Management of recurrent depression

1. Reassess the diagnosis and current risk

• Severity, functional impairment, psychotic symptoms, catatonia, and suicidality
• Past episode pattern, prior response and adverse effects from treatments
• Adherence, alcohol or substance use, medical comorbidity, sleep problems, psychosocial stressors
• Possible bipolar disorder, especially past hypomania/mania, antidepressant-induced activation, family history, or unusually recurrent episodes. Antidepressant monotherapy is not appropriate for bipolar depression.
• Physical contributors where indicated, such as thyroid disease, anaemia, medication effects, and neurological or chronic illness.

2. Treat the acute episode

• Psychological therapy: CBT, behavioural activation, interpersonal therapy, or other evidence-based therapy. Combine with an antidepressant for more severe, chronic, or recurrent illness when appropriate.
• Antidepressant medication: If a prior drug produced good remission and was tolerated, restarting it is often reasonable. SSRIs are common first choices; selection should take account of prior benefit, adverse effects, withdrawal risk, interactions, sleep, anxiety, and overdose toxicity.
• Assess response early: Check adherence, side effects, suicidality, and symptom change. Lack of any improvement after about 2 to 4 weeks warrants a review, rather than simply waiting indefinitely. The Maudsley guide notes that absent early improvement predicts a lower chance of eventual response. The Maudsley Prescribing Guidelines in Psychiatry, p. 369.
• Inadequate response: First confirm diagnosis, dose, duration, adherence, and ongoing psychosocial or medical drivers. Then consider optimizing the dose if appropriate, switching antidepressants, adding structured psychotherapy, or specialist-guided augmentation/combination treatment. NICE identifies augmentation or combination approaches as options after inadequate response, but these require careful monitoring. The Maudsley Prescribing Guidelines in Psychiatry, p. 369.

3. Continue treatment after remission

• Continue the effective antidepressant at the same therapeutic dose for at least 6 months after remission in most patients.
• For recurrent depression, longer continuation and maintenance treatment is often indicated, especially with residual symptoms or frequent/severe prior episodes.

4. Decide who needs maintenance treatment

• Two or more prior depressive episodes, especially recent or frequent episodes
• Severe, prolonged, psychotic, or suicidal past episodes
• Residual depressive symptoms after apparent recovery
• Chronic depression
• Relapse after previous medication discontinuation
• Ongoing psychosocial adversity, isolation, substance misuse, or major medical/psychiatric comorbidity

5. Relapse-prevention psychological treatment

• Maintenance CBT or mindfulness-based cognitive therapy
• Identifying personal early-warning symptoms
• A written relapse-prevention plan: triggers, coping strategies, sleep routine, support contacts, and when to seek professional help
• Addressing relationship, occupational, financial, trauma-related, and substance-use contributors

6. Monitoring during maintenance

• Mood and functioning, preferably with a validated measure such as PHQ-9
• Suicidal thoughts and safety
• Medication adherence and adverse effects, including sexual dysfunction, weight change, sleep disturbance, and emotional blunting
• New stressors, substance use, medical illness, and pregnancy plans
• The person’s view of ongoing benefit versus burden

7. Stopping antidepressants

• Consider it only after sustained remission and a review of relapse risk.
• Taper gradually, usually over weeks to months, individualized to the drug, dose, duration of use, prior withdrawal symptoms, and patient preference.
• Distinguish withdrawal symptoms from relapse. Withdrawal often begins soon after reduction and may include dizziness, “electric shock” sensations, flu-like symptoms, anxiety, insomnia, and emotional lability.
• Provide a follow-up plan and rapid access to care if depressive symptoms return.

8. Treatment-resistant or severe recurrent depression