Psychiatric Times - Category 1 Credit
|To earn AMA PRA Category 1 Credit(s)™:
Read the article "Diagnosing and Treating ADHD in Adults" from the May 2008 issue of Psychiatric Times, complete the posttest and the evaluation. (Note: A score of at least 70% must be achieved in order to be awarded credit.)
The posttest will be scored instantly and results will be shown onscreen. Please make a copy of your test results for your continuing education records. After submitting the activity evaluation, you may then print a Statement of Credit for your records.
You must keep your own records of this activity. Copy this information and include it in your continuing education file for reporting purposes.
CME LLC is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
CME LLC designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
CME LLC is approved by the California Board of Registered Nursing, Provider No. CEP12748, and designates this educational activity for 1.5 contact hours for nurses.
The American Nurses Credentialing Center (ANCC) accepts AMA PRA Category 1 Credits™ toward recertification requirements.
The American Academy of Physician Assistants (AAPA) accepts AMA PRA Category 1 Credits™ from organizations accredited by the ACCME.
Sponsored by CME LLC for 1.5 Category 1 credits.
Original release date 06/08. Approved for CME credit through May 2009.
After reading this article, you will be familiar with:
• The difference between recovery and remission in major depressive disorder.
• How residual symptoms affect long-term outcomes.
• The clinical implications of relapse and recurrence.
• The reasons for the proposed changes in assessing recovery.
Who will benefit from reading this article?
Psychiatrists, primary care physicians, neurologists, nurse practitioners, and other health care professionals. Continuing medical education credit is available for most specialists. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing board.
Dr Belaise is a research fellow in the Affective Disorders Program of the department of psychology at the University of Bologna in Italy. Dr Fava is professor of clinical psychology at the University of Bologna and clinical professor of psychiatry at the State University of New York at Buffalo. The authors report that they have no conflicts of interest concerning the subject matter of this article.
In clinical medicine, the term recovery connotes the act of regaining or returning to a normal or usual state of health. However, there is lack of consensus about the use of this term (which may indicate both a process and a state), as well as of the related word remission, which indicates a temporary abatement of symptoms. Such ambiguities also affect the concepts of relapse (the return of a disease after its apparent cessation) and recurrence (the return of symptoms after a remission).
In an attempt to overcome these flaws, Frank and associates1 proposed a set of definitions that they developed after a review of longitudinal studies of mood disorders. The development of these criteria helped decrease inconsistencies among research reports, yet it did not touch some key issues in the conceptualization of these terms.
First, according to their definitions, recovery occurs when the number and severity of symptoms fall below the threshold used for defining onset. This subthreshold level of symptoms remains for a specified period. However, this state cannot be equated with being asymptomatic and provides room for a wide range of subclinical conditions.
Second, the definition of remission parallels the traditional medical concept of convalescence, a transitional period of reintegration after illness. The trajectory of the process is thus an important additional dimension that requires a longitudi- nal consideration of the development of disorders, encompassing prodromal, acute, and residual symptoms.2
Finally, the distinction between recovery and full remission is made on temporal grounds only. Neither recovery nor full remission differentiate whether active treatment is associated, even though recovery implies that therapy may have been discontinued. A depressed patient who has recovered and is currently drug-free is thus equated with another patient who is receiving long-term, high-dose antidepressant treatment.
The need to develop standardized criteria for remission has received increasing attention, in the study of mood disorders and other psychiatric illnesses, such as schizophrenia and obsessive-compulsive disorder.3-8 There is growing awareness of the importance of achieving full recovery, to avoid later adverse outcomes.4 After a review of the literature on residual symptoms as the most important target for full treatment of the depressive episode and a discussion of the clinical and theoretical implications of this topic, we will analyze the concept of recovery in unipolar major depressive disorder.
In the past decade, increased attention has been paid to the presence of residual symptoms after treatment of major depression.9-11 Residual social maladjustment in recovered depressed patients was reported by several investigators and was found to correlate with long-term outcome.12-15, Residual symptoms following drug treatment and psychotherapy in depressed patients have been correlated with poor long-term outcome.13,16-20
A strong relationship between prodromal and residual symptoms was also substantiated.21 This hypothesis achieved independent replication and is supported by several lines of evidence.22 The most frequently reported symptoms involved anxiety and irritability. These findings were consistent with previous studies on prodromal symptoms of depression, which overlapped with results concerned with interpersonal friction, irritability, and anxiety and underwent independent replication.9,12,23-27 Thus substantial residual symptoms appear to characterize patients whose depression responded to pharmacological or psychological therapies. Anxiety, irritability, and interpersonal friction, in addition to specific depressive symptoms, appear to be common residual symptoms.
There has been increasing awareness of the frequency of relapse and recurrence in the long-term outcome of depression.28 Unfavorable outcome seems to parallel the presence of substantial residual symptoms in patients who are judged to be in remission and no longer in need of active treatment. Indeed, residual symptoms are probably the most consistent predictors of relapse. In the same vein, there is increasing awareness that current forms of treatment seem to be insufficient for many adults and adolescents with depression.29,30 Expanding the definition of remission thus appears to play a key role in yielding an optimal treatment outcome.4,31
There are 2 main strategies for going beyond current, unsatisfactory levels of remission. The first is provided by augmentation and combination treatments; the other, by sequential strategies (Table 1).32,33 The evidence that may support the first strategy is, at present, purely inferential, except for the combination of pharmacotherapy and psychotherapy.34,35
If residual symptoms are the rule after completion of drug or psychotherapeutic treatment and their presence has been correlated with poor outcome, residual symptoms on recovery may progress to become prodromal symptoms of relapse. Thus, treatment directed toward residual symptoms may yield long-term benefits.2 In line with this hypothesis, treatments that are administered in a sequential order (psychotherapy after pharmacotherapy, psychotherapy followed by pharmacotherapy, one drug treatment following another, and one psychotherapeutic treatment following another) may be more successful in increasing the spectrum of therapy and in eliminating residual symptoms.33
There is a substantial body of evidence that supports the use of cognitive-behavioral therapy (CBT) after successful pharmacotherapy for decreasing the likelihood of relapse during follow-up 21,36-39; in 3 of the studies, follow-up was up to 6 years.36-38 The rationale of this approach is to use CBT resources when they are most likely to make a unique and separate contribution to patient well-being and to achieve a more pervasive recovery. It has been suggested that the most effective drugs in treating acute depression may not be the most suitable for postacute or continuation treatment.10
1. Frank E, Prien RF, Jarrett RB, et al. Conceptualization and rationale for consensus definitions of terms in major depressive disorder. Arch Gen Psychiatry. 1991;48:851-855.
2. Fava GA, Kellner R. Staging: a neglected dimension in psychiatric classification. Acta Psychiatr Scand. 1993;87:225-230.
3. Fava GA. The concept of recovery in affective disorders. Psychother Psychosom. 1996;65:2-13.
4. Paykel ES. Achieving gains beyond response. Acta Psychiatr Scand Suppl. 2002;415:12-17.
5. Kupfer DJ. Achieving adequate outcomes in geriatric depression: standardized criteria for remission. J Clin Psychopharmacol. 2005;25 (suppl 1): S24-S28.
6. van Os J, Burns T, Cavallaro R, et al. Standardized remission criteria in schizophrenia. Acta Psychiatr Scand. 2006;113:91-95.
7. Falloon IR. Antipsychotic drugs: when and how to withdraw them? Psychother Psychosom. 2006;75:133-138.
8. Simpson HB, Huppert JD, Petkova E, et al. Response versus remission in obsessive-compulsive disorder. J Clin Psychiatry. 2006;67:269-276.
9. Paykel ES. Remission and residual symptomatology in major depression. Psychopathology. 1998;31:5-14.
10. Fava GA, Fabbri S, Sonino N. Residual symptoms in depression: an emerging therapeutic target. Prog Neuropsychopharmacol Biol Psychiatry. 2002;26:1019-1027.
11. Boulenger JP. Residual symptoms of depression: clinical and theorhetical implications. Eur Psychiatry. 2004;19:209-213.
12. Paykel ES, Weissman MM. Social adjustment and depression. A longitudinal study. Arch Gen Psychiatry. 1973;28:659-664.
13. Judd LL, Akiskal HS, Zeller PJ, et al. Psychosocial disability during the long-term course of unipolar major depressive disorder. Arch Gen Psychiatry. 2000;57:375-380.
14. Nasser EH, Overholser JC. Recovery from major depression: the role of support from family, friends, and spiritual belief. Acta Psychiatr Scand. 2005;111:125-132.
15. Furukawa TA, Takenchi H, Hiroe T, et al. Symptomatic recovery and social functioning in major depression. Acta Psychiatr Scand. 2001;103: 257-261.
16. Paykel ES, Ramana R, Cooper Z, et al. Residual symptoms after partial remission: an important outcome in depression. Psychol Med. 1995; 25:1171-1180.
17. Nelson JC, Portera L, Leon AC. Residual symptoms in depressed patients after treatment with fluoxetine or reboxetine. J Clin Psychiatry. 2005;66:1409-1414.
18. Simons AD, Murphy GE, Levine JL, Wetzel RD. Cognitive therapy and pharmacotherapy for depression. Sustained improvement over one year. Arch Gen Psychiatry. 1986;43:43-48.
19. Jarrett RB, Kraft D, Doyle J, et al. Preventing recurrent depression using cognitive therapy with and without a continuation phase: a randomized clinical trial. Arch Gen Psychiatry. 2001;58:381-388.
20. Bockting CL, Spinhoven P, Koeter MW, et al; Depression Evaluation Longitudinal Therapy Assessment Study Group. Prediction of recurrence in recurrent depression and the influence of consecutive episodes on vulnerability for depression: a 2-year prospective study. J Clin Psychiatry. 2006;67:747-755.
21. Fava GA, Grandi S, Zielezny M, et al. Cognitive behavioral treatment of residual symptoms in primary major depressive disorder. Am J Psychiatry. 1994;151:1295-1299.
22. Mahnert FA, Reicher H, Zalandek K, Zapotoczky HG. Prodromal and residual symptoms in recurrent depression. Eur Neuropsychopharmacol. 1997;7:158-159.
23. Fava GA, Grandi S, Canestrari R, Molnar G. Prodromal symptoms in primary major depressive disorder. J Affect Disord. 1990;19:149-152.
24. van Praag HM. About the centrality of mood lowering in mood disorders. Eur Neuropsychopharmacol. 1992;2:393-404.
25. Nystrom S, Lindegard B. Depression: predisposing factors. Acta Psychiatr Scand. 1975;51:77-87.
26. Murray LG, Blackburn IM. Personality differences in patients with depressive illness and anxiety neurosis. Acta Psychiatr Scand. 1974;50: 183-191.
27. Kennedy N, Paykel ES. Residual symptoms at remission from depression: impact on long-term outcome. J Affect Disord. 2004;80:135-144.
28. Fava GA, Ruini C, Belaise C. The concept of recovery in major depression. Psychol Med. 2007;37:307-317.
29. Trivedi MH, Rush AJ, Wisniewski SR, et al; STAR*D Study Team. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Am J Psychiatry. 2006;163:28-40.
30. Bartlett JA, Schleifer SJ, Johnson RL, Keller SE. Depression in inner city adolescents attending an adolescent medicine clinic. J Adolesc Health. 1991;12:316-318.
31. Keller MB. Past, present and future directions for defining optimal treatment outcome in depression: remission and beyond. JAMA. 2003; 289:3152-3160.
32. Fava M, Rush AJ. Current status of augmentation and combination treatments for major depressive disorder: a literature review and a proposal for a novel approach to improve practice. Psychother Psychosom. 2006;75:139-153.
33. Fava GA, Ruini C, Rafanelli C. Sequential treatment of mood and anxiety disorders. J Clin Psychiatry. 2005;66:1392-1400.
34. Otto MW, Smits JA, Reese HE. Combined psychotherapy and pharmacotherapy for mood and anxiety disorders in adults. Clin Psychol Sci Pract. 2005;12:72-86.
35. Hollon SD, Jarrett RB, Nierenberg AA, et al. Psychotherapy and medication in the treatment of adult and geriatric depression: which monotherapy or combined treatment? J Clin Psychiatry. 2005;66:455-468.
36. Fava GA, Rafanelli C, Grandi S, et al. Six-year outcome for cognitive behavioral treatment of residual symptoms in major depression. Am J Psychiatry. 1998;155:1443-1445.
37. Fava GA, Ruini C, Rafanelli C, et al. Six-year outcome of cognitive behavior therapy for prevention of recurrent depression. Am J Psychiatry. 2004;161:1872-1876.
38. Paykel ES, Scott J, Cornwall PL, et al. Duration of relapse prevention after cognitive therapy in residual depression: follow-up of controlled trial. Psychol Med. 2005;35:59-68.
39. Ma SH, Teasdale JD. Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. J Consul Clin Psychol. 2004;72:31-40.
40. Fava GA. Can long-term treatment with antidepressant drugs worsen the course of depression? J Clin Psychiatry. 2003;64:123-133.
41. Feinstein AR, Horwitz RI. Problems in the "evidence" of "evidence-based medicine." Am J Med. 1997;103:529-535.
42. Ryff CD, Singer B. Psychological well-being: meaning, measurement, and implications for psychotherapy research. Psychother Psychosom. 1996;65:14-23.
43. Zimmerman M, McGlinchey JB, Posternak MA, et al. How should remission from depression be defined? The depressed patient's perspective. Am J Psychiatry. 2006;163:148-150.
44. Jahoda M. Current Concepts of Positive Mental Health. New York: Basic Books; 1958.
45. Ryff CD. Happiness is everything, or is it? Explorations on the meaning of psychological well-being. J Person Soc Psychol. 1989;57:1069-1081.
46. Fava GA, Ruini C. Development and characteristics of a well-being enhancing psychotherapeutic strategy: well-being therapy. J Behav Ther Exp Psychiatry. 2003;34:45-63.
47. Fava GA, Ruini C, Rafanelli C. Psychometric theory is an obstacle to the progress of clinical research. Psychother Psychosom. 2004;73:145-148.
48. Bech P. Modern psychometrics in clinimetrics: impact on clinical trials of antidepressants. Psychother Psychosom. 2004;73:134-138.
49. Faravelli C. Assessment of psychopathology. Psychother Psychosom. 2004;73:139-141.
50. Fava GA. The intellectual crisis of psychiatric research. Psychother Psychosom. 2006;75:202-208.
51. Tedlow J, Fava M, Uebelacker L, et al. Outcome definitions and predictors in depression. Psychother Psychosom. 1998;67:266-270.