Beliefs about the causes of depression and recovery and their impact on adherence, dosage, and successful tapering of antidepressants.

BACKGROUND: Continuation of antidepressant medication (ADM) after remission is widely used to prevent depressive relapse/recurrence. Little is known about predictors of ADM use in terms of adherence, dosage, and successful tapering. The current study aimed to explore beliefs about the causes of depression and recovery (i.e., causal beliefs) and to examine whether they predict ADM use. METHODS: The data were drawn from a controlled trial and an extension of this trial with additional experience sampling. In total, 289 remitted patients with recurrent depression (ADM ≥ 6 months) were randomly assigned to Preventive Cognitive Therapy (PCT) with ADM tapering, PCT with maintenance ADM, or maintenance ADM alone. Adherence, ADM dosage, and causal beliefs regarding the first and last depressive episodes were explored via questionnaires. RESULTS: Most patients mentioned stressful life events as cause of depression, although more patients tended to endorse external causes for the first episode and internal causes for the last episode. ADM was most often mentioned as helpful during recovery from both episodes. Over half of all patients were adherent and under half of the patients in the tapering condition were able to complete the taper. Causal beliefs did not predict ADM use. CONCLUSIONS: The results suggest that causal beliefs play little role in the use of maintenance ADM. More information is needed on factors contributing to successful tapering. The results must be interpreted with caution as this is not a naturalistic study and the results might be biased toward a more favorable view regarding ADM.

Prediction of recurrence in recurrent depression: a 5.5-year prospective study.

OBJECTIVE: Depression is a disease with high recurrence rates. Identifying predictors of recurrence and their relative importance in patients with recurrent depression is important for a better understanding of the course of this disease. This type of knowledge can be used to optimize and tailor preventive strategies of recurrence. In this study, we examined predictors of recurrence over a 5.5-year follow-up period and quantified to which extent these predictors explained observed variation in recurrence. METHOD: Data from 172 remitted recurrently depressed patients over a 5.5-year follow-up period were used. Recurrence was assessed with the Structured Clinical Interview for DSM-IV. Illness-, stress-, and coping-related factors were examined as predictors of recurrence. Multiple Cox regression analysis was used, and explained variation was assessed to quantify the relative importance of the predictors. Patients were recruited between February 2000 and September 2000. RESULTS: Number of previous episodes and residual symptoms explained each 15% of the variation in recurrence, indicating a medium effect size. The final multivariate prediction model included: a higher number of previous episodes, more residual symptoms, and lower levels of positive refocusing (explained variation 29%, indicating a strong effect size). CONCLUSION: In our multivariate prediction model, the number of previous episodes, residual symptoms, and a specific coping style were predictors of recurrence over a 5.5-year follow-up period in remitted recurrently depressed patients. Preventive therapies should focus on these factors. Although a substantial part of variation in recurrence (29%) was explained by these predictors, most of it remains unexplained. Consequently, recurrence remains a difficult to predict and only partially understood phenomenon. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Register Identifier: ISRCTN68246470.

Health related quality of life in recurrent depression: a comparison with a general population sample.

BACKGROUND: In the acute phase major depressive disorder (MDD) is a disabling disease. We compared HRQOL in patients with remitted MDD (rMDD) with a community sample and longitudinally assessed the relation between depressive symptoms and HRQOL in recurrently depressed patients. METHODS: We used 12-month data of patients from the Depression Evaluation Longitudinal Therapy Assessment (DELTA) study. HRQOL was assessed with the Medical Outcome Short Form (SF-36). Remission was determined with the Structured Clinical Interview for DSM-IV and depressive symptoms were assessed with the Beck Depression Inventory. Patients' mean SF-36 scores were compared with those of an age- and sex-matched Dutch reference population. The longitudinal relation between levels of SF-36 and levels of depressive symptomatology was assessed with a repeated measures linear regression analysis using the mixed models module. RESULTS: In patients with rMDD in the remitted phase, especially in women, both physical and mental HRQOL was lower than in a Dutch population sample. An increase in the level of depressive symptoms corresponded to a decrease in all scales of the SF-36. CONCLUSION: Also in remitted rMDD patients, especially in women, HRQOL is lower than in the general population which emphasizes that also in this phase of recurrent depression HRQOL deserves attention. Furthermore, in patients with rMDD a higher depressive symptom severity level is associated with a lower HRQOL. These findings imply that residual symptoms should be treated aggressively and HRQOL enhancement therapies should be developed.

Predictors of nonadherence to continuation and maintenance antidepressant medication in patients with remitted recurrent depression.

OBJECTIVE: To identify predictors of nonadherence to continuation and maintenance antidepressant medication among patients with remitted recurrent depression. METHOD: We used data of 91 remitted, recurrently depressed patients (at least 2 major depressive episodes as assessed by the Structured Clinical Interview for DSM-IV Axis I Disorders) treated with continuation and maintenance antidepressant medication in a 2-year prospective study. Patients were recruited at psychiatric centers and through media announcement from February 2000 through September 2000. Adherence was assessed with the Medication Adherence Questionnaire. Nonadherence on this scale indicates that patients missed 20% or more of their antidepressant medication. We determined nonadherence point prevalences at the 7 assessment points. Based upon these 7 assessments, we found nonadherence percentages ranging from 39.7% to 52.7% with a mean of 46.5% over 2 years. We examined a set of potential risk factors (patient-related, disease-related, and treatment-related) measured at baseline. RESULTS: In univariate analysis using a stringent significance level (p

Adherence to continuation and maintenance antidepressant use in recurrent depression.

BACKGROUND: In chronic diseases adherence is a problem. Little is known about adherence to antidepressants after the acute phase in recurrent depression. This study evaluates adherence to antidepressants in the continuation and maintenance phase in remitted recurrently depressed patients. METHODS: We prospectively assessed adherence to continuation and maintenance antidepressant use, the longest phase in antidepressant treatment, over 2 years and the association of adherence with future recurrence in 131 recurrently depressed patients remitted on antidepressants. LIMITATIONS: Self reported non-adherence. RESULTS: Non-adherence ranged from 39.7% to 52.7%; 20.9% were always non-adherent, 48.4% were intermittently non-adherent and 30.8% were always adherent. Adherence rates did not significantly differ between intermittent and continuous antidepressant users (37.2% vs. 25%). Non-adherence predicted time to recurrence. CONCLUSION: Non-adherence to continuation and maintenance antidepressant treatment in recurrent depression is frequent, like in other chronic diseases, and a potential risk of recurrence. Doctors continuously have to be aware of this problem and should keep on discussing it with their patients. Finally, as many patients don't seem to be able or willing to take AD as prescribed, alternatives to prevent relapse deserve more attention.

Continuation and maintenance use of antidepressants in recurrent depression.

BACKGROUND: Maintenance antidepressant (AD) medication is the most commonly used preventive strategy in a highly recurrent disease, i.e. depression. Little is known about the discontinuation of maintenance AD use and the association with recurrence in daily clinical practice. The purpose was to examine the discontinuation rate of maintenance AD in daily clinical practice in recurrently depressed patients and the associated risk of recurrence. METHODS: Prospectively AD maintenance medication and recurrence were examined in 172 euthymic patients with recurrent depression. AD user profiles before recurrence (nonusers, intermittent users, continuous users) were examined and related to recurrence over a 2-year follow-up period. RESULTS: Less than half of the patients (42%) used AD continuously. Taking into account the minimal required adequate used dosage (> or = 20 mg fluoxetine equivalent), only 26% of the patients used AD as recommended by international guidelines. Despite continuous use of AD, 60.4% relapsed in 2 years. This relapse rate was comparable to the rate of the intermittent users (63.6%). In patients who stopped taking AD after remission and who received additional preventive CT, the recurrence rates were significantly lower than in non-AD-using patients treated with usual care (8 vs. 46%). CONCLUSIONS: The majority of recurrently depressed patients treated with AD discontinue maintenance AD therapy in daily primary and secondary clinical practice. AD seems to offer poor protection against relapse in this patient group. Patients who stopped using AD experienced less relapse, especially if they were treated with preventive CT. Alternative maintenance treatments (including preventive cognitive therapy after discontinuation of AD) should be studied in recurrently depressed patients with intermittent good remission, not only in secondary but also in primary care.