Response to treatment: Gaining and maintaining remission from depression

Journal of Family Practice, Dec, 2003 by Jaye Hefner, Adam Keller Ashton, Dale A. D'Mello, Bezalel Dantz, F. George Leon, Gary A. Matson, C. Brendan Montano, James F. Pradko, Norman Sussman, Bertrand Winsberg

In determining the patient's treatment status, it is important to fully define the following terms: remission, recovery, relapse, and recurrence.

* Although often used to designate a person diagnosed with depression who is no longer depressed, remission refers specifically to a total resolution of all depressive symptoms for a period of time less than 2 months.

* Recovery refers to the absence of any depressive symptoms for a sustained period of time greater than 2 months.

* Relapse is defined as a depressive episode occurring within 5 to 9 months of initial response to antidepressant therapy.

* Recurrence is defined as a depressive episode occurring 12 months or more into recovery. (1)

Importance of continuous reassessment

Managing depression into remission requires reassessment of symptoms and the patient's level of functioning throughout the course of treatment. Ongoing reassessment is critical to good clinical practice and should be a routine procedure for family physicians. Adequate monitoring of a patient's response to treatment and remission status involves a qualitative clinical assessment of patient mood, functioning, and well being, and a quantitative measure of depressive symptoms obtained through use of a standardized depression scale (eg, Zung). By monitoring mood, a physician can objectively follow a patient's continued response to antidepressant therapy.

Patient self-assessment tools

To correctly monitor patients' progress, one could use the examination room visual analog (featured on the back cover)to quickly reassess a patient's status. The authors believe that tools such as this should be incorporated into patient assessment at every office visit. Any suggestion of an inadequate level of antidepressant response detected should be evaluated further using a more sophisticated, validated measure. Still, the authors agree that no tool is likely to be as reassuring to patient and practitioner alike as a brief, direct interview.

In the course of reassessment, it should be noted that (clinically speaking) remission is a patient's return to his or her premorbid state of mood and function. Therefore, the physician should establish a baseline for the patient's premorbid mood and function which will serve as a barometer of progress during treatment. The authors believe that a realistic methodology for ascertaining a patient's progress in recovering from depressive anhedonia is the identification of 3 activities that a patient enjoyed engaging in prior to onset of the mood disorder.

Likelihood of relapse or recurrence

To prevent relapse or recurrence and to maximize recovery and remission, the APA guidelines suggest continuing pharmacotherapy for at least 16 to 36 weeks after remission (without relapse). However, practitioners should expect patients with major depression to eventually relapse or experience a recurrence of their depression, even after their first episode. (2)

The 5-year estimated rates of recurrence among patients with major depression in the short term are:

* 50% after 1 depressive episode

* 75% after 2 episodes

* 90% after 3 episodes. (1)

Over the longer term, additional evidence suggests that patients who have experienced just 1 previous episode of depression can expect a relapse rate of 85% when followed for a 15-year period. (2) Based on these statistics, one would be wise to consider that many depressed patients may need to be treated with lifelong maintenance therapy, especially after experiencing 3 episodes of depression.

Preventing relapse by selecting the most appropriate medication at onset

This brings full circle the importance of choosing an appropriate antidepressant medication right from the start of therapy. Careful consideration must be given to potential side effects--acute and chronic--both in the short and long term. An antidepressant medication to which a patient may respond well in the short term (ie, with mood elevation), may create long-term problems (ie, unwanted side effects). This may represent a short-term and short-sighted solution to a long-term problem.

Summary

In conclusion, depressive illness represents a major healthcare problem. Patients with this problem increasingly seek the help of family physicians to ameliorate depressive symptoms. Because untreated or poorly treated depression has the potential to negatively impact a patient's overall heath and quality of life, the onus is on family physicians to be vigilant and astutely diagnose depressive illness, no matter what its presentation.

Likewise, once a diagnosis is made, appropriate antidepressant therapy must be initiated promptly and monitored meticulously. With full knowledge that depression's course is often chronic and therapeutically difficult, it can nonetheless be professionally and personally rewarding for the family physician to meet that challenge, leading their patients with depression toward a better quality of life.

REFERENCES

(1.) Kupfer DJ, ed. Psychopharmacology: The Fourth Generation of Progress. New York, NY: Raven Press, Ltd; 1995:335-345.