eMedicine Specialties > Psychiatry > Adult

Depression: Follow-up

Author: Ravinder N Bhalla, MD, Assistant Clinical Professor of Child Psychiatry, University of Medicine and Dentistry of New Jersey; Medical Director, Mental Health Clinic of Passaic; Consulting Staff, Christian Health Care Center
Coauthor(s): Pascale Moraille-Bhalla, MD, Medical Director, Outpatient Clinic of Hoboken University Medical Center; Staff Psychiatrist, Mental Health Clinic of Passaic
Contributor Information and Disclosures

Updated: Feb 3, 2010

Follow-up

Further Inpatient Care

• Inpatient care is indicated in major depressive disorder when there is a risk of harm to the patient, to others, or when the patient's symptoms are sufficiently severe to warrant initiation of treatment in a more controlled setting. These commonly include situations of depression with psychotic features, progressive inanition, suicidality, or inability to care for oneself at home. When ECT is indicated as therapy, many practitioners initiate treatment on an inpatient basis, although outpatient initiation of therapy is increasingly common.
• The current climate of insurance controls on treatment typically does not allow prolonged inpatient stays in the treatment of major depressive disorder. Hospitalization is used more commonly to control acute severe symptoms, with early discharge to home or to lower levels of care such as partial hospitalization.

Further Outpatient Care

• The successful treatment of major depressive disorder requires good follow-up care after the acute episode is resolved. This ongoing care usually takes place in an outpatient setting.
• Major depressive disorder tends to be a recurrent condition. While some patients experience a single episode, observing recurrences over time is more common (50-80%). A percentage of individuals have relapses of sufficient frequency to warrant long-term use of antidepressants as a preventive therapy. Other patients can discontinue treatment after resolution of an episode and can restart treatment when symptoms reappear. Most studies suggest that, once an episode is resolved successfully, treatment should be continued for 6 months to 1 year to reduce the risk of relapse of symptoms. The decision to continue treatment beyond that time depends on patient preference and past history of recurrences.
• Psychotherapy is an invaluable treatment modality in the management of major depressive disorder, addressing as it does both potential precipitating and maintaining factors of the depressive episode. In moderate-to-severe depression, psychotherapy is most effective once the somatic and melancholic symptoms have improved with medication. While psychotherapy can help with the interpersonal and cognitive dysfunction that can arise from, and predispose to, depressive illness, long-term psychotherapy does not appear to have a major role in treating major depressive disorder.

Complications

• Potential complications of major depressive disorder may develop across the biopsychosocial spectrum.
• Medical: Completed suicides number more than 30,000 per year in the United States. Other adverse outcomes may arise from attempts at self-injury, untreated medical conditions, or physical decline due to inanition. Medical and surgical prognosis and recovery also are affected adversely by concurrent major depressive disorder.
• Psychosocial: Major depressive disorder, particularly when chronic or untreated, can contribute to unemployment or failure in school, social isolation, substance abuse, and marital/family dysfunction.

Prognosis

• With appropriate treatment, 70-80% of individuals with major depressive disorder can achieve a significant reduction in symptoms, although as many as 50% of patients may not respond to the initial treatment trial.
• Untreated at 1 year, 40% of individuals with major depressive disorder will continue to meet criteria for the diagnosis, while an additional 20% will have a partial remission. Partial remission and/or a history of chronic major depressive disorder are risk factors for recurrent episodes and treatment resistance.

Patient Education

• Education plays an important role in the successful treatment of major depressive disorder. Patients should be aware of the rationale behind the choice of treatment, potential adverse effects, and expected results. The involvement of the patient in the treatment plan can enhance medication compliance and referral to counseling. Over the long term, patients also may become aware of signs of relapse and may seek treatment early.
• For excellent patient education resources, visit eMedicine's Depression Center. Also, see eMedicine's patient education article Depression.
• The following Web sites are great resources for patient and family education:
  • National Institute of Mental Health, Depression
  • MedlinePlus, Depression
  • FamilyDoctor.org, Depression
  • Depression and Bipolar Support Alliance
  • Families for Depression Awareness

Miscellaneous

Medicolegal Pitfalls

• The most common medical pitfall in the treatment of major depressive disorder is the management of treatment-resistance depression (TRD). According to Rush et al, 67% of patients fail to remit with first-line therapy.⁹ The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial applied various treatment strategies with an final remission rate of 67%. At this point, reassessing, diagnosing, and treating the patient becomes important, as well as having a broad range of strategies available to offer the patient.
  • Assessment should include (1) adequacy of medication dose, duration of treatment, and compliance; (2) accuracy of diagnosis and possible medical conditions; and (3) possible comorbid psychiatric conditions such as substance abuse, anxiety disorders, or personality disorders.
  • Assuming that (1) the assessment of the diagnosis is correct, (2) there are no significant complicating diagnoses, and (3) the current treatment has been at a therapeutic dose for a sufficient amount of time, possible interventions for persistent symptoms can include the following:
    • Increasing the medication dose to the maximum tolerated
    • Changing to a different antidepressant
    • Adding psychotherapy or more intensive care if not already completed
    • Augmenting the current medication
    • Considering the use of ECT
  • Augmentation combinations can include the following:
    • Lithium plus any antidepressant
    • Buspirone plus a TCA or SSRI
    • Triiodothyronine added to any antidepressant
    • A TCA added to an SSRI
    • Methylphenidate or dextroamphetamine added to any antidepressant other than an MAOI
    • The addition of bright-light therapy to any antidepressant
  • Aripiprazole (Abilify) was recently approved as an adjunct to antidepressants. More recently, 3 positive, double-blind, placebo-controlled trials investigating the use of adjunctive aripiprazole in major depressive disorder were published.
    • In the first such study, Berman and colleagues focused on the use of aripiprazole augmentation for patients resistant to up to 1-3 retrospective (historical) antidepressant trials.¹⁰ To confirm treatment resistance, those patients underwent an 8-week, open-label trial with either an SSRI (fluoxetine, sertraline, paroxetine, or escitalopram) or an SNRI (venlafaxine). The patients who made insufficient symptom improvement had either aripiprazole or placebo added to their SSRI or SNRI regimen, under double-blind conditions and for a total of 6 weeks. A statistically significant difference in remission rates was also observed, with 26% remission for aripiprazole versus 15% remission for placebo (P <.05). This study also reported relatively low rates of discontinuation due to intolerance in the 2 treatment groups (2% for aripiprazole and 1.7% for placebo (P >.05).
    • The results of a second study of identical design recently presented at a major scientific meeting also demonstrated greater remission rates for patients treated with adjunctive aripiprazole compared with patients given placebo. The results of these 2 trials lead to the approval, by the US Food and Drug Administration (FDA), of a new treatment indication for aripiprazole as adjunctive treatment to antidepressants for antidepressant-resistant major depressive disorder. This was the first-ever approval for an adjunctive treatment in major depressive disorder, and the first-ever approval for the use of any medication for treatment-resistance depression by the FDA.¹¹
    • The third trial also demonstrated that aripiprazole augmentation is efficacious and well-tolerated in patients with major depressive disorder who have not adequately responded to antidepressant monotherapy. The primary outcome was improvement in depressive symptoms as assessed by a decrease in the Montgomery-Asberg Depression Rating Scale (MADRS).¹²
• Another common pitfall in the treatment of major depressive disorder involves the risk of suicidal or homicidal behavior. Routinely interviewing patients at each visit for suicidal or homicidal ideation and documenting the assessment are important. Legitimate concern regarding the patient's safety, or his or her possible danger to others, takes precedence over confidentiality. In such circumstances, the physician has a duty to act either to prevent self-injury suicide or to warn an identified potential target of violence.
• Another common pitfall is misdiagnosing bipolar depression as major depressive disorder, which leads to insufficient or inadequate treatment if not switching to an outright manic episode. Some patients with treatment-resistance depression may fall under this phenomena. The Mood Disorders Questionnaire is helpful in this differentiation between unipolar and bipolar depression.¹³ Screening Assessment of Depression-Polarity (SAD-P) found presence of delusions during a current episode of major depression, a number of prior episodes of depression, and a family history of major depression or mania to be highly correlated with bipolar major depression.¹⁴
• The STEP-BD study demonstrated that when treating bipolar depression, using a mood stabilizing medication alone resulted in a similar outcome compared with using a mood stabilizer plus an antidepressant medication. Therefore, adding the antidepressant medications showed no additional benefit. In addition, the results suggested that adding paroxetine or bupropion to the mood stabilizer showed no increased risk of hypomanic or manic symptoms. Lamotrogine was found to be helpful in bipolar depression but only quetiapine is FDA-approved for treatment of acute bipolar depression.¹⁵

Special Concerns

• Pregnancy can present a potentially difficult clinical situation when complicated by depression. Major depressive disorder is quite common in women during the childbearing years. Major depressive disorder can have a significant negative impact on a woman's experience of pregnancy and parenting, as well as on her functioning as a new parent. As with all medical conditions that arise during pregnancy, the risks and benefits of pharmacotherapy should be evaluated.
• While it is preferable to avoid the use of medication during pregnancy, the benefits of prompt medical treatment of major depressive disorder often may outweigh the risks of exposure of the fetus to an antidepressant. While untested in controlled trials, there is no clear evidence that available antidepressants are teratogenic. In severe depression during pregnancy, especially in cases of psychosis, agitation, or severe retardation, ECT can be the safest and quickest treatment option.
• Depression in the postpartum period is a common and, potentially, very serious problem. Prompt diagnosis and intervention are essential to mitigate the negative impact on the mother and her infant.
  • More than 80% of women can develop mood disturbances in the postpartum period. Most of these women experience a transient syndrome called baby blues, which is characterized by tearfulness and mood changes that resolve spontaneously in a few days to 2 weeks. However, more than 10% of women meet criteria for major depressive disorder during the first year following delivery. Many of these patients are not identified as depressed and do not receive treatment.
  • Postpartum psychosis, while far less common, does occur, and is more likely to arise in patients with a history of psychosis or bipolar disorder.
  • Principles of treatment for postpartum major depressive disorder are the same as for depression during any other time of life. The patient should be assessed for danger to herself or to her children, as well as for other symptoms such as psychosis or substance abuse. Most antidepressants probably can be used safely during breastfeeding; however, this has not been studied thoroughly, and the same risk-benefit considerations should be applied as when treating depression during pregnancy.
• Seasonal affective disorder
  • This is a form of major depressive disorder that arises during the winter months and resolves during the spring and summer months. Studies suggest that SAD also is mediated by alterations in CNS 5-HT. SAD appears to be triggered by alterations in circadian rhythm and sunlight exposure. Patients with SAD are more likely to report atypical symptoms such as hypersomnia and increased appetite. BLT for SAD is used at an intensity of 10,000 lux for 30-90 minutes daily, usually within an hour of arising in the morning.
  • As with any effective antidepressant, therapeutic light boxes have the potential to precipitate a manic episode in susceptible individuals. Other common adverse effects include eye irritation, restlessness, and transient headaches. These lamps are not a significant source of UV light. Conventional antidepressants, with or without BLT, also can be used to treat SAD.
• Remission versus response
  • In recent years, an increased emphasis has been on achieving remission in the treatment of depression. Remission is defined as having minimal or no symptoms (17-item Hamilton Depression Rating Scale [HAMD 17] score £7). Patients who do not achieve remission are more likely to have a relapse.
  • Response is defined as a 50% reduction in symptoms.
  • Thase performed a meta-analysis comparing the efficacy of the dual-acting agent duloxetine with the SSRI antidepressants in terms of remission rates. His meta-analysis and other similar pooled analyses demonstrated that antidepressants with multiple neurotransmitter actions, such as venlafaxine, mirtazapine, and duloxetine, appear to have distinct advantages in terms of faster onset of action, higher rates of remission, and increased efficacy in addressing the somatic/pain symptoms often inherent in the patient with depression.¹⁶

• Search for CME/CE on This Topic »

• Late-Onset Depression (Psychiatry)
• Substance-Induced Mood Disorders, Depression and Mania (Psychiatry)
• Depression and Suicide (Emergency Medicine)
• Depression (Pediatrics: Developmental and Behavioral)

• Depression Center
• Depression Overview
• Depression Causes
• Depression Treatment
• Depression Symptoms

• Unresolved Depression Doubles Risk for Mortality in Post-MI Patients
• Depression and Smoking Pose Similar Risks for Mortality
• Depression in Older Cancer Patients Responds Better to Collaborative Program

• Comorbid Chronic Illness and the Diagnosis and Treatment of Depression in Safety Net Primary Care Settings
• Depression After Coronary Artery Disease Is Associated With Heart Failure
• AAFP Guideline for the Detection and Management of Post-Myocardial Infarction Depression

• Depression Resource Center
• Bipolar Disorder Resource Center