Continuation
Period
This
period usually lasts 5 to 8 months after the end of the acute treatment period.
The goal at this phase is the prevention of re-lapse. There is a high risk of
relapse if treatment is discontinued after the acute treatment phase. The
National Institutes of Health Consensus Development Conference on the Mood
Disorders (1985) reported a cumulative relapse rate of 15% after 6 months and
22% after 12 months. Keller and colleagues (1982) found that the two best
predictors of relapse were a high number of previous depressive episodes
(greater than three predicted relapses) and underlying dysthymic disorder.
Once a patient
has responded to a medication, the medica-tion should be continued for a
minimum of 4 to 6 months, begin-ning from the point of initial response. The
World Health Organi-zation (1989) recommended 6 months as a minimum period for
continuation of treatment after the acute phase, and the American Psychiatric
Association (2000b) recommended a minimum of 16 to 20 weeks of treatment
following the full remission of symp-toms. This period should be lengthened for
the patient with a his-tory of longer depressive episodes.
Surprisingly,
few studies exist that directly look at the effi-cacy of antidepressants for
continuation therapy. However, there exists at least one placebo-controlled
study for each of the SSRIs (Montgomery et
al., 1988, 1993; Montgomery and Dunbar, 1993; Doogan and Caillard, 1992),
nefazodone (Feiger et al., 1999) and
mirtazapine (Montgomery et al.,
1998).
In the
past, it was suggested that, on achievement of eu-thymia, doses could be
reduced. However, it is more likely that levels similar to those needed at the
acute stage of treatment will be required throughout the continuation period.
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