Recurrence, of depression

The obvious goal of therapy for the depressed patient is the resolution of depressive symptoms and a return to euthymia. Once symptoms have resolved, then the purpose of ongoing therapy is to prevent relapse and recurrence of depressive symptoms. One extremely important outcome in the treatment of MDD is the prevention of suicidal attempts. Other essential outcomes include improvement of the patient s quality of life, normalization of functioning in areas such as work and relationships, avoidance or minimization of adverse effects, and reduction of health care costs.15... 

The closest things to true antiserotonin medications used by psychiatrists are those used to treat serotonin-induced side effects. In particular, cyproheptadine has an overall serotonin-blocking effect. With repeated use, this medication can theoretically cause depression and anxiety, and there are case reports of recurrence of depressive symptoms following frequent administration of cyproheptadine. 

Discontinuation. Especially in SSRIs with shorter half-lives (e.g., paroxetine), sudden or rapid cessation may induce withdrawal symptoms that can mimic a relapse or recurrence of a depressive episode (e.g., tiredness, irritability). Furthermore, there is the clinical impression that rapid discontinuation of antidepressants may induce relapses or recurrences of depression. Therefore, if these medications need to be discontinued, they should be tapered progressively. 

Comorbid disorders may influence the onset, maintenance, and recurrence of depression (Birmaher et al., 1996a,b). Therefore, in addition to the treatment of depressive symptoms, it is of prime importance to treat the comorbid conditions that frequently accompany the depressive disorder. 

If at the end of the continuation phase it is decided that the antidepressants should be discontinued, this should be done gradually (e.g., over 6 weeks) to avoid withdrawal effects such as sleep disturbance, irritability, or gastrointestinal symptoms, which may lead the clinician to misinterpret the need for continued medication treatment. Clinical practice has suggested that rapid discontinuation of antidepressants may precipitate a relapse or recurrence of depression. In children and adolescents, it is recommended that treatment be discontinued while they are on extended vacations, rather than during the school year. 

Lewinsohn, P.M., Allen, N.B., Seeley, J.R., and Gotlib, I.H. (1999) First onset versus recurrence of depression differential processes of psychosocial risk./ Abnorm Psychol 108 483 89. 

A higher percentage of patients would be expected to relapse in the crossover design for two reasons. First, a significant portion of the patients in the crossover study had, in fact, responded specifically to the drug treatment. After a period of stabilization, these patients were randomly reassigned to placebo and thus would be expected to relapse. Second, a basic problem in the crossover design is that withdrawal symptoms can mimic the recurrence of depressive symptoms. That is true for the SSRIs, particularly fluvoxamine and paroxetine, because of their relatively short half-lives. 

Bialos D, GillerE, Jatlow P, et al. Recurrence of depression after discontinuation of long-term amitriptyline treatment. Am J Psychiatry 1982 139 325-329. 

FIGURE 14-28. Several issues of importance in assessing women s vulnerability to the onset and recurrence of depression are illustrated here. These include first onset in puberty and young adulthood premenstrual syndrome (PMS) and menstrual magnification as harbingers of future episodes or incomplete recovery states from prior episodes of depression and two periods of especially high vulnerability for first episodes of depression or for recurrence if a woman has already experienced an episode, namely, the postpartum period and the perimenopausal period. 

Five women using the Norplant system developed major depression, two of whom also developed obsessive-compulsive disorder and one of whom also developed agoraphobia (28). They had no prior psychiatric history but developed major depression within 1-3 months after insertion of Norplant. The depression worsened over time and in all cases resolved within 1-2 months after removal of Norplant. There was no recurrence of depression after 7-8 months in four cases available for follow-up. In addition to major depression, obsessive-compulsive disorder developed in two women and symptoms of agoraphobia developed in one woman during Norplant treatment, which resolved after removal. 

Apathy syndromes We and others have noted an apathy syndrome in some patients after months or years of successful treatment with SSRIs. Patients often confuse this syndrome with a recurrence of depression, but the two conditions are quite distinct. The syndrome is characterized by a loss of motivation, increased passivity, and often feelings of lethargy and flatness. ... Mistakenly interpreting the apathy and lethargy for a relapse of depression, and hence increasing the dose of medication, will worsen the symptoms. 

Note that the apathy syndrome is so spellbinding that patients often confuse this syndrome with a recurrence of depression. As the textbook indicates, doctors can make the same mistake of failing to identify the drug as causal. 

TABLE 3.2. Risk Factors for Recurrence of Depressive Episodes... 

Must weigh the risk of treatment (first trimester fetal development, third trimester newborn delivery) to the child against the risk of no treatment (recurrence of depression, maternal health, infant bonding) to the mother and child... 

Must weigh the risk of freafmenf (firsf frimesferfefal developmenf, fhird frimesfer newborn delivery) fo fhe child againsf fhe risk of no freafmenf (recurrence of depression, mafemal healfh, infanf bonding) fo fhe mofher and child... 

---