Disease Management

Mood disorders are chronic disorders, with high rates of relapse on discontinuation of drug therapy, making it important that treatment be conceptualized as a long-term process (Kraepelin, 1921; Angst et al., 1973; Keller et al., 1982; Kupfer et al., 1992). Medications restore function but the disease process is not cured.

Most patients with a mood disorder will have more than one episode. Recurrence rates for depression are estimated to be at least 50 percent for patients with one episode of major depression and 80 to 90 percent if the person has had two episodes (Angst, 1990; Kupfer, 1991). Seventy to 90 percent of patients with a successfully treated major depression will experience a recurrence of illness when placebo is substituted for active medication during a 3-year maintenance phase, as opposed to only 15 to 20 percent taking a full dose of imipramine (Frank et al., 1990).

Three phases of treatment have been proposed: acute, continuation, and maintenance treatment phases (Kupfer, 1991). The stages are defined in relation to the status of symptoms and involve the concepts of treatment response, relapse, remission, recurrence, and recovery (Frank et al., 1991). Response refers to a partial diminution in symptoms following initiation of drug treatment (usually 50 percent reduction). Relapse involves the return of some symptoms of a disease during or on cessation of treatment. Remission refers to a diminution of the symptoms of a disease and implies that there has been a clinically meaningful decrease of same (usually 70 percent or greater reduction). Recurrence describes the return of symptoms after a remission. Recovery describes a more complete remission, implying the absence or near absence of symptoms.

The acute treatment phase begins with a clinical interview, diagnostic assessment, physical and neurological examination, and clinical and laboratory studies as appropriate (Schulberg et al., 1998; American Psychiatric Association, 2000). The goals of this phase include establishing a diagnosis, defining a short-term and long-term multi-disciplinary treatment plan, selecting the most appropriate medication, titrating the dose to a therapeutic range, monitoring of side effects, compliance, and determining the magnitude and quality of response. This phase lasts from 6 to 12 weeks and patients are usually seen every 1 to 2 weeks during this phase.

If a response is obtained, then the continuation phase ensues and consists of monitoring for completeness of response and side effects. Discontinuation of medication during or before this phase is complete is associated with a high rate of relapse (Prien and Kupfer, 1986; Kupfer, 1991). Continuation treatment lasts 4 to 9 months and can be thought of as a consolidation phase. A recent World Health Organization (WHO) consensus meeting suggests that the minimum period of time for continuation treatment is 6 months (WHO Mental Health Collaborating Centers, 1989; Kupfer et al., 1992; Altamura and Percudani, 1993).

Maintenance is in general thought to be prophylactic, although it is increasingly clear that for many patients this phase is essential, not simply to prevent new episodes but to maintain the response since the illness persists. Newer data suggest that medication dosing during the maintenance phase should continue at the same level as during the acute phase and that supportive psychotherapy can help to reduce the rate of relapse and recurrence (Frank et al., 1990; Kupfer et al., 1992).

Patients should be seen every 4 to 12 weeks for the first year of maintenance treatment and at 6-month to yearly intervals thereafter. The frequency of visits during this phase should be individualized based on psychosocial factors, compliance, and presence of symptoms and side effects. Rates of depressive relapse appear to be higher when antidepressant drugs are discontinued rapidly compared to a slow (3 to 4 weeks) taper (Robinson et al., 1991; Kupfer, 1991). Therefore, if an antidepressant is discontinued, it should be tapered over at least a 4-week period.

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