Recurrent depressive disorder

Mauri, M., Sarno, N., Rossi, V. M., Armani, A., et al., Personality disorders associated with generalized anxiety, panic, and recurrent depressive disorders. Journal of Personality Disorders 6(2), 162-167, 1992. 

Baastrup PC, Poulsen JC, Schou M, et al Prophylactic lithium double-blind discontinuation in manic-depressive and recurrent-depressive disorders. Lancet 2 326-330, 1970... 

Bergmann, NiIBner and Demling 1993 80 mild to moderate depressive episode or recurrent depressive disorder, currently mild to moderate episode (ICD-10 F32.0, F32.1, F33.0, F33.1) Esbericum 3x1 capsule Amitriptyline-HCl 30 mg 6 weeks A 76 completed patients (30 Hyp, Ref 38) R HAMD decrese in mean total score from 13.82 to 6.34 (ref 1S.26 to 6.63) response rate (total score <10) 84% (ref 73.7%) Bf-S decrease in mean total score from 31.45 to 24.22 (ref 28.21 to 24.13) Daily sleeping time increase in mean sleep duration from 5.60 hours to 6.58 hours (ref 5.51 to 6.73)... 

VoTbach, Amoldt and HUbner 1997 209 recurrent depressive disorder, current episode severe without psychotic symptoms (1CD-10 F33.2) Jarsin (LI 160) 3 x 600 mg Imipramine 3 x 50 mg 6 weeks, stepwise dose increase during the 1st week with both treatments A All patients randomized (Hyp 107, Ref 102), testing for equivalence within an a priori defined 25% interval of deviation R HAMD-17 decrease in mean total score from 25.3 to 14.4 (ref 26.1 to 13.4), hypothesis of non-equivalence could not be rejected (p=0.21, test procedure according to Anderson and Hauck) response rate (decrease in total score 50%) 35.3% (ref 41.2%), p<0.02 for equivalence (descriptive)... 

Czekalla and colleagues [271] looked for potential effects of Hypericum extract on cardiac conduction, since it is well-known that tricyclic antidepressants can delay atrioventricular conduction. Of 84 patients treated with the Hypericum extract LI 160 and 76 patients receiving imipramine in a therapeutic drug trial [253] evaluable ECG recordings were available at baseline and after 6 weeks of treatment. All patients suffered from a severe episode of recurrent depressive disorder [ICD-10 F 33.2] the daily doses were 3 x 600 mg LI 160 and 3 x 50 mg imipramine, respectively. 

Recurrent depressive disorder >1 depressive episode, separated by at least 2 synptom-free months Focus on relapse indicators and early intervention... 

Depression is a common, serious, sometimes fatal illness that is chronic and recurrent in nature, impairs family life, reduces social adjustment, and is a burden on the community (Klerman and Weissman, 1992). This disease chronicity magnifies hoth its societal impact and its economic burden. It has been estimated that more than 17% of the disability associated with mental disorders is the result of depressive disorders (Rosenbaum and Hylan, 1999), and that the global burden of depression, measured in terms of disability-adjusted life years, will rank second only to ischaemic heart disease by the year 2020 (Murray and Lopez, 1996). 

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. 

Major depressive disorder, recurrent Bipolar disorder, type I ... 

Major depression is characterized by one or more episodes of major depression, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (Table 70-1). Symptoms must have been present nearly every day for at least 2 weeks. Patients with major depressive disorder may have one or more recurrent episodes of major depression during their lifetime. 

Lithium is used in the prophylaxis and treatment of mania and in the prophylaxis of bipolar disorders and recurrent depression. Lithium should be stopped 24 hours before major surgery but the normal dose can be continued for minor surgery, with careful monitoring of fluids and electrolytes. After major surgery, renal function is reduced and this may compromise clearance of lithium. Lithium is a drug with a narrow therapeutic index and it should be avoided if possible in patients with renal impairment. Renal function should be tested before initiating treatment. If lithium is given to patients with renal impairment, a reduced dose should be used and serum lithium concentrations should be monitored closely. 

Unipolar and bipolar depressive disorders in children and adolescents are serious conditions. The pathophysiology of these disorders is poorly understood. The new tools available through neuroimaging techniques will help to unravel the neuroanatomical systems involved in the onset and recurrence of these disorders. There is a need for more developmentally informed predinical research and more studies of the normal development of the neural systems implicated in emotional regulation. 

Emslie, G.J., Armitage, R., Weinberg, W.A., Rush, A.J., Mayes, T.L., and Hoffmann, R.E (2001) Sleep polysomnography as a predictor of recurrence in children and adolescents with major depressive disorder. Int J Neuropsychopharmacol 4 159-168. 

Major depressive disorder (MDD) is a familial recurrent illness associated with poor psychosocial and academic outcome an increased risk for other psychiatric disorders, suicide, and suicide attempts and a high rate of depression and psychological difficulties in adult life (Birmaher et ah, 1996b Goodyer et ah, 1997 Lewin-sohn et ah, 1999 Pine et ah, 1998 Rao et ah, 1999 Weissman et ah, 1999a,b). The prevalence of MDD in children and adolescents is approximately 2% and 6%, respectively (Birmaher et ah, 1996b). Thus, early identification and prompt treatment of this disorder at its early stages is critical. 

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. 

It is still debated whether patients with two previous episodes should receive maintenance treatment. Overall, maintenance treatment has been recommended for adult depressed patients with two episodes who have one or more of the following criteria (Depression Guideline Panel, 1993) (1) a family history of bipolar disorder or recurrent depression, (2) early onset of the first depressive episode (before age 20), and (3) both episodes were severe or life threatening and occurred during the past 3 years. Given that depression in youth has similar clinical presentation, sequelae, and natural course as in adults, these guidelines should probably be applied for youth with two previous major depressive episodes. 

Given the current literature, antidepressant therapy should be initiated in youth with SUD and depression if the depressive symptoms persist during a period of abstinence, if such abstinence is unable to be achieved, or early in treatment if there is a history of recurrent depression. The efficacy of buproprion (Wellbutrin) in youth with SUD and depression is currently being explored (Solhkhah and Wilens, unpublished data). The antidepressants have little abuse potential and are generally very safe, although buproprion (Wellbutrin) should be avoided in youth with eating disorders or seizures. 

A typical example of diagnostic splintering provides the group of mood disorders. One reads about major depression, minor depression, double depression, dysthymia, unipolar and bipolar depression, depressive personality, depression not otherwise specified, brief recurrent depression, subsyndromal symptomatic depression, mixed anxiety depression disorder, seasonal depression, and adjustment disorder with depressive mood. 

Source. Adapted from Greden JR Recurrent Depression A Lifetime Disorder. Indianapolis, IN, Dista Products Division, Eli Lilly and Company, 1992 (video-tape/monograph). Used with permission. 

Comparisons of imipramine versus placebo for prevention of recurrences 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... 

Bjork K The efficacy of zimelidine in preventing depressive episodes in recurrent major depressive disorders—a double-blind placebo-controlled study. Acta Psychiatr Scand Suppl 308 182-189, 1983... 

Francis PT, Pangalos MM, Bowen DM Animal and drug modelling for Alzheimer synaptic pathology. Prog Neurobiol 39 517-545, 1992 Frank E, Kupfer DJ, Perel JM, et al Three-year outcomes for maintenance therapies in recurrent depression. Arch Gen Psychiatry 47 1093-1099, 1990 Frank E, Prien R, Jarrett RB, et al Conceptualization and rationale for consensus definitions of terms in major depressive disorder. Arch Gen Psychiatry 48 851-855, 1991... 

Frank E, Kupfer DJ, Perel JM, et al Comparison of full-dose versus half-dose pharmacotherapy in the maintenance treatment of recurrent depression. J Affect Disord 27 139-145, 1993... 

Post RM Transduction of psychosocial stress into the neurobiology of recurrent affective disorder. Am J Psychiatry 149 999-1010, 1992 Post RM Mechanisms underlying the evolution of affective disorders implications for long-term treatment, in Progress in Psychiatry Severe Depressive Disorders. Edited by Grunhaus L, Greden JE. Washington, DC, American Psychiatric Press, 1994, pp 23-65... 

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. 

It is indicated in neurotic, reactive, masked endogenous, recurrent depression depression with insomnia, depression, enuresis, panic disorder, neurogenic pain, urticaria and nausea and vomiting during chemotherapy maniac depressive psychosis in depressive phase. 

Major depression is a significant risk factor for suicide. The presence of suicidal ideation should be assessed initially and repeatedly over the course of treatment. In this respect, depressive disorders are a major health care problem, contributing to 70% of suicide-related deaths (with a 15% mortality risk associated with suicide in untreated recurrent major episodes). 

Mueller Tl, Leon AC, Keller MB, et al. Recurrence after recovery from major depressive disorder during 15 years of observational follow-up. Am J Psychiatry 1999 156 1001-1006. 

Two issues have emerged from the literature on maintenance treatment for depressive disorders. First, the condition is often recurrent and debilitating. Second, antidepressants (in doses comparable with acute treatment levels) with or without various psychotherapeutic approaches, can favorably alter the longitudinal course. Fig. 7-2 shows the strategy we recommend. 

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