Recurrent major depression in adults and young people

Most patients with major depression will experience more than one episode in their lifetime. Episodes that occur after having achieved full remission are referred to as recurrent episodes.

If the patient is not taking an antidepressant at the time of recurrence, treat the recurrent episode with the antidepressant that previously achieved remission; however, also consider the guidance on antidepressant choice here. Use the recommended starting dose (see Antidepressant regimens for major depression in adults and young people) and target the dose that previously achieved remission. The same dose provides greater protection from recurrence than using a reduced prophylactic dose.

If the recurrence occurs while the patient is taking an antidepressant, consider increasing the dose of antidepressant, which may help achieve remission of symptoms. If a dose increase is not possible, consider using a different antidepressant. See Antidepressant regimens for major depression in adults and young people or, if 2 or more antidepressants have been trialled, see Treatment-resistant major depression in adults and young people. When changing from one antidepressant to another, refer to Switching antidepressants.

If a patient has had 2 or more depressive episodes within 5 years, 3 or more cumulative episodes, psychotic depression or a serious suicide attempt, continue antidepressant therapy for 3 to 5 years—sometimes lifelong therapy is required.

Psychological therapies, such as cognitive behavioural therapy (CBT), either alone or in conjunction with antidepressants, reduce the likelihood of depressive relapse. After acute treatment, 3-monthly ‘booster’ sessions with a psychologist during the first year of recovery can help prevent further relapse.

During remission, address factors that increase the risk of recurrent episodes, if possible. Educate patients and, if appropriate, their family, carers or significant others, on how to identify early warning signs of relapse and develop a plan for early intervention.

After the antidepressant course is complete, review the need for further management, taking into account any comorbid conditions and risk factors for further relapse. Some patients require lifelong antidepressant therapy.

Augmenting antidepressants with lithium reduces recurrences of major depression, especially for patients who experience recurrent depressive episodes while taking antidepressants. Augmentation with lithium is ideally initiated under the guidance of a psychiatrist. Combination treatment with an antidepressant and lithium may be required for long-term prophylaxis if prophylactic treatment with an antidepressant alone is inadequate.

There is a limited role for maintenance electroconvulsive therapy (ECT) in the specialist treatment of severe recurrent treatment-resistant depression.