Treatment strategies to improve and sustain remission in major depressive disorder

Madhukar Trivedi, Ella Daly
ajor depressive disorder (MDD) is a serious, debilitating illness that affects persons of all ages, races, and socioeconomic backgrounds. The Institute of Medicine (IOM) report, Priority Areas for National Action: Transforming Health Care Quality, lists major depression among 20 priority areas for health care quality improvement, identifying the aim "to improve national rates of diagnosis and appropriate treatment of major depression." 1 MDD occurs in up to one in eight individuals during their
more » ... iduals during their lifetime, making it one of the most prevalent of all medical illnesses. According to the Diagnostic and Statistical Manual-Fourth Edition Text Revision (DSM-IV TR), 2 the point prevalence rates for MDD are approximately 2.3% to 3.2% in men and 4.5% to 9.3% in women, with a lifetime risk for developing an episode of 7% to 12% for men and 20% to 25% for women. Depression currently ranks fourth for disability-adjusted life-years worldwide 3 and is projected to jump to second global leading cause of disability by 2020. The recent National Institute of Mental Health-funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study showed that remission rates are modest even after two state-of-the-art, diligently delivered treatment steps with the support of depression care specialists. 4-6 Even following four steps, there still remain a large percentage of patients who do not benefit. 7 Treatment-resistant depression Treatment-resistant depression (TRD) is a common problem in the treatment of MDD, yet little agreement exists 377 S t a t e o f t h e a r t Major depressive disorder (MDD) is an often chronic, recurrent illness affecting large numbers of the general population. In recent years, the goal of treatment for MDD has moved from mere symptomatic response to that of full remission (ie, minimal/no residual symptoms). The recent Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial showed that even with systematic measurement-based treatment, approximately one third of patients reach full remission after one treatment trial, with only two thirds reaching remission after four treatment trials. Treatment-resistant depression (TRD) is therefore a common problem in the treatment of MDD, with 60% to 70% of all patients meeting the criteria for TRD. Given the huge burden of major depressive illness, the low rate of full recovery remains suboptimal. The following article reports on some current treatment strategies available to improve rates of, and to sustain, remission in MDD.