Treatment of Recurrent Depression

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Realizing this cycle wasn't going to go away on its own, Kelly finally decided to seek help. She received a formal diagnosis of depression and was prescribed antidepressants. But Kelly says the medication she tried proved not to be the answer for her. It often takes trial and error to find the best type of medication or combination of medication to effectively treat depression, explains James Greenblatt, MD, an assistant clinical professor at the Tufts University School of Medicine in Massachusetts, medical director of a private integrative psychiatric practice near Boston, and author of The Breakthrough Depression Solution.

For Kelly, the depression diagnosis did have a positive outcome: She was ready to address the problem and find answers to help her manage her recurrent depression. To manage her depressive episodes and prevent relapse, Kelly began searching for additional depression therapies, including acupuncture. As with traditional medications, acupuncture is not a one-size-fits-all treatment option for depression. Managing depression is multifaceted and complex, and your treatment plan may need to be modified at times. That makes it critical to discuss any complementary therapies with your doctors and therapists to ensure all aspects of treatment are working together.

Kelly says that though acupuncture was helping her feel better, "I knew I still wasn't 'cured. Even when I was feeling good, I had very little energy and was generally apathetic most of the time.

Major depressive disorder

She was beginning to feel hopeful that she could control her depression. Kelly continued to look for more ways to cope with her recurrent depression.

The underlying vulnerability is always there, waiting to be triggered by the right set of circumstances. Untreated depression can be extremely debilitating to an individual, interfering with every part of life. In addition, severe depression can potentially lead to suicide if it does not receive immediate attention. Depression has been linked to a variety of illnesses including heart disease, obesity, diabetes, Alzheimer's disease, and other chronic disorders.

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Having depression can make it more difficult to treat other medical illnesses because of the lack of motivation and energy associated with depression make it more difficult for patients to comply with their treatment regimens. Current evidence suggests that someone who has had one episode of depression has a 50 percent risk of another. With each additional episode, this risk rises, increasing to 70 percent after a second episode and 90 percent after the third. Depression is quite treatable so there is no need to "buck up" and suffer through an episode.

While it might seem heroic to tough it out, it is not necessary and in fact, it is dangerous to your health. That said, self-care , such as sleeping well, eating well, and not abusing alcohol or drugs to cope can absolutely help you feel better faster. Many people with depression, however, understandably struggle with self-care during episodes. Getting the appropriate treatment can shorten the length and severity of the episode.

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Antidepressants can start to relieve the symptoms of depression in as little as two to four weeks before the illness has time to linger and possibly grow worse. According to research from the University of South Australia, the average duration of antidepressant treatment is two years in people under 24 years, three years in people 35 to 44, and up to five years 55 to While it's not impossible that a particular episode of depression will go away on its own if given enough time, there are some very compelling and important reasons why a person should not hesitate to get professional help.

Relief from severe depression and suicidal ideation within hours: from synapses to symptoms

Timely and adequate treatment should always be the goal when someone presents with symptoms of depression. Everything feels more challenging when you're dealing with depression. Get our free guide when you sign up for our newsletter. Preventing recurrent depression: long-term treatment for major depressive disorder. Depression and the Link with Cardiovascular Disease. Front Psychiatry.

Managing chronic depression

Burcusa, S. Antidepressant withdrawal after continuation and maintenance should always be gradual, over a minimum of 3 months and longer after longer maintenance periods, to avoid withdrawal symptoms or rebound relapse. Trials of interpersonal therapy in the prevention of recurrence show some benefit, but effects are weaker than those of drug and additional benefit in combination is limited. There is better evidence for effects of cognitive therapy in preventing relapse and an emerging indication for its addition to antidepressants, particularly where residual symptoms are present.

This paper will review the use of medication, principally antidepressants, and of psychological treatments in the longer term treatment of unipolar depression. Most modern treatments for depression are comparatively recent in development. Tricyclic and MAO inhibitor antidepressants were introduced at the end of the s, other medications, and modern specific psychological and psychotherapeutic treatments tailored to depression, later.

Prior to the modern antidepressant era many follow-up studies of depression were published. Robins and Guze 1 , in reviewing these, found a wide range of outcomes in different studies.

Longer term outcome in depression

The advent of antidepressants produced optimism regarding the treatment of depression, but in fact relatively few long-term follow-up studies of depression were published in the s and s. More recent studies have made it clear that, although the immediate outcome of depression following treatment is good in terms of improvement, there are continuing problems in the longer term.

When the first antidepressants were introduced, it was assumed that only short-term treatment of about 3 months was usually required. By the mid s, it was becoming apparent that this was often too short and by the early s antidepressants were usually continued longer. Problems in spite of this pattern of treatment became evident with follow-up studies reported by Keller and colleagues from the US 3 —6.

The remainder had courses characterised by recovery and recurrences. More recent studies have found similar outcomes 10 , A further problem which has become increasingly clear is occurrence of residual symptoms after partial remission 12 , which occurs in up to one-third of depressed patients, and is associated with very high risk of relapse. Data are still lacking on depression treated in primary care, the common setting for treatment of depression in most countries, and on patients presenting with index episodes requiring psychiatric out-patient rather than in-patient treatment.

These groups, more mildly ill than hospitalised subjects, might have better outcome. The renewed attention to longer term outcome has led to a more precise terminology The term remission is now used to describe the earlier part of the time when symptoms have subsided. It may be complete or incomplete with residual symptoms and it may be followed by subsequent problems. The term recovery is used by contrast to describe a state of freedom from symptoms which is both complete and persistent. The word relapse has been reserved for an early return of symptoms which can be regarded as return of the original episode, and the term recurrence for a later occurrence of symptoms which can be regarded as a new episode.

There is no precise separation between these two, but there is evidence that rates of symptom return are highest in the first 6—12 months after remission and then diminish In parallel, a new terminology has developed in relation to drug treatment. The term continuation therapy has been applied to the continuation of antidepressants following acute treatment which ought to be routine for some months, with the purpose of preventing relapse. The term maintenance treatment is applied to longer treatment aimed at preventing recurrence in those at high risk. Since the s, good evidence has accumulated regarding the efficacy of longer term antidepressant treatment 14 , The earliest studies were of tricyclic antidepressants and MAO inhibitors, but there are now increasing studies of SSRIs and newer drugs.

It would appear that all drugs which have substantial acute antidepressant effects have some effects in prevention of relapse and recurrence.

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Table 1 shows results of randomised controlled trials RCTs of continuation in relapse prevention. These have usually been withdrawal studies comparing effects of treatment for 6—9 months in responders to acute treatment, with withdrawal to placebo after 2—3 months. All the studies showed considerable benefit from continuation, with relapse rates at least halved. The absolute rates vary among studies because of sample characteristics.

Relapse rates were particularly high after discontinuation of MAO inhibitors, although it is unclear whether this indicates a particular effect of the drugs, or something about the kinds of patients likely to respond to them.

12 signs of a depression relapse

Two further studies, not shown in the table, examined effects of administering antidepressants or placebo after ECT 16 , Both found relapse rates lowered on antidepressants. A controlled trial of antidepressant augmentation by lithium found significantly higher relapse rates after early lithium withdrawal than continuation A recent study 19 employed a staged randomised design, with withdrawal to placebo after 3 months, 6 months or one year. It is recommended that where response to acute antidepressant treatment has occurred, there should routinely be a following continuation period.

Recommendations for its length have been for approximately 6 months after response 20 or for 4 months after complete remission with no residual symptoms In view of the Reimherr study, a longer period of 9—12 months after complete remission would now appear more prudent. Withdrawal should always be slow over at least 3 months. Relapse is particularly likely to follow drug withdrawal in patients with residual symptoms 22 , In some patients, withdrawal will be followed by return of depressive symptoms.

Where withdrawal has been slow, this may occur while the patient is still on a low dose. Clinical experience indicates that this phenomenon usually reflects impending relapse, and if the symptoms persist, full dose should be resumed followed by continuation for a further 9—12 months.

Some of these patients relapse again on later drug withdrawal and a period of maintenance treatment then becomes appropriate. ECT continuation after acute treatment has not been tested in controlled trials but one is now under way in the US. Occasionally patients are encountered clinically who respond to ECT but relapse repeatedly when it is stopped, in spite of vigorous treatment with antidepressants and lithium.

There may be a limited place for continuing it with a reduced frequency of 1—4 per month for up to 6 months. In the author's view, longer continuation or maintenance is best avoided, in view of effects on memory and anaesthetic risks in out-patients.

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  • There have also been many controlled trials of antidepressants versus placebo in longer term maintenance of 2 years or more in prevention of recurrences. These are summarised in Table 2. The most common design is again a withdrawal one, after acute treatment of recurrent depression, and response. The more recent studies have also required a symptom-free continuation period before randomised assignment to the maintenance phase has commenced. A few studies have started maintenance treatment de novo , following acute treatment with a variety of antidepressants or ECT.

    Controlled trials of antidepressant maintenance in prevention of recurrence in unipolar depression. Maintenance studies also show benefit from long-term antidepressants although differences between drug and placebo treated groups are not as marked as for continuation therapy, and a few studies have been negative.