Beyond Acute Treatment of Depressive Disorders
Mark Hyman Rapaport, MD
Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, and the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles
Depression is a long-term illness that requires 3 phases of treatment—acute, continuation, and maintenance therapy—to prevent recurrence.1 Acute treatment has been thoroughly studied, while continuation and maintenance treatment have received less attention. However, MDD is an ongoing illness for many people, and all 3 treatment phases should be implemented to achieve and maintain remission from depression.
The duration of continuation therapy is debatable, but usually the acute phase lasts up to 12 weeks, and the continuation phase lasts 3 to 6 months.2 The purpose of the continuation phase is to maintain the improvements achieved during the acute phase and to prevent relapse. Studies3,4 have shown that patients who continue effective acute phase medication or psychotherapy during the continuation phase have lower rates of relapse than those who discontinue treatment (AV 1).
Clinicians should carefully monitor patients throughout continuation treatment, keeping in mind that the dose or frequency of treatment that was beneficial during the acute phase may not remain as effective during the continuation phase. Modifications should be made when necessary to ensure continued improvement or sustained remission; however, little data are currently available about how to fine-tune continuation phase interventions.
In all treatment phases, clinicians should measure not only the patient’s symptoms but also quality of life, overall functioning and productivity, and psychological well-being (eg, autonomy and self-acceptance5). Research6,7 has shown that symptom improvement alone does not necessarily result in quality of life or functional improvement. Some questions that need to be more carefully investigated in continuation therapy research include: (1) What should be the frequency of continuation visits? (2) What should be the content of these visits? and (3) What types of interventions should be implemented when acute treatment approaches are no longer as effective as they were initially?
Few controlled studies have investigated maintenance therapy for MDD, probably because obtaining this type of data is costly and time consuming. Still, the necessity of maintenance treatment to prevent relapse and recurrence of depression is well-known. Patients with certain risk factors for recurrence—more than 2 depressive episodes,8 longer depressive episodes,8 multiple active axis I disorders (such as substance or alcohol use disorders and anxiety disorders),8 older age at onset (after 60 years),8 comorbid medical illnesses,9 lack of psychosocial support,9 difficulty achieving remission,9 or the presence of residual symptoms after remission10—may need maintenance treatment more than others. The idea of long-term therapy should be discussed with these patients at the beginning of treatment.
Placebo-controlled trials11–14 have reported the efficacy of continued full-dose medications throughout maintenance treatment in protecting against future episodes of depression (AV 2). However, in each of these studies, a substantial number of participants experienced a recurrence. Although the number of recurrences was significantly fewer than in the placebo groups, this finding emphasizes the need to individualize treatment for patients with MDD, even during the maintenance phase of therapy.
Psychotherapy can also be efficacious maintenance treatment and may not require the full dose (or visit frequency) that was needed during acute treatment; however, the difficulty of attaining remission during acute treatment may affect the efficacy of maintenance psychotherapy (AV 3).15 Frank et al16 examined the effect of IPT as maintenance treatment in women with recurrent depression. The study reported that about three fourths of patients who achieved remission in the acute phase with weekly IPT and received maintenance IPT experienced no recurrence of depression during 2 years of follow-up. No difference was found between weekly, twice-monthly, or monthly maintenance IPT sessions in preventing recurrence. However, participants who required both IPT and an SSRI to achieve remission in the acute phase had a significantly shorter time to recurrence than those who remitted with IPT alone (P < .02). More research about combination therapies for recurrent depression is needed.
Information about maintenance phase treatment in real-world settings is scarce. A STAR*D report17 discussed results from a 1-year, naturalistic follow-up phase in patients with MDD who achieved response or remission with acute treatment. The study found that patients who took longer to respond or remit with acute phase therapy had higher rates of relapse during the follow-up phase. Those who achieved response but not remission during the acute phase were at particularly high risk for poor long-term outcomes. Because patients chose whether or not to participate in the follow-up phase, those who did participate may have been particularly motivated to continue treatment, and thus these data may actually be overly optimistic.
More in-depth studies of maintenance therapy are needed to determine approaches that are likely to benefit individual patients. In addition, specific questions need to be addressed. These unanswered questions include: (1) If long-term outcomes should be individually tailored for patients, what are those elements? and (2) Besides maintaining symptom remission, should quality of life and functioning be addressed, and, if so, how?
Research supports the need for both continuation and maintenance therapy when treating patients with depressive disorders. All phases of treatment should be individualized to the patient’s needs to increase the likelihood of positive outcomes. However, more research about how to best individualize treatment is needed. Current data suggest that rigorous and vigorous intervention by clinicians can substantially improve patients’ long-term outcomes.
IPT = interpersonal psychotherapy
MDD = major depressive disorder
SSRI = selective serotonin reuptake inhibitor
STAR*D = Sequenced Treatment Alternatives to Relieve Depression
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