The Concept of Recovery in Major Depression
The Concept of Recovery in Major Depression
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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