes be true. Engagement with appropriate psychological interventions should be regarded as a positive when looking at risk from the biopsychosocial perspective.

Claims managers should be looking to ensure that claimants are receiving evidence-based interventions that give the best chance of long-term recovery both at the individual level and through those who are providing rehabilitation services to their clients.

Endnotes

1. Depression in Adults: Prevention of Relapse, NICE guideline CG90 (update) evidence review C, Nov. 2021. https://www.nice.org.uk/guidance/GID-CGWAVE0725/documents/evidence-review-3. Last access 28.12.2021.
2. Depression in Adults: NICE guideline draft for consultation, Nov. 2021. https://www.nice.org.uk/guidance/gid-cgwave0725/documents/draft-guideline-4. Last access 28.12.2021.
3. Canadian Mental Health Association: Preventing Relapse of Mental Illnesses, 2011. Retrieved from: https://www.heretohelp.bc.ca/sites/default/files/preventing-relapse-of-mental-illnesses.pdf. Last access 28.12.2021.
4. Ibid at Endnote 1.
5. Ibid at Endnote 1.