Prevention unipolar depression

Clarke, G.N., Hawkins, W, Murphy, M., Sheerer, L.B., Lewiston, P.M., and Seeley, J.R. (1995) Targeted prevention of unipolar depressive disorder in an at-risk sample of high school adolescents a randomized trial of a group cognitive intervention. / Am Acad Child Adolesc Psychiatry 34 312-321. 

TABLE 20-1. Efficacy of antidepressant maintenance versus placebo in prevention of unipolar depression... 

Lithium has been proven effective for acute and prophylactic treatment of both manic and depressive episodes in patients with bipolar illness (American Psychiatric Association 2002). However, patients with rapid-cycling bipolar disorder (i.e., patients who experience four or more mood disorder episodes per year) have been reported to respond less well to lithium treatment (Dunner and Fieve 1974 Prien et al. 1984 Wehr et al. 1988). Lithium is also effective in preventing future depressive episodes in patients with recurrent unipolar depressive disorder (American Psychiatric Association 2002) and as an adjunct to antidepressant therapy in depressed patients whose illness is partially refractory to treatment with antidepressants alone (discussed in Chapter 2). Furthermore, hthium may be useful in maintaining remission of depressive disorders after electroconvulsive therapy (Coppen et al. 1981 Sackeim et al. 2001). Lithium also has been used effectively in some cases of aggression and behavioral dyscontrol. 

In bipolar depressed patients, lithium (with or without concurrent antidepressants) is the maintenance treatment of choice, with divalproex (DVPX) or carbamazepine as potential alternatives (see also Chapter 10, Maintenance/Prophylaxis ). Maintenance lithium has also been shown to prevent relapse in recurrent unipolar depression (Table 7-22). 

Franchini L, Gasperini M, Perez J, et al. A double-blind study of long-term treatment with sertraline or fluvoxamine for prevention of highly recurrent unipolar depression. J Clin Psychiatry 1997 58 104-107. 

It is important to make a conceptual distinction between lithium s relative prophylactic effect for the manic and the depressive phases of a bipolar disorder and, by extension, its ability to prevent recurrent depressions in unipolar disorder. 

The mood stabilizer lithium was developed as the first treatment for bipolar disorder. It has definitely modified the long-term outcome of bipolar disorder because it not only treats acute episodes of mania, but it is the first psychotropic drug proven to have a prophylactic effect in preventing future episodes of illness. Lithium even treats depression in bipolar patients, although it is not so clear that it is a powerful antidepressant for unipolar depression. Nevertheless, it is used to augment antidepressants for treating resistant cases of unipolar depression. 

A distinction between idiopathic depression and bipolar disorder is not always easy at the first episode, and it is important to determine when another episode of depression occurs whether it is relapse of recurrence. Relapse is defined as the reappearance of signs or symptoms of depression within the same treated episode, often when treatment is stopped prematurely. Recurrence is defined as the reappearance of signs of depression after a symptom-free and treatment-free period. This distinction is important because MDI warrants specific long-term preventive treatment whereas simple depression does not. Treatment can be envisioned for manic episodes, for depression, and for MDI (including recurrent unipolar disease). 

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