Major depressive disorder relapse

Eava M, Schmidt ME, Zhang S, et al. Treatment approaches to major depressive disorder relapse. Part 2 Reinitiation of antidepressant treatment. Psychother Psychosom 2002 71(4) 195-199. 

Versiani M, Mehilane L, Gaszner P, Arnaud-Castiglioni R. Reboxetine, a unique selective NRI, prevents relapse and recurrence in long-term treatment of major depressive disorder. J Clin Psychiatry 1999 60 400-406. 

STRATEGIES FOR PREVENTION OF RELAPSE OF MAJOR DEPRESSIVE DISORDER... 

Chronic dysthymia followed by major depressive disorder ( double depression ) Prompt relapse following prior treatment discontinuation Strong positive family history of recurrent mood disorders Coexisting medical problems or complication of aging that would make a future episode hazardous... 

Keller MB, Shapiro RW, Lavori PW, et al Relapse in major depressive disorder analysis with the life table. Arch Gen Psychiatry 39 911-915, 1982b Keller MB, Klerman GL, Lavori PW, et al Treatment received by depressed patients. JAMA 248 1848-1855, 1982c... 

Preventing relapse is of critical importance in the life course of major depressive disorder, and every effort should be made to ensure patient compliance. 

Depression as an emotion is common and usually short-lived. As a symptom it can occur in most psychiatric disorders as well as other medical conditions, e.g. hypothyroidism, Parkinson s disease. As an illness, major depressive disorder (MDD), it is less common but, nevertheless, moderate to severe forms affect 5-10% of people in their lifetime and milder forms 20-30%. After a first episode, prophylaxis is required for at least 6 months and ideally 12 months to prevent relapse. This should usually be with the dose of antidepressant to which the patient initially responded. Those with recurrent episodes require prophylaxis over many years. 

Escitalopram was efficacious in patients with major depressive disorder in short-term, placebo-controlled trials, three of which included citalopram as an active control, and in a 36-week study in the prevention of relapse in depression (7). It has also been used to treat generalized anxiety disorder, panic disorder, and social anxiety disorder. Results also suggest that, at comparable doses, escitalopram demonstrates clinically relevant and statistically significant superiority to placebo treatment earlier than citalopram. The most common adverse events associated with escitalopram include nausea, insomnia, disorders of ejaculation, diarrhea, dry mouth, and somnolence. Only nausea occurred in more than 10% of patients taking escitalopram. 

Possibly the best evidence suggesting involvement of norepinephrine and serotonin in major depressive disorder devolved from depletion studies (Delgado et al., 1990). In these stndies, patients who have responded to treatment for depression are given procedures, which deplete brain levels of serotonin or norepinephrine. Serotonin levels are decreased by nse of a low monoamine diet, followed by a drink which inclndes all the amino acids except the serotonin precnrsor tryptophan. Norepinephrine levels are depleted by administration of alpha-methylparatyrosine. In patients who had responded to treatment with a serotonergic antidepressant, depletion of serotonin cansed a prompt and dramatic, but brief reoccurrence of the symptoms of major depression. In patients who had responded to treatment with a noradrenergic antidepressant, depletion of norepinephrine caused a relapse into depression. The converse was not true in other words, serotonin depletion did not canse relapse in patients who responded to noradrenergic antidepressants, and vice versa. 

Goodwin GM, Emsley R, Rembry S, Rouillon F. Agomelatine prevents relapse in patients with major depressive disorder without evidence of a discontinuation syndrome a 24-week randomized, doubleblind, placebo-controlled trial. J Clin Psychiatry 2009 70(8) 1128-37. 

Bipolar disorder is a mood disorder characterized by one or more episodes of mania or hypomania, often with a history of one or more major depressive episodes.1 It is a chronic illness with a course characterized by relapses and improvements or remissions. Mood episodes can be manic, depressed, or mixed. They can be separated by long periods of stability or can cycle... 

Chapter /, Modem Psychopharmaceuticals, written by Dr Hossein Fatemi, and Chapter 5, Psychopharmaceuticals and the Treatment of Mental Disorders, provide succinct, up to date, and well-referenced information on how to use the major classes of psychotropic drugs. The latter chapter discusses in a frank and balanced manner the ambivalence towards the use of pharmacologic agents in mental disorders felt by some, and the limitations on the achievements of current drugs as ideal therapies for schizophrenia, bipolar disorder and major depression in particular. Clearly, much has been accomplished, but many needs, especially for prevention of relapse, removal of specific types of symptoms, and restoraton of work and social function, remain to be accomplished by drug and psychosocial therapies. 

Panic disorder typically starts in the third decade of life, although it may start in childhood or late in life as well. It is a recurrent, chronic, and disabling condition, in which relapses after remission are common. Panic disorder affects females twice as often as males, and after remission, women are more likely to relapse than men. The long duration of illness and the presence of agoraphobia portend a less favorable prognosis. Suicide risk is comparable to that seen among patients with major depression. 

Bipolar patients with substance abuse disorders are more likely to have an earlier onset of illness, mixed states, higher relapse rates, poorer response to treatment, higher suicide risk, and more hospitalizations. Approximately 10% to 15% of adolescents with recurrent major depressive episodes subsequently have an episode of mania or hypomania. 

The natural history of major depression (either as unipolar depression or depressive phases of bipolar disorder) is that individual episodes tend to remit spontaneously over 6—12 months however, there is a high risk of relapse of depression for at least several months after discontinuation of antidepressant treatment. This risk is estimated at 50% within 6 months and 65—70% at 1 year, rising to 85% by 3 years. To minimize this risk, it is best to continue antidepressant medication for at least 6 months following apparent clinical recovery. Continued use of initially therapeutic doses is recommended, although tolerability and acceptance by patients may require flexibility. 

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