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Letters

Patients with depression can be taught how to improve recovery

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7299.1428/a (Published 09 June 2001) Cite this as: BMJ 2001;322:1428
  1. Giovanni A Fava (fava{at}psibo.unibo.it), professor of clinical psychology,
  2. Chiara Ruini, research fellow,
  3. Lara Mangelli, research fellow
  1. Department of Psychology, University of Bologna, 40127 Bologna, Italy

    EDITOR—Andrews has emphasised the chronic nature of depression and the need for endorsing treatment protocols such as those used for diabetes.1 He has also raised the issue of being more honest with people about their prognosis and the need for prolonged treatment, particularly pharmacotherapy. But duration of treatment does not seem to affect long term prognosis once the drug is stopped.2

    Whether you treat a depressed patient for three months or three years, it does not matter when you stop the drug. Indeed, a non-significant trend suggests that the longer the drug treatment is, the higher the likelihood of relapse.2 Despite treating depression effectively in the short term, antidepressant drugs may worsen its course through a sensitisation process.3 Several clinical findings point to this possibility: paradoxical (depression-inducing) effects of switching antidepressants and cycle acceleration in bipolar disorder; tolerance to the effects of antidepressants during long term treatment; the onset of resistance on rechallenge with the same antidepressant in some patients; and withdrawal syndromes after drugs that elevate mood are stopped.3

    The pharmaceutical industry may not like this hypothesis, but a promising alternative exists. Treatment of depression by pharmacological means is likely to leave residual symptoms in most patients.4 Such symptoms hinder lasting recovery and are one of the strongest risk factors for relapse. In two randomised controlled studies cognitive behavioural treatment of residual symptoms significantly improved long term outcome of recurrent depression. 4 5 In our affective disorders programme we tell our depressed patients that depression is likely to recur. But we also teach them that if they can change their lifestyle (with its maladaptive consequences), decrease their residual symptoms (particularly anxiety and irritability), and improve their psychological wellbeing the chances of a lasting recovery are far better.4

    Rather than look to diabetologists, psychiatrists should be more inclined to look to cardiologists when they encourage their patients to reduce their risk factors (including type A behaviour) after a myocardial infarction. In our experience, patients in remission generally like the open and challenging nature of this type of communication. If people have a right to the truth, as Andrews says, they are entitled to the full story.

    References

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