Tell Me More About Depression.
8. Can depression be cured?
Depression is a recurrent illness. After one episode the risk of recurrence is 50%; increasing to 70% after two episodes and 90% following a third episode. This information has led to a growing emphasis on long term maintenance treatment and strategies to prevent recurrences, including Cognitive Behavioral Therapy (CBT) and preventive medication.
The goal of treatment is to achieve remission (i.e. absence) of symptoms so that the individual returns to a normal lifestyle. (see Figure 1) Complete remission usually requires treatments for 12 or more weeks. There is evidence to support longer term treatments with anti-depressants to reduce the risk of recurrence. Details are presented in Figure 2.
Figure 1: The phases of treatment of depression
| Phase |
Duration |
Objectives |
Activities |
| Acute |
6-12 weeks, or longer |
• Remission of symptoms
• Return to previous full function |
• Establish therapeutic alliance
• Provide education
• Choose treatment
• Monitor response |
| Maintenance |
6 months following remission, or longer |
• Prevention of relapse
and recurrence |
• Provide education
• Manage side-effects
• Rehabilitation
• Monitor for recurrence |
|
Figure 2: Recommendations for maintenance treatment of major depression
| • All patients should continue on anti-depressants for at least 6 months after a full remission of symptoms. |
| • Patients with the following risk factors require longer maintenance treatment – at least 2 years, and for some, lifetime: |
| |
• chronic episodes (> 2years duration).
• severe episodes (suicidality, psychotic depression).
• resistant or hard-to-treat episodes.
• frequent episodes (2 episodes in past 2 years).
• recurrent episodes (3 or more lifetime episodes).
• older age (>65 years). |
| • The anti-depressant dosage in the maintenance phase should be the same dosage as in the acute phase. |
| • If the decision is made to discontinue an anti-depressant, the anti-depressant should be tapered slowly to avoid discontinuation symptoms. |
| • Psycho-education about early signs of relapse should continue (e.g., recurrence of sleep disturbances), and patients should have regular follow-up every 2-3 months. |
| • Psychotherapy, e.g., Cognitive Behavioural Therapy (CBT), may be helpful to prevent relapses. |
| • Co-morbid medical conditions and psychiatric disorders should be treated and rehabilitation programs (e.g. vocational counselling) may be helpful. |
|
References:
Lam RW, Kennedy SH. Evidence-based strategies for achieving and sustaining full remission in depression: focus on metaanalyses. Can J Psychiatry 2004;49(3 Suppl 1):17S-26S.
Keller MB. Past, present, and future directions for defining optimal treatment outcome in depression: remission and beyond. JAMA 2003;289:3152-3160.
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