Child and Adolescent Psychiatric Clinics of North America
Relapse and Recurrence in Pediatric Depression
Section snippets
Phases of treatment
Differences in terminology (eg, relapse, recurrence) as related to outcomes make comparisons across studies difficult. A consensus has emerged to divide the treatment of depression into three phases, however: acute (leading to clinical response and remission of symptoms), continuation (preventing relapse of symptoms of the treated episode), and maintenance (preventing new episodes, or recurrences, of depression in subjects identified as having recovered from their index episode) [12], [13], [14]
Naturalistic follow-up
Although little is known about long-term interventions for children and adolescents with depression, substantially more is known about the consequences and naturalistic course of depression over time, regardless of treatment interventions. Depression in children and adolescents often leads to significant functional impairment in school and work and can be associated with legal problems [18], [19], [20], [21]. Many adolescents who have depression are at increased risk for substance abuse,
Follow-up of youth initially treated with psychosocial therapies
Naturalistic follow-up studies of children and adolescents treated with acute psychotherapy have yielded inconsistent findings. Birmaher and colleagues [50] reported no differences between adolescents treated with cognitive behavioral therapy (CBT), systemic behavioral family therapy, or nondirective supportive therapy at 2-year follow-up, despite having shown significant differences in favor of CBT in the 16-week acute phase of treatment. Although the depressed adolescents treated acutely with
Risk factors for relapse and recurrence
Relatively few studies have examined factors related to relapse and recurrence in depressed youth. There is some support for illness variables, such as comorbidity (eg, anxiety disorders, behavioral disorders), diagnosis (depression plus dysthymia), illness severity, history of prior episodes, age of onset, suicidality, ongoing residual symptoms, poor functioning, psychosocial stressors, family history of recurrent depression, and family conflict, being important contributors to relapse [5],
Continuation treatment with cognitive therapy
Continuation trials using psychosocial strategies in adults have demonstrated that cognitive therapies delivered in the continuation phase of treatment can prevent relapse successfully [74]. Two types of continuation CBT treatment studies have been described in the literature: (1) CBT delivered in the acute and continuation phases and (2) sequential treatment strategies in which pharmacotherapy is used for acute treatment and CBT is added during the continuation phase.
Using continuation phase
Continuation treatment with pharmacotherapy
Studies of continuation treatment for depressive disorders in adults have used varying methodology [87]. In adults, prophylactic drug treatment reduces the risk of relapse and recurrence of depressive episodes compared with no treatment [88] and reduces the severity of subsequent episodes [89]. Discontinuation of antidepressants soon after the response to treatment is associated with return of original symptoms in approximately 50% of patients [90]. Residual symptoms have been shown to predict
Maintenance treatment
Maintenance treatment to prevent recurrence (new episodes of depression) is warranted in some patients and may last up to several years [95], [96], [97]. The American Psychiatric Association recommended several factors to consider when determining if patients need maintenance treatment, including risk of recurrence (eg, number of prior episodes, presence of comorbid conditions, and residual symptoms between episodes), severity of episodes (eg, suicidality, psychotic features, and severity of
Summary
Depression is a chronic illness in children and adolescents that often leads to long-term difficulties with recurrent episodes of depression. As such, standard treatment must continue beyond acute symptom reduction to a chronic disease management model, such as those used in pediatric asthma and diabetes [103], [104], [105]. Within the chronic disease management model, treatment interventions are directed not only at the urgent or acute concern but also at the prevention of future problems. For
Clinical implications
Although little research is available on continuation and maintenance treatments in the pediatric age group, our knowledge about the naturalistic course of depression in this age group and information from adult trials provide guidance for clinicians who treat children and adolescents with depression. First, regardless of the type of treatment being provided, all depressed youth must be treated to remission of depression, not just symptom improvement. Patients being treated for 3 to 4 months
Future needs
Research into long-term treatments for children and adolescents who have depression is limited yet vitally important to improve our understanding to prevent poor outcomes in this population. Continuation trials of psychotherapy and pharmacologic trials in larger samples are needed. It is also important to determine which therapeutic intervention techniques are the most beneficial in preventing relapse. That is, do general CBT techniques often used in acute treatments prevent relapse, or are
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