1. How long do I need to continue to take antidepressant medication?
A few months after my symptoms had disappeared, I decided that I no longer needed the antidepressants, gradually lowered the dose and came off them. About 4 weeks later I realised this was not such a smart move! The symptoms of depression had definitely returned, and not wanting to ever return to the world of depression, I went straight to my doctor to resume treatment.
Mine is a common story. All too often we hear that people who have taken medication for depression and stopped it once they were feeling better, find that the symptoms of depression very quickly return. Professor Keller's presentation showed that rather than just feeling "better" (responding), we need to feel "well" (remission), and maintain this level for some time before we stop treatment. Apart from the obvious reasons for this, the research showed that this was a key factor in preventing a relapse of the major depression.
What this means is that rather than our aim being a reduction in the symptoms of depression (response), our aim should be to get to the point where we have little or no symptoms remaining (ie 'a-symptomatic),are feeling well, and maintain this a reasonable period of time (remission). The time frame suggested by Professor Keller was 6 to 9 months of minimal or no symptoms of depression. Note that this period doesn't start when we begin medication, but from when we are feel well again – ie 'a-symptomatic'. Often it can take some time to find the right medication for us as an individual, and then some time for us to recover to the point where the symptoms are gone.
The research presented by Professor Keller showed that there is a significant correlation between the length of time that a person continues with treatment following 'remission' and the probability of a relapse.
2. Will I recover from depression? Will it return?
While it is impossible to state with any certainty whether a particular person will have a further depressive episode once they have recovered, there are some factors that do influence the likelihood of the depression returning. Those presented by Professor Keller are:
Risk factors for recurrent depression: (Who needs maintenance therapy?)
1. History of frequent and/or multiple episodes
2. Major depression plus dysthymia (ongoing mild depression)
3. Onset after 60 years of age
4. Long duration of individual episodes
5. Family history
6. Poor symptom control during continuation therapy
7. Co-morbid anxiety disorder or substance abuse.
While once we are in a particular situation there is not a lot we can do about the first 5 of the risk factors, we can do something about the last two. That is, we can influence – and hopefully reduce the risk of the depression returning by:
1. Achieving remission (feeling 'well') rather than just recovery (feeling 'better') and continuing treatment for 6 to 9 months after remission is achieved.
2. Making sure that not only is the depression correctly diagnosed and treated, but that any other related conditions such as anxiety, drug or alcohol abuse, etc are treated / addressed as well.
Ongoing maintenance treatment is recommended for people who have had more than three episodes of major depression or who have had more than two episodes plus any of the risk factors listed above. The goal here is to prevent new (recurrent) episodes of major depression. The suggested duration for ongoing maintenance treatment is 2 'episode cycles' (This may be several years).
Role of Psychotherapy
The generally accepted preferred treatment for depression is a combination of psychotherapy and antidepressant medication. While in the above discussion, the focus has been on issues relating to antidepressant medication, psychotherapy plays an important role in treating depression.
Professor Keller presented the following important research results comparing:
Medication alone – 50% experience elimination of symptoms in 10 weeks
Therapy alone - 50% experience elimination of symptoms in 10 weeks
Medication + Therapy – 85% experience elimination of symptoms in 10 weeks
Note that the 'therapies' used in this study were Cognitive Behavioural Therapy and Interpersonal Relationship Therapy – as appropriate for the particular person.
The role of therapy in ongoing maintenance was not investigated, but it does make sense to ensure that the skills and techniques we learn during the initial therapy be reinforced and continually practiced not only during treatment, but beyond and into our healthy lives!
Disclosure: The sponsors of the Marty Keller Tour were Wyeth Pharmaceuticals, manufacturers of Efexor-XR.
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