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The Director Discusses: Preventing Recurrences

Photo: John F. Greden, M.D.Chances are if you are reading this discussion board, you or someone you care about may be experiencing depression. Perhaps you are just beginning to learn facts about this illness.

One of the most daunting realities about depression is that it tends to return—even when it is initially treated successfully. This can be discouraging news, especially at the early stages of facing depression. The counteracting good news is that although recurrences are common, there are steps you can take to minimize their severity and actually prevent most of them.   

The first and most important step is to see depression from the very beginning—the first episode, if possible, even if mild— as a condition that will require your vigilance and care throughout your lifetime and not as a single episode to be addressed and then forgotten.  Then you can prepare to do what it takes to not only get well but perhaps most importantly, to stay well. 

How common is recurrence?
Studies indicate patients face a 60% or higher risk that their depression will recur within five years of initial treatment when they have had several episodes. Within 10 years, the risk increases to 75%, and to nearly 90% within 15 years.  The recurrence pattern associated with Bipolar Disorder seems to be well-recognized by the public, but there is less awareness that Clinical Depression also has an episodic, recurrent course.

What do we know about why depression recurs?
Past research on depression has tended to study individual disease episodes and how they can be resolved through one or more treatment methods. This is not the whole picture. Only recently have clinical researchers begun to reasonably characterize how depression comes and goes in patients over time. We have not yet determined exactly why depression tends to recur in a given individual, and patterns vary considerably, nor are we able to accurately predict which individuals face the highest risk of recurrence. However, recent studies shed light on how frequently depression returns, and what we can do to prevent recurrence.

We have learned that the more episodes one has had, the more likely another will occur if untreated.  These episodes also then tend to come closer together.  Geddes and his colleagues described in a pivotal article in Lancet in 2003 that for individuals who have had multiple episodes, when treatment is stopped, their odds of recurrence are considerably higher if they stop treatment or switch to placebo treatment than those who continue their effective antidepressant treatments (Geddes et al, 2003). They also pointed out that the treatment effects would have been even better if all patients had been adherent. The goal is not just achieving wellness; it is maintaining wellness.  Maintenance treatment over many years or a lifetime is a difficult concept for some to accept, but being forthright, it is essential for many.

What can be done to keep depression from recurring once it has been successfully treated?
Studies indicate that the most common behavior preceding recurrence is the discontinuation of treatment. Frequently, patients who begin to feel better may cease treatment, thinking they are “cured.”  Failing to refill prescriptions, attend therapy, or follow their self-care program all are warning signs of greater risk of recurrence. Sometimes stopping treatment is related to cost, side effects, or stigma.  Whatever the reasons, over time, depression episodes generally recur when no treatment is provided. Many studies also document that each subsequent recurrence tends to be worse than previous episodes, and with each episode, they tend to become more difficult to treat.

The key to preventing recurrence is maintenance
Committing to ongoing treatment over a long period of time—perhaps for the rest of your life—is the best strategy for ensuring that depression remains in check, especially for those who have had multiple episodes. That means continuing with your treatment plan on good days, weeks, or months, as well as bad, so that you are equipped to cope with unavoidable stressors that can ignite a recurrence of depression.
 
Research has yet to outline a definitive treatment for chronic or recurrent depression, but it suggests that a combination of medication and psychotherapy may be more effective than either method alone in treating patients whose depression has returned.

Simply stated, scientific evidence is encouraging us to view depression as a condition requiring care over a lifetime, a condition virtually mandating a focus upon prevention of recurrences. This represents a true paradigm shift for both doctors and patients—a change in focus from simply “getting well” to “getting well and staying well.” I hope you find the Depression Center’s Web site and information from the Center’s health experts useful resources in your journey towards such wellness, and I encourage you to visit the Depression Center’s new “Toolkit” at www.depressiontoolkit.org.  

Merci,

John F. Greden, M.D.


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