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Chapter: Essentials of Psychiatry: Antidepressants

Antidepressants: Maintenance Period

The goal of the maintenance period is to prevent the recurrence of depression.

Maintenance Period


The goal of the maintenance period is to prevent the recurrence of depression. There are a number of reasons to consider long-term prophylactic therapy for depression rather than medication withdrawal. Depression is a lifelong disease, with recurrence be-ing the norm rather than the exception (Keller et al., 1992). As the number of acute episodes increases, the risk of future episodes increases as well, and the interval between episodes shortens. Each subsequent episode carries a higher morbidity and disabil-ity. Although better understood in bipolar disorder, there is a fear that treatment response may decrease with an increasing number of depressive episodes (Greden, 1993).


A number of factors can influence the decision of when it is appropriate to maintain long-term prophylaxis for depression. The seriousness of previous episodes, the severity of impairment caused by such episodes, the degree of response to previous treat-ments and the ability of the patient to tolerate the drug all play a role. Central in the decision process is the concept of recur-rent depression: that some patients are more likely than others to have a recurrence of the disease. Three previous episodes of depression make recurrent depression likely. The best predictors of the likelihood of recurrence appear to be older age of onset and number of episodes. Greden (1993) proposed that long-term maintenance is the treatment of choice for the following groups of patients: 1) those who were 50 years old or more at the time of the first depressive episode, 2) those who were 40 years old or more at first episode and have had at least one subsequent recur-rence, and 3) anyone who has had more than three episodes.


The recommended length of maintenance treatment needs further clarification as well. Recommended lengths of time vary from 5 years of treatment to indefinite continuation. There are only a handful of studies on maintenance antidepressant treatment.


Equally important in preventing recurrence of depression is the problem of maintaining adherence to medication long af-ter the acute episode has resolved. Proper education and support will help with compliance. Toleration of side effects is impor-tant and evidence suggests that patients are more likely to com-ply with the agents that have more favorable side-effect profiles. The serotonin reuptake inhibitors are generally the best tolerated antidepressants.


Although lower doses for prophylaxis have been recom-mended, there are few data to support this contention. Even though lower doses may increase compliance, full doses should be used until new information indicates otherwise.


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