Depression is a complicated and multi-dimensional mental health issue that affects millions worldwide. It is more than simply “feeling sad” or “having a bad couple of weeks,” it is a serious disorder that affects your thinking capacity, your emotions, your behaviours, and your overall functioning. Understanding how to manage depression successfully includes knowing how it develops, setting treatment goals, and developing strategy for long-term success. In clinical practice and the research literature, professionals often refer to the “4 R’s of depression”: Response, Remission, Recovery, and Relapse/Recurrence.
Understanding the stages of depression will help patients and their caregivers or when we think about clinical planning with patients, their goals, and concerns, and will also provide perspective to those of us who work in mental health professionally. Let us look at each of these stages of depression and hypothesize ways in which they will provide direction in the pursuit of health and wellness.
Understanding the 4 R’s of depression
The 4 R’s of depression—Response, Remission, Recovery, and Relapse/Recurrence—are important phases that can help to understand the process involved in the illness. Response refers to a change in depressive symptoms related to initial treatment—the individual has become noticeably better, but they likely still have some symptoms. Remission follows, as depressive symptoms have almost completely resolved, and the individual has returned to some level of functioning, which is a meaningful treatment goal. Recovery is defined as a sustained period of remission, generally months, with very little risk for immediate Relapse (return of symptoms in a period of remission) and returning to a state of emotional and psychological stability. Even with the Recovery phase, there is risk for Relapse (return of symptoms in remission) or Recurrence (a new episode of depression following Recovery).
Understanding that an individual has Response, Remission, and Recovery is important because it relates to the potential for continuous care and management of depression symptoms following ongoing adjustments to care to either reduce symptoms or avoid the recurrence of symptoms in the future.
What are the 4 R's of depression?
1. Response: The First Sign of Progress
Response is the first stage of improvement when beginning treatment for depression, and it is defined as a 50% or more reduction in severity of depression symptoms as measured with clinical scales. When a patient begins treatment, whether it is medication, therapy, reforming their lifestyle, or some combination of these, the first goal is to achieve a response and may notice early indicators of response, such as feeling more energetic, sleeping better, feeling less hopeless and being able to engage in daily activities.
It is important to note that response does not mean it is an unequivocal recovery; some symptoms may still remain. Response is meaningful because it is an indication of treatment effort, it adds to the patient’s sense of efficacy and motivation to continue treatment, and it is also useful to the healthcare provider as they track progress. If the patient does not respond or exhibits insufficient response, it encourages clinicians to modify the treatment plan, while they still monitor the patient’s progress toward remission or recovery.
2. Remission
In the context of depression, remission can be described as the absence of depressive symptoms that allows normal functionality (although some minor emotional ups and downs may remain). The treatment goal is to induce remission, which is quite different than just feeling “a little better” from being depressed – it is to feel well again. Remission can usually be assessed using standardized clinical tools such as the Hamilton Depression Rating Scale (HAM-D), or the Patient Health Questionnaire (PHQ-9), and is often identified by a stable mood, emotional capacity, normal sleep and appetite, increased engagement in prior hobbies and activities, improved cognitive function and concentration.
Remission is important because it has better long-term outcomes, and significantly lowers the risk of future episodes of depression. It can also mean a greatly improved quality of life and the capacity to return to a full personal, professional, and social role. Finally, these outcomes associated with remission also lowers the risk of relapse, meaning fewer remaining symptoms, and therefore, a reduced risk of ultimately falling back into depression.
3. Recovery
Recovery is defined as able to sustain remission for an extended period, often six months or longer, and represents enduring mental health and resilience. Recovery implies not only the absence of depressive symptoms, but also being able to live a rich and fulfilling life with emotional resilience. The signs of recovery include resilience to ordinary life stresses, healthy relationships personally and professionally, and absence of significant return of depressive symptoms.
Recovery is important in prevention of depression becoming chronic, personal development, and restoration of self-confidence from the reinforcement of self-control. To utilize recovery, therapy or medication should continue as appropriate, a robust support system should be cultivated, self-care should include exercise, mindfulness, stress management, and mental health should be monitored for early indications of warning signs.
4. Relapse/Recurrence: When Depression Returns
Relapse indicates a re-emergence of symptoms of depression before one has fully recovered from a depressive episode. Recurrence refers to the first onset of a new episode of depression once the person was previously fully recovered. Because depression can often be recurrent and may require ongoing treatment and monitoring, it is important to identify the differences between relapse and recurrence. Different factors can be associated with relapse. These can include the early discontinuation of therapy or medication and the initial treatment of inadequately addressing the issues.
Other factors can include high stress or unresolved emotional problems, and biological vulnerabilities (e.g., genetic risk). Signs of relapse would include depressed symptoms returning, social withdrawal, reduced interest or pleasure in activities, changes in sleep, changes in appetite, and reduced self-esteem. Prevention of relapse will focus on adherence to maintenance treatment, scheduled follow-up appointments with a healthcare provider, maintenance of healthy living practices, and managing symptoms through an early warning response.
Conclusion
The 4 R’s of depression are Response, Remission, Recovery, and Relapse/Recurrence provide practical, hopeful guidelines to manage depression. Whether you are just starting to think about therapy or have been addressing your mental health for years, applying these principles can help. There are countless ways to help you on your journey, from personalized depression therapy to supportive depression groups NYC. Don’t hesitate to reach out to a licensed depression therapist in NYC or sign on for depression counseling in NYC that best meets your needs. Your healing journey begins when you recognize you deserve better and take that first, courageous step toward a happier, healthier life.
References
- Ma, S., Yang, J., Yang, B., Kang, L., Wang, P., Zhang, N., Wang, W., Zong, X., Wang, Y., Bai, H., Guo, Q., Yao, L., Fang, L., & Liu, Z. (2021). The Patient Health Questionnaire-9 vs. The Hamilton Rating Scale for Depression in Assessing Major Depressive Disorder. Frontiers in Psychiatry, 12, 747139. https://doi.org/10.3389/fpsyt.2021.747139
- Jeronimus, B. F. (2018). Empirical evidence for definitions of episode, remission, recovery, relapse and recurrence in depression: A systematic review. Epidemiology and Psychiatric Sciences, 28(5), 544. https://doi.org/10.1017/S2045796018000227
- “Depression (major depressive disorder) – Symptoms and causes.” Mayo Clinic, 14 October 2022, https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007
- “Depression – StatPearls.” NCBI, https://www.ncbi.nlm.nih.gov/books/NBK430847/
