CG123 Common mental health disorders - National Institute for ...

Further assessment of risk and need for treatment, and routine outcome monitoringservice users, ECT tends to be used less frequently, and for treatment-resistant disorders.It is more likely to be used as first-line treatment in older populations. As aresult, findings are often mixed, with some studies reporting no effect of age on treatmentresponse.Finally, it is important to consider some of the therapeutic factors that can improvetreatment response. DODD2004 report that the greater the therapist–patient alliance,the better the pharmacological outcome, especially when the alliance is rated positivelyby the therapist. Optimism, from the psychiatrist or the patient, is also animportant predictor and research suggests that optimism correlates positively withimproved response (DODD2004).Factors predicting risk of recurrenceNeither gender, age, socioeconomic status or marital status were found to be associatedwith the risk of recurrence (FEKADU2009, HARDEVELD2010). However,older age may be associated with more previous episodes and greater medical comorbidity,which in turn increases rates of relapse (MITCHELL2009).With regard to personal factors, service users who, after achieving remission,experience impaired functioning (be it in work, relationship or leisure domains)appear to have a higher risk for recurrence of major depression. Similarly, use ofmoderate coping skills and having low self-efficacy can also result in higher risk ofrecurrence of major depression. Finally, although the evidence is mixed, having apersonality disorder can also be a predictor for recurrence (HARDEVELD2010).Interestingly, experiencing a severe life event and having low social support did notappear to relate to recurrence.A large number of clinical factors have been found to predict rates of recurrence.Age of onset of first depressive episode in particular is an important factor, with eachadditional year of age at onset lowering the risk by 0.96 (95% CI, 0.93 to 0.99).However, this finding has not always been successfully replicated (FEKADU2009).Similarly, shorter duration of illness at intake, lower illness severity during follow-upand fewer previous episodes are often cited as reducing the rate of recurrence(HARDEVELD2010). Risk of relapse has been found to increase from 55.3% afterStep 2 of treatment to 64.6% after Step 3 and 71.1% after Step 4 (FEKADU2009).The presence of both subclinical symptoms and comorbid axis I disorders alsoappear to increase the rate of recurrence. With regard to comorbid symptoms,dysthymia and social phobia (HARDEVELD2010), and delusions and agitation(FEKADU2009) have all been associated with an increase in the risk of recurrence.Research indicates that service users with subclinical symptoms after recovery frommajor depression relapse around three times faster than those without such symptoms(HARDEVELD2010). The rate of relapse for those entering follow-up with residualsymptoms has been estimated at around 58.6%, compared with 47.4% for those withoutresidual symptoms ( 2 6.4; p 0.01; FEKADU2009). However, the timeframe in which to measure relapse is important, because at 8 to 10 years’ follow-upthis difference is no longer significant (HARDEVELD2010). Residual symptomsaffect not only remission but also global functioning. According to FEKADU2009,participants with residual symptoms were more likely than participants without residual164