While I usually find medical presentations a little boring (even if I am able to understand what they are actually saying!), the presentation by Professor Martin B Keller on "Treatment Strategies in Depression and Generalised Anxiety Disorder" was a different story. Professor Keller addressed issues that are of real interest 'people like us'. In particular there were two issues he spoke about that we hear people asking questions about every day and that are closely related

1. How long do I need to continue to take medication after I am feeling well?
2. Will I recover from depression? Will it return?

This article only looks at depression however we will include the information presented on GAD on depressioNet. Now as I am about as far from being a health care professional as is possible and this is my layman's translation of Professor Keller's presentation, I need to do the 'depressioNet nag' up front.

A few months after my symptoms had disappeared, I decided that I no longer needed the antidepressants, gradually lowered the dose and came off them. About 4 weeks later I realised this was not such a smart move! The symptoms of depression had definitely returned, and not wanting to ever return to the world of depression, I went straight to my doctor to resume treatment.

Mine is a common story. All too often we hear that people who have taken medication for depression and stopped it once they were feeling better, find that the symptoms of depression very quickly return. Professor Keller's presentation showed that rather than just feeling "better" (responding), we need to feel "well" (remission), and maintain this level for some time before we stop treatment. Apart from the obvious reasons for this, the research showed that this was a key factor in preventing a relapse of the major depression.

What this means is that rather than our aim being a reduction in the symptoms of depression (response), our aim should be to get to the point where we have little or no symptoms remaining (ie 'a-symptomatic),are feeling well, and maintain this a reasonable period of time (remission). The time frame suggested by Professor Keller was 6 to 9 months of minimal or no symptoms of depression. Note that this period doesn't start when we begin medication, but from when we are feel well again – ie 'a-symptomatic'. Often it can take some time to find the right medication for us as an individual, and then some time for us to recover to the point where the symptoms are gone.

The research presented by Professor Keller showed that there is a significant correlation between the length of time that a person continues with treatment following 'remission' and the probability of a relapse.

2. Will I recover from depression? Will it return?

While it is impossible to state with any certainty whether a particular person will have a further depressive episode once they have recovered, there are some factors that do influence the likelihood of the depression returning. Those presented by Professor Keller are:

Risk factors for recurrent depression: (Who needs maintenance therapy?)

1. History of frequent and/or multiple episodes
2. Major depression plus dysthymia (ongoing mild depression)
3. Onset after 60 years of age
4. Long duration of individual episodes
5. Family history
6. Poor symptom control during continuation therapy
7. Co-morbid anxiety disorder or substance abuse.
While once we are in a particular situation there is not a lot we can do about the first 5 of the risk factors, we can do something about the last two. That is, we can influence – and hopefully reduce the risk of the depression returning by:

1. Achieving remission (feeling 'well') rather than just recovery (feeling 'better') and continuing treatment for 6 to 9 months after remission is achieved.

2. Making sure that not only is the depression correctly diagnosed and treated, but that any other related conditions such as anxiety, drug or alcohol abuse, etc are treated / addressed as well.

Ongoing maintenance treatment is recommended for people who have had more than three episodes of major depression or who have had more than two episodes plus any of the risk factors listed above. The goal here is to prevent new (recurrent) episodes of major depression. The suggested duration for ongoing maintenance treatment is 2 'episode cycles' (This may be several years).

Role of Psychotherapy

The generally accepted preferred treatment for depression is a combination of psychotherapy and antidepressant medication. While in the above discussion, the focus has been on issues relating to antidepressant medication, psychotherapy plays an important role in treating depression.

Professor Keller presented the following important research results comparing:

Medication + Therapy – 85% experience elimination of symptoms in 10 weeks

Note that the 'therapies' used in this study were Cognitive Behavioural Therapy and Interpersonal Relationship Therapy – as appropriate for the particular person.

The role of therapy in ongoing maintenance was not investigated, but it does make sense to ensure that the skills and techniques we learn during the initial therapy be reinforced and continually practiced not only during treatment, but beyond and into our healthy lives!

Disclosure: The sponsors of the Marty Keller Tour were Wyeth Pharmaceuticals, manufacturers of Efexor-XR.

The presentation by Professor Martin Keller included references to the following:

Allgulander et al. Br J Psychiatry 2001; 179: 15-22
Coryell et al. Am J Psychiatry 1993; 150:720-727
Conwell Crisis 1994; 15: 153-154
Davidson et al. J Clin Psychiatry 1999; 60: 528-535
Depression Guideline Panel AHCPR Publication 93-0550. 1993
DSM-IV, Washington DC : American Psychiatric Association 1994
DSM-IV, Washington DC : American Psychiatric Association 2000
Doogan & Calliard Br J Psychiatry 1992; 160: 217-222
Feiger et al. Int Clin Psychopharmacol 1999; 14: 19-28
Fisher & Durham Psychol Med 1999; 29: 1425-1434
Gelenberg et al. JAMA 2000; 283: 3082-3088
Hackett et al. J Psychopharmcol 1998; 12: 273-278
Hackett presented at 1st Int Forum Mood & Anxiety Disorders, Monte Carlo 2000
Hirschfield et al. JAMA 1997; 277: 333-340
Keller. Arch Intern Med 1990; 150: 946-948
Keller et al. Arch Gen Psychiatry 1986; 43: 458-466
Keller et al. Arch Gen Psychiatry 1992; 49:809-816
Keller et al. Manuscript in preparation, 2002 (years 16-20)
Keller, Unpublished data
Keller et al. J Clin Psychiatry 1995; 56: 22-29
Keller et al. J Clin Psychiatry 1995; 54: 4-9
Kessler et al. Br J Psychiarty 1996; 168 (suppl 30): 17
kunz et al. Presented at ECNP 2000 Munich Germany
Lavori et al. Int J Melh Psychiatry 1994; 4: 211-229
Montgomery et al. Br J Psychiatry Suppl 1988; 3: 67-76
Montgomery & Duntar. Int Clin Psychopharmacol 1993; 8:189-195
Montgomery et al. Int Clin Psychopharmacol 1993; 8: 181-188
Montgomery et al. Int Clin Psychiatry 1998; 13: 63-73
Rickets et al. Am J Psychiatry 2000; 157: 968-974
Rickets et al. Arch Gen Psychiatry 1993; 50: 884
Robbins et al. Review of Psychiatry, Vol 7 American Psychiatric Press 1988
Salinas et al. Presented at IPS, Philadelphia 2000
Thase. J Clin Psychiatry 1999; 60 (suppl 22): 3-6
Thase et al. Br J Psychiatry 2001; 178: 234-241
Wellis et al. Arch Gen Psychiatry 1992; 49: 788-794
Wells et al. JAMA 1989; 262: 914-919
Wittchen et al. Arch Gen Psychiaty 1994; 51: 355-364
Yonkers et al. Br J Psychiatry 2000; 176: 544-549

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