Maintenance

The third large segment of mental health interventions identified by the Institute of Medicine is the area of maintenance. Even though the treatment of acute episodes of depression and other disorders may be quite effective, relapse or recurrence of such an episode can be not only as disruptive as the first experience of clinical depression, but, at times, even more demoralizing. The fear that this painful condition will recur can have a major impact on a person's outlook. Approximately 50% of persons who have had one major depressive episode have a second; 70% of those with two have a third; and 90% of those with three have a fourth. These figures suggest two important goals for the mental health field: preventing the first episode (as described earlier) and, if the first episode occurs, providing interventions that will maintain a healthy mood state, thus forestalling relapse and recurrence.

Current convention uses the terms relapse and recurrence in relatively well-defined ways. When treatment with antidepressants is effective, depressive

Depression — Applied Aspects symptoms diminish within a few weeks. In the 1980s, it was found that if antidepressant therapy was ended, a large proportion of patients began to exhibit symptoms again. The conclusion was that the processes underlying the mood dysregulation were still active, but that the medication was able to control the symptoms. Once medication ended, the symptoms reappeared. This reappearance was thought to be part of the same episode of depression. Now, the reappearance of symptoms within a year of the start of the episode is called relapse. Once the person has been free of clinical symptoms of depression for a year or more, the depressive episode is considered to be over. If symptoms reappear in the future, such an event is a recurrence.

Studies in which individuals who responded well to pharmacotherapy were followed for 1 or 2 years after treatment ended have found rates of relapse or recurrence as high as 70%. This has led to the recommendation that pharmacotherapy be continued for several months, and perhaps years, after the acute depressive episode has subsided. Some clinicians now state that for certain patients, lifetime maintenance pharmaco-therapy is indicated.

Similar studies in which individuals who responded well to cognitive therapy have been followed have found much lower relapse rates of approximately 35% after 1 or 2 years. This has led to speculation that cognitive therapy may have an advantage in terms of reducing relapse or recurrence rates. More studies designed specifically to answer this question are needed.

What is clear at this time is that individuals who have had a depressive episode are at high risk for repeated episodes of clinical depression. These individuals should be taught to monitor their mood state and to obtain treatment as soon as possible after the onset of significant depressive symptoms in the future.

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