There is increasing literature on the unsatisfactory degree of remission that current therapeutic strategies yield in unipolar depression. The aims of this review were to survey the available literature on residual symptoms of depression, to introduce new targets for therapy and to outline a more stringent definition of recovery.
Studies were identified by using MEDLINE (English language articles published from 1967 to June 2006; keywords: recovery, remission, residual symptoms, sequential treatment, drugs and psychotherapy, related to depressive disorder and depression) and a manual search of the literature and Index Medicus for the years 1960-2006.
Most patients report residual symptoms despite apparently successful treatment. Residual symptoms upon remission have a strong prognostic value. There appears to be a relationship between residual and prodromal symptomatology. The concept of recovery should involve psychological well-being.
Appraisal of subclinical symptomatology in depression has important implications for pathophysiological models of disease and relapse prevention. New therapeutic strategies for improving the level of remission, such as treatment on residual symptoms that progress to become prodromes of relapse, may yield more lasting benefits.
"Thus, it seems important to identify low mental well-being to avoid lingering absence and, in the longer-term perspective, disability pensions. In psychiatric research, it has been suggested that well-being is an important complement to diagnostic procedures of symptoms because it has higher relevance to an individual’s quality of life, and it may better capture recovery or subclinical symptoms [35,38,39]. "
[Show abstract][Hide abstract] ABSTRACT: Mental health problems are common in the work force influence work capacity and sickness absence. The aim was to examine self-assessed mental health problems and work capacity as determinants of time until return to work (RTW).
Employed women and men (n=6140), aged 19--64 years, registered as sick with all-cause sickness absence between February 18 and April 15, 2008 received a self-administered questionnaire covering health, and work situation(response rate 54%). Demographic data was collected from official registers. This follow-up study included 2502 individuals. Of these, 1082 were currently off sick when answering the questionnaire. Register data on total number of benefit compensated sick-leave days in the end of 2008 were used to determine the time until RTW. Self-reported persistent mental illness, the WHO (Ten) Mental Well-Being Index and self-assessed work capacity in relation to knowledge, mental, collaborative and physical demands at work were used as determinants. Multinomial and binary logistic regression analyses were used to estimate odds ratios with 95% confidence intervals (CI) for the likelihood of RTW.
The likelihood of RTW (>=105 days) was higher among those with persistent mental illness OR=1.75 (95 % CI, 1.21-2.52) and those with low mental well-being OR= 2.18 (95% CI, 1.69-2.82) after adjusting for age and gender. An analysis of employee who were off sick when they answered the questionnaire, the likelihood of RTW (>=105 days) was higher among those who reported low capacity to work in relation to knowledge, mental, collaborative and physical demands at work. In a multivariable analysis, the likelihood of RTW (>=105 days) among those with low mental well-being remained significant OR=1.93 (95% CI 1.46-2.55) even after adjustment for all dimensions of capacity to work.
Self-assessed persistent mental illness, low mental well-being and low work capacity increased the likelihood of prolonged RTW. This study is unique because it is based on new sick-leave spells and is the first to show that low mental well-being was a strong determinant of RTW even after adjustment for work capacity. Our findings support the importance of identifying individuals with low mental well-being as a way to promote RTW.
"In the Stockholm Outcome of Psychoanalysis and Psychotherapy Project (Sandell et al., 2000), the development of social functioning was virtually the same whether a patient had been in psychoanalysis or psychotherapy; mean improvement was almost exactly equal in both groups, and within-group effect sizes were small for both groups. Personality functioning is hypothesized to play a contributing role in the development of depression (Akiskal, Hirschfeld, & Yerevanian, 1983; Kendler, Gatz, Gardner , & Pedersen, 2006; Krueger, 2005; Morey et al., 2007), and impairment in personality functioning, beyond its significance for social adjustment and life satisfaction, has been shown to predispose individuals for symptom persistence, relapse, and recurrence (Fava et al., 2007). Therefore, improvement in personality functioning may function as a mediator for the stability of symptom change, and Grande and colleagues (2009) indeed found that personality change at post-treatment was a predictor of patient self-reported symptom change at 3-year follow-up. "
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to investigate the effectiveness of long-term psychoanalytic and psychodynamic psychotherapies. In a prospective, randomized outcome study, psychoanalytic (mean duration: 39 months, mean dose: 234 sessions) and psychodynamic (mean duration: 34 months, mean dose: 88 sessions) therapy were compared at post-treatment and at one-, two-, and three-year follow-up in the treatment of patients with a primary diagnosis of unipolar depression. All treatments were carried out by experienced psychotherapists. Primary outcome measures were the Beck Depression Inventory and the Scales of Psychological Capacities, and secondary outcome measures were the Global Severity Index of the Symptom Checklist 90-R, the Inventory of Interpersonal Problems, the Social Support Questionnaire, and the INTREX Introject Questionnaire. Interviewers at pre- and post-treatment and at one-year follow-up were blinded; at two- and threeyear follow-up, all self-report instruments were mailed to the patients. Analyses of covariance, effect sizes, and clinical significances were calculated to contrast the groups. We found significant outcome differences between treatments in terms of depressive and global psychiatric symptoms, personality functioning, and social relations at three-year follow-up, with psychoanalytic therapy being more effective. No outcome differences were found in terms of interpersonal problems. We concluded that psychoanalytic therapy associated with its higher treatment dose shows longer-lasting effects.
"Associations between melancholic syndrome and differences in antidepressant treatment response therefore remain controversial. An additional drawback with previous research has been the restriction of treatment outcome measurement to depressive, although there have been recent calls for a more multifaceted evaluation including psychological well-being and functioning (Fava et al., 2007). To our knowledge, there have been few studies to investigate a range of treatment outcomes in MDD with melancholic features. "
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: This study aimed to determine whether major depressive disorders with melancholic and without melancholic features differ with respect to their responses to treatment with antidepressants. METHODS: From a nationwide sample of 18 hospitals in South Korea, 559 presenting patients with major depressive disorder were recruited. The DSM-IV based Structured Clinical Interview was administered for confirmatory diagnoses and depression subtypes with/without melancholic features. After baseline evaluation, they received naturalistic clinician-determined antidepressant interventions. Assessment scales for evaluating depression (HAMD), anxiety (HAMA), global severity (CGI-s), and functioning (SOFAS) were administered at baseline and re-evaluated at 1, 2, 4, 8, and 12 weeks later. RESULTS: At baseline, the 243 (43.5%) participants with melancholic features were more likely to have a previous history of depression, and had higher HAMA and lower SOFAS scores. After adjustment for baseline status, participants with melancholic features were more likely to achieve and to experience shorter times to CGI-s remission and associated with an enhanced global symptomatic remission with any antidepressant treatment. They were more likely to achieve and to experience shorter times to CGI-s remission and this difference was strongest in those receiving selective serotonin reuptake inhibitor (SSRI) antidepressants treatment. LIMITATIONS: The study was observational, and the treatment modality was naturalistic. CONCLUSIONS: These findings suggest a faster and more evident global response to pharmacotherapy in melancholia compared to other depressive syndromes, particularly where SSRI agents are used.
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