ORLANDO — Hunt for insomnia and fatigue after depression treatment because they are the most common residual symptoms, according to a presentation at a psychopharmacology congress sponsored by the Neuroscience Education Institute.
An estimated 35%–45% of patients achieve remission with an antidepressant. “That means one-third of the time, you get lucky and they do very well,” Dr. Thomas L. Schwartz said. “That also means 55%–65% do not get fully better.”
Even if patients respond well, be consistent and systematic with follow-up. “Depression likes to come back” and about 80% relapse rate over 7 years, said Dr. Schwartz, director of Adult Outpatient Services, State University of New York in Syracuse.
With aggressive treatment of major depressive disorder, for example, many patients still experience three clusters of residual symptoms: insomnia; hypersomnia with fatigue and related symptoms; and problems with concentration, lack of interest, or a lack of mental energy. Multiple clusters are common in full treatment responders with major depressive order (J. Clin. Psychiatry 1999;60:221–5). After 8 weeks of treatment, 57% of 108 full responders to fluoxetine had two or more residual symptoms, 26% had one residual symptom, and only 17% had no residual symptom.
“If you leave people with three residual symptoms, they will be in trouble. Leave them with two and they will still be in trouble. Get them as well as you can,” said Dr. Schwartz, who is also director of the Depression and Anxiety Disorders Research Program at SUNY Upstate Medical University.
Sometimes, treating insomnia is very important, he said. It can lead to the other two main residual symptoms, fatigue and poor concentration. In one study, depression response was faster and more robust when patients took fluoxetine plus a sleep aid, eszopiclone (Lunesta), for 8 weeks, compared with fluoxetine plus placebo (Biol. Psychiatry 2006;59:1052–60). There were substantial sleep improvements in the dual treatment group as well.
Depressed mood, suicidal ideation, and psychomotor retardation are the least common residual symptoms of treatment of major depressive disorder.
For antidepressant treatment, “do the tried-and-true first, and treat aggressively,” Dr. Schwartz said. “The aim is to reduce all symptoms wherever possible.”
Psychotherapy with medication can also work well. If patients are depressed and have executive dysfunction, they may not be able to remember what they are told in therapy. “So treat with a medication first and then augment with psychotherapy.”