TREATING SYMPTOMS IN DEPRESSION
Treatment objectives

Effective depression therapy spans beyond improvement and cessation of clinical symptomatic presentations. To optimise the patient’s chances of achieving remission, residual symptoms should be assessed and addressed, steps should be taken to prevent relapse wherever possible, and treatment adherence should be encouraged throughout the course of therapy.1,2

 

Achieving remission

A review of the landmark STAR*D study revealed that almost 50% of patients with major depression do not achieve remission following treatment with two different SSRIs3

Remission in depression is defined as a return to ‘normalcy’ for the patient, whereby they are fully recovered from all symptoms of the condition.4 In addition, a number of quantifiable definitions of remission exist in line with different assessments of depression severity.5 For example, a score of ≤7 on the Hamilton Depression Rating Scale is occasionally used to define remission in clinical studies, while a score of ≤4 on the Montgomery-Åsberg Depression Rating Scale can also be used.5,6 However, in clinical practice, patients deemed to be in remission often continue to experience residual depressive symptoms, and treatment up to the point of complete remission is not common practice.2

Treating residual symptoms

Residual cognitive symptoms have been shown to present, on average, for 44% of the time during periods of ‘remission’ in patients initially diagnosed with depression2

The presence of residual symptoms following determination of remission, of which cognitive dysfunction is among the most prevalent, is often detrimental both to the patient and those around them, as any residual impairment often reduces the patient’s productivity at work and general quality of life.2,7 Over time, this can cause the patient to relapse into another major depressive episode, or even a chronic course of depression.2,7

Preventing relapse

In one study of patients considered to be in remission, 76% of those with residual symptoms relapsed within 10 months, compared to 25% of those with no apparent residual symptoms.8

Cessation of the emotional manifestations of depression is not enough to achieve recovery. As residual symptoms can increase a patient’s risk of relapse, these must also be assessed and addressed appropriately.2,7 One recommended way of ensuring that this is done is to repeatedly evaluate symptom severity at each follow-up appointment, using the same assessments used during the initial diagnostic process.9 This provides a marker of symptom progression and treatment success over time, and may aid the recognition of these residual symptoms, and hence their appropriate treatment.9

Maintaining adherence

In one study, only 30% of patients with depression remained adherent to their treatment after 3 months – almost 50% lower than that seen in diabetic and hypertensive patients in the same study.10

Adherence to antidepressant treatment is essential for a successful outcome, and should be maintained for at least 6 months after symptom cessation.11,12 Yet, in the aforementioned study, while 30% of patients with depression were adherent to their medication 3 months after treatment initiation, this decreased further to 20% after 6 months, and just 8% after 12 months, highlighting the extent of non-adherence among patients with the condition.10 Such reduced adherence can increase the risk of recurrence and/or relapse in depression, in addition to promoting the persistence of depressive symptoms.13,14 Prolonged depression or relapse also places great burden on healthcare systems as patients seek further care from their treating physician,15 and increases the risk of concomitant medical conditions such as coronary heart disease or diabetes.16,17 Adherence is therefore an important challenge to overcome, and collaborative approaches to patient care such as pharmacist-provided patient education and disease management programs may help those with depression to continue treatment as recommended by their doctor.18,19 To learn more about adherence in antidepressant treatment, visit the ‘Addressing adherence’ page

     

    References
    1. Akerblad AC et al. Response, remission and relapse in relation to adherence in primary care treatment of depression: a 2-year outcome study. Int Clin Psychopharmacol 2006; 21: 117-124.
    2. Conradi HJ et al. Presence of individual (residual) symptoms during depressive episodes and periods of remission: a 3-year prospective study. Psychol Med 2011; 41: 1165–1174.
    3. Coplan JD et al. A neurobiological hypothesis of treatment-resistant depression – mechanisms for selective serotonin reuptake inhibitor non-efficacy. Frontiers in behavioral neuroscience 2014; 8: 189.
    4. Mezzasalma MAU. Evaluation of major depression in a routine clinical assessment. Diabetol Metab Syndr 2010; 2: 9.
    5. Zimmerman M et al. How should remission from depression be defined? The depressed patient’s perspective. Am J Psychiatry 2006; 163: 148–150.
    6. Zimmerman M et al. Defining remission on the Montgomery-Åsberg depression rating scale. J Clin Psychiatry 2004; 65(2): 163–168.
    7. Greer TL et al. Defining and measuring functional recovery from depression. CNS Drugs 2010; 24(4): 267–284.
    8. Paykel ES. Partial remission, residual symptoms and relapse in depression. Dialogues Clin Neurosci 2008; 10(4): 431–437.
    9. Culpepper L. Cognition in MDD: implications for primary care. In: Cognitive dysfunction in Major Depressive Disorder. Ed: McIntyre R, Cha D, 2015.
    10. National Council on Patient Information and Education (2007).
    11. Bucci KK et al. Strategies to improve medication adherence in patients with depression. Am J Health-Syst Pharm 2003; 60: 2601-2605.
    12. The treatment and management of depression in adults, NICE clinical guideline 90. 2009.
    13. Doesschate MC et al. Adherence to continuation and maintenance antidepressant use in recurrent depression. J Affect Dis 2009; 115: 167-170.
    14. Melfi CA et al. The effects of adherence to antidepressant treatment guidelines on relapse and recurrence of depression. Arch Gen Psychiatry 1998; 55(12): 1128-1132.
    15. Lin EHB et al. Relapse of depression in primary care. Arch Fam Med 1998; 7: 443-449.
    16. Gan Y et al. Depression and the risk of coronary heart disease: a meta-analysis of prospective cohort studies. BMC psychiatry 2014; 14: 371.
    17. Talbot F and Nouwen A. A review of the relationship between depression and diabetes in adults. Diabetes Care 2000; 23: 1556-1562.
    18. Badamgarav E et al. Effectiveness of disease management programs in depression: a systematic review. Am J Psychiatry 2003; 160: 2080-2090.
    19. Gilbody S et al. Educational and organisational interventions to improve the management of depression in primary care – a systematic review. JAMA 2003; 289(23): 3145-3151.
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