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Goals of Treatment
The goals of treatment in MDD are full remission of symptoms of depression with restoration of optimal work and social func-tioning. During the course of treatment ongoing education of the individual and family regarding remission, relapse and recurrence is critical. This education alerts both those affected by the illness and their families to the early signs of relapse and can assist in prevention of recurrence. Improved social and work functioning following an episode of depression is an important associated goal of treatment. Many studies have demonstrated the benefit of de-pression-specific psychotherapy as an important aspect of main-taining remission and improving work and social functioning. The establishment of a collaborative working relationship among the patient, family and psychiatrist is an essential aspect of recovery. The data which demonstrate efficacy in psychiatric management and treatment infers that a collaborative relationship is present.
All psychiatric treatment whether pharmacotherapy or psycho-therapy or the integration of pharmacotherapy and psychotherapy, first requires a well-established diagnostic formulation in order to achieve optimal response to treatment. As the diagnostic process is undertaken an ongoing therapeutic alliance must be established. In the treatment of MDD an understanding of the clinical history of each individual’s distress is necessary. As the clinical history is elic-ited the appropriate target signs and symptoms of MDD are obtained and the patient is educated as to the nature of the symptom patterns which represent his or her unique form of depressive disorder.
The phases of treatment include:
· An acute phase directed at reduction and elimination of de-pressive signs and symptoms, and active restoration of psy-chosocial and work functioning.
· A continuation phase directed at prevention of relapse and re-duction of recurrence through ongoing education, pharmaco-therapy and depression-specific psychotherapy.
· A maintenance phase of treatment directed at prevention of future episodes of depression based upon the patient’s per-sonal history of relapse and recurrence.
Acute phase treatment may involve all interventions that are di-rected toward decreasing signs and symptoms of depression and maintaining the individual’s capacity to work and interact with oth-ers in a manner consistent with premorbid levels of social and work functioning. The acute phase treatments may include supportive psychotherapy focusing on resolution of current disputes. A form of supportive therapy may be combined with recommendations for pharmacotherapy. The standard pharmacotherapies which are avail-able for treatment of depression have increased dramatically in the past two decades. In mild to moderate depressive disorder, more depression-specific forms of psychotherapy have been established including cognitive–behavioral psychotherapy, interpersonal psy- chotherapy, or short-term dynamic psychotherapy. In these forms of psychotherapy, which have been studied to address mild to moder-ate nonbipolar depressive disorder, the focus of the psychotherapy is very clearly explicated to the patient before the initiation of the psychotherapy. For severe depressive disorder with melancholic or psychotic features, these specific forms of short-term psychotherapy may not be as effective as focused pharmacotherapy. Pharmaco-therapy in these conditions is associated with more rapid treatment response than is psychotherapy. During the acute phase of treatment for depressive disorder the optimal treatment should result in resolu-tion of depressive signs and symptoms anytime between week 8 and week 16 of treatment. If resolution of depressive signs and symptoms does not occur during the first 2 to 4 months then the initial diagnos-tic formulation must be reviewed and alternative treatment strate-gies must be introduced. Some of the factors associated with lack of complete treatment response include the presence of cooccurring personality disorders, concurrent alcohol or substance abuse, a poor therapeutic alliance leading to lack of adherence to treatment recom-mendations, and persistent or unfavorable side effects of treatment.
When acute phase treatment does lead to remission of signs and symptoms, then the next phase of treatment begins. This phase of treatment is termed continuation treatment and its goal is prevention of relapse. It is often necessary to main-tain ongoing pharmacotherapy for 6 to 12 months after an acute episode of depression during this continuation phase, because there is substantial vulnerability to relapse if medication treat-ment is prematurely interrupted. During the continuation phase ongoing psychotherapy may be particularly important to address residual symptoms of depression, and to alert the individual to a depressive response to subsequent traumatic circumstances, as well as ongoing clinical interaction with significant others is re-quired in order to address persisting interpersonal conflicts, and may promote even more complete recovery from the depressive episode. The continuation phase of treatment typically lasts 9 to 12 months to minimize the risk of recurrent episode. If this repre-sents the initial episode of depression, then medication treatment may be carefully withdrawn at the end of the continuation phase. However, if this represents a history of recurrence of depression (particularly two or more episodes in the preceding 3 years), maintenance treatment may well be recommended. In addition, maintenance treatment is recommended if two prior episodes have occurred within one’s lifetime.
Maintenance treatment of MDD is focused on prevention of future episodes of depression, after a recent recurrence of MDD and a prior history of two or more episodes of MDD. Often the maintenance phase of treatment involves ongoing treatment with antidepressants or alternatively mood-stabilizing treatment (particularly lithium carbonate), or a combination to sustain recovery from depression. When there is early onset (adolescent onset) of depressive symptoms with associated psychosocial impairment, then ongoing maintenance treatment along with rehabilitative psychotherapy may be most critical. During maintenance treatment, continuing education of the patient and family, identification of prodromal symptoms, and continuing efforts at work and psychosocial rehabilitation are indicated. Often the trials of maintenance pharmacotherapy in depression demonstrate the preventive benefit of maintenance medication. In the most often quoted study, recurrence rates of 20 to 25% were found in individuals maintained with full dose of imipramine, while the recurrence rate was 80 to 100% in those patients treated with placebo. The advantage of ongoing maintenance medicine has also been demonstrated at 5 to 10 years. With tricyclic antidepressants, maintenance medication is likely more effective at full dose rather than lower doses. Limited data exists as to the dosing of SSRIs or other types of antidepressants in maintenance treatment.
The site of treatment for MDD is based upon the severity of the acute episode and the psychiatrist’s judgment of the individual’s potential for suicide. Individuals with mild to moderate depres-sion are often treated in primary care or psychiatry office settings. Acute phase pharmacotherapy involving antidepressant medica-tion is often initiated by a primary care physician. However, the overall longitudinal care of MDD in primary care is the subject of increasing attention. Typically, individuals do not receive treat-ment for long enough periods and there is limited attention to the domains of social or work functioning. The referral to a psychia-trist may include a request for more expertise regarding medica-tion as well as the need for depression-specific psychotherapy. In addition, there has been a lack of focused attention to the role of integrated psychotherapy and pharmacotherapy in primary care. Inpatient treatment for depression is recommended when there is an immediate risk for suicide or recent suicide attempt. In these settings safety of the individual is the primary concern and often more intensive treatments including electroconvulsive therapy may be initiated. When there are comorbid general medical con-ditions and psychiatric disorders, inpatient psychiatric hospitali-zation may be useful to stabilize both the general medical condi-tion as well as the associated psychiatric disorder.
Initiation of treatment follows a careful psychiatric diagnostic in-terview. Assessment of the longitudinal clinical history must rule out bipolar disorder, comorbid PTSD, other anxiety disorders, and personality disorder. A completed mental status examina-tion is used to rule out associated psychosis or marked cognitive disruption. When these procedures are conducted empathically, the beginning of a favorable therapeutic alliance is established. In all circumstances an effective therapeutic alliance facilitates recovery from MDD.
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