Over fifteen years of experience with reasonably safe drug
treatments for depression has given the mental health world a new
understanding of the disorder, a more accurate sense of its true course
and a new set of goals. It's no longer enough merely to be treated for
depression; it's necessary to be cured completely.
Increasingly, the aim of treatment is not to make patients better
but to make them well. In the absence of complete remission from an
episode of depression, the disorder tends to recur, even to settle in
more or less permanently. What's more, studies now show that the longer
patients remain sick, the harder it is to ever make them completely
Improvement is not enough. The existence of even low-level symptoms
can have deleterious effects on the brain itself, not simply increasing
the likelihood of subsequent episodes but actually accelerating their
Experts find that complete remission requires treatment for a
minimum of nine months—and that's for an acute first episode. Beyond
the disappearance of symptoms patients should experience a minimum of two
months of well-being before treatment is stopped.
Guidelines drawn up by psychiatrists themselves state that people
who have chronic depression—an episode lasting two years or more—
need to be treated for two years after full remission has occurred. And
if you have recurrent depression, marked by multiple depressive episodes,
treatment should last indefinitely. Just as with chronic disorders like
hypertension and diabetes, maintenance treatment is necessary.
But here's the rub. Few patients now take antidepressants in a way
that gives them a shot at curing the condition. The average duration of a
prescription is about 100 days.
According to a national study of depression, 40% of sufferers get
no treatment at all for their condition. And a scant 22% get anything
resembling adequate care.
Unfortunately, that shifts onto patients themselves the
responsibility for seeing that the treatment they get is adequate. Buyer
Over time it has become clear that people who don't achieve full
remission are at high risk for relapse and for doing poorly. Even if they
don't have a full relapse of depression they don't fare well in terms of
social and occupational function.
And for some people, returning to "normal" isn't good
enough."Twenty-five percent of depressive episodes are preceded by
dysthymia," a more or less chronic low-grade mood disturbance, observes
Martin Keller, M.D., chairman of psychiatry at Brown University. "These
people need to do better than return to their normal self. The
differences are dramatic between those who are asymptomatic and
functioning well and those with some symptoms."
It may be that the future will bring indicators of remission that
more precisely reflect the subtleties of neurobiologic disturbance that
underlie the disorder. Researchers know that multiple brain areas go awry
in depression, and following even successful treatment it takes an
extended period of time for brain circuitry to reset itself, leaving
patients vulnerable to relapse well after overt symptoms
But for now, no unambiguous end-point of treatment has been defined
and no specific test of cure exists. The most reliable indicators of
remission are the disappearance of manifest symptoms, complete resumption
of roles you enjoyed both inside and outside the home, and the subjective
sense of return to well-being.
Although it sounds vague, what social scientists call your level of
"psychosocial functioning" provides what is probably the most sensitive
sign of recovery. This includes your ability to work efficiently and
well, the absence of friction in relationships with spouse, friends and
colleagues, your physical health, and the overall quality of your life.
Improvements in social adjustment, ability to concentrate and to work
productively seem to take the longest, as can a sense of
Dr. Keller suggests that during periods of depression you keep a
list of the particular symptoms you are experiencing. Then as you undergo
treatment and begin to feel better, go through the symptom list and
monitor how well you are doing on each element.