Doctors and Patients frequently attest to the fact that certain symptoms of depression drag on well after the main symptoms appear to have subsided. On the face of it these may seem quite modest, after all, the term ‘residual’ suggests nothing more significant than a left-over. Unfortunately they also represent a constant reminder of the fact that such people are more likely to become depressed more rapidly.
The dilemma in such circumstances is whether a patient should be exposed to a more complex form of treatment or treatments in an attempt to remove every symptom or whether this is implausible and impractical. An obvious thing to mention at this point is the fact that we really don’t know what the effects of a battery of treatments might actually have.
As things stand the goals of antidepressant treatment are to achieve symptomatic relief. It is accepted that this may not mean remission for a significant number of depressed people in which case the goal is more realistically based around some improvement in their quality of life.
In one study of 1500 people with bipolar disorder it was discovered that whether they were currently in an episode of major depression or had only a few symptoms, but not sufficient to trigger a diagnosis, measures of daily living were equally poor. Factors such as work, relationships, recreation and overall life satisfaction were very similar. Put another way, low-level depression seemed as bad as major depression with sadness and the inability to experience pleasure as marked.
So, is a goal of treatment remission in depression enough when we know the chance of relapse is so high? Part of the debate revolves around the implications of stepping up the treatment regime. More liberal use of medication (combined medication) increases the costs as well as the likelihood of side effects and drug interaction. A problem exists that relatively few clinical trials have been conducted to show the effects of polypharmacy, yet many patients report taking several different forms of medication in various combinations.
There is little doubt that depression is a difficult disease to treat. Arguably, the more complex the treatment package the greater the likelihood of non-adherence to treatment. Can complex pharmaceuticals alone prevent the onset of major depression? The fact that so many people with depression are burdened with psycho-social issues suggests to me these have as much, and possibly greater significance, than pharmaceuticals alone. Where should we place the emphasis?
Keitner, G.I., Solomon, D.A., Ryan, C.E (2008) STAR*D: Have We Learned the Right Lessons? American Journal of Psychiatry 165:1. http://ajp.psychiatryonline.org/cgi/content/full/165/1/133
Kramer, P. D. (2008) To Treat or Not to Treat: The Debate Over Residual Symptoms of Depression. Psychology Today. http://psychologytoday.com/print/1634