Update on the diagnosis and treatment of depression

Medicine and Health Rhode Island, Oct 2003 by Attiullah, Naureen, Zimmerman, Mark

The second target dosage is the maximum - the one you will prescribe in the event of non-response or partial response. Patients should be on the maximum dose for at least a month before judging the medication ineffective. A failed trial should rarely extend beyond 12 weeks. By the end of the first or second week the patient should be receiving the initial target dose. If there is little-no improvement by the end of one month, the dosage should be increased. By the end of the second month of treatment, the dosage should be maximized. And by no later than the end of the third month, the goals of treatment should be met, or nearly met, or the physician should consider the next step.

ACHIEVING REMISSION

For most patients the goal of treatment is remission-a return to baseline. Often patients improve, but do not remit. The use of questionnaires is a cost-effective method of assessing treatment progress.

Once the patient has started on the medication, the dose should be increased until the patient achieves a response or the dose cannot be increased any further because of limiting side effects or until the patient reaches the maximum recommended dose. The goal is to give the patient an adequate trial of medication, which is loosely defined as the patient reaching the maximum recommended dose for at least four weeks, before deciding whether the medication is effective. If the patient goes into remission, s/he should stay on that dose for the continuation phase. If the patient was not able to increase the dose because of side effects, a change in antidepressants might be warranted. If the patient does not respond to the maximum recommended dose, the antidepressant should be switched. If the patient has had a partial response, some evidence shows that augmentation with medications such as Lithium, thyroid or another antidepressant may be more effective than a switch to another antidepressant.

For some patients, especially those with chronic or recurrent depression, a complete resolution of symptoms may not be a realistic goal. Their goal should be reduced symptoms and improved functioning.

Continuation treatment

Continuation treatment typically lasts 4-9 months after symptom remission. In theory the duration depends on an estimate of when the episode would have remitted spontaneously. In reality, this recommendation is based on research demonstrating that discontinuation before this time is associated with an increased likelihood of relapse. Patients with longer prior episodes would be candidates for lengthier treatment.

Continuation phase medication treatment should end with a gradual taper of medications and careful symptom assessment during and for several months following discontinuation. Whenever clinically feasible, continuation medication should be at the dosage used during acute phase treatment. This recommendation is based on evidence from maintenance trials using lower doses of TCAs which found a higher recurrence rate than was obtained with full-dosage treatment.