_______________________________________________________________________ Depression and Suicide
Maintenance Treatment Phase Preventing recurrence is a key goal during the maintenance phase of 6 to 24 months or longer. Clinicians should focus on healthy life strategies, personality vulnerabilities, long-term self-management, and clinical strategies to reduce recurrence and help the patient return to full functioning and quality of life. For a significant proportion of patients with MDD, maintenance pharmacologic, psychologic, complementary and alternative medicine, and neurostimulation treatments play a role in preventing recurrence. Other key clinician activities include treating comorbidities and monitoring for recurrence [62; 139; 142]. Treatment Duration As noted, the antidepressant dose that leads to a satisfactory acute therapeutic response should be maintained during long- term treatment to prevent relapse and recurrence of depression [143; 144]. Historically, practice guidelines recommended initial treatment continuation for 6 to 12 months, but this is not supported by evidence and discontinuation decisions should not be based on treatment duration alone [145]. The two most important factors are maintaining current response and preventing relapse. Risk factors associated with chronic MDD or recurrent MDE include [62]: • Earlier age of onset • Severity of the initial episode (e.g., higher number of symptoms, suicidal ideation, psychomotor agitation) • Greater number of previous episodes
in limbic-cortical pathways and inhibitory control functions of prefrontal cortical regions [149]. Psychosocial treatments are preferred by many individuals with MDD, and psychotherapies can be sequenced as add-on approaches for insufficient initial antidepressant response or used as initial treatment, with antidepressants reserved for poor response to psychosocial treatment. However, many patients with more severe depres- sion or cognitive impairment will require some degree of pharmacologic treatment to engage and maintain participation in psychotherapy [150].
The American Psychiatric Association recommends use of a depression-focused psychotherapy alone as an initial treatment choice for patients with mild-to-moderate major depressive disorder, with clinical evidence supporting the use of cognitive-
behavioral therapy. (https://psychiatryonline.org/pb/assets/raw/sitewide/ practice_guidelines/guidelines/mdd.pdf. Last accessed July 6, 2023.) Strength of Recommendation : I (Recommended with substantial clinical confidence) Cognitive-Behavioral Therapy CBT is a structured, circumscribed psychologic intervention that is grounded in the cognitive-behavioral model of affective disorders, which posits that irrational beliefs and distorted attitudes toward the self, the environment, and the future perpetuate depressive affects and compromise functioning [22]. When CBT is used for depression, the patient works collaboratively with the therapist to identify maladaptive or self-defeating thoughts, beliefs, and interpretations and their impact on current symptoms, feelings states, and/or problem- solving abilities. Therapeutic techniques include patient education and patient-therapist collaboration to choose goals, identify unhelpful thoughts, develop experiments to challenge the accuracy of such thoughts, and identify alternative beliefs through questions that explore beliefs that exacerbate depres- sion. Treatment incorporates structured practice outside of therapy, with scheduled activities, mood tracking, thought recording and challenging, and interpersonal skills practice. CBT can be delivered via computer software and/or by group therapy format [64]. Mindfulness-Based Cognitive Therapy Mindfulness-based cognitive therapy integrates standard CBT with mindfulness-based skills, including mindfulness meditation, guided imagery, experiential exercises, and other techniques. The goal is to assist patients with MDD in recog- nizing, detaching from, and accepting negative thoughts or affect while embracing self-compassion, without necessarily
• Disrupted sleep-wake cycle • Comorbid psychopathology • Family history of psychiatric illness • Presence of negative cognitions
• High neuroticism • Poor social support • Stressful life events The duration of untreated MDD is strongly linked to antide- pressant nonresponse [62; 146]. When patients with these characteristics show substantial response or remission, the focus is helping the patient maintain their level of treatment response. When antidepressants are discontinued, have a contingency plan in place for prompt intervention if relapse occurs [38]. Early antidepressant discon- tinuation usually results from side effects, lack of improvement, inadequate education about the illness, failure to engage the patient during follow-up, and psychosocial factors [147; 148]. PSYCHOTHERAPY The objective of psychotherapy (sometimes referred to as psychologic or psychosocial therapy) is to change thinking and behavior patterns, which in turn reduces emotion and stress reactivity in limbic regions and increases connectivity
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