ABSTRACT
INTRODUCTION Depression is currently among the most treatable illnesses that we see in medicine. Similar to any other medical illness, depression should be treated to full remission and, ultimately, to recovery. Remission has now become the standard of care for treating individuals with major depression, and should be the goal of treatment for the patient who partially responds in the first episode or the patient who may have failed to respond to multiple treatments. Unfortunately, up to 50% of patients who “respond” to their antidepressant treatment fail to fully “remit” (1). Data from long-term clinical trials of antidepressant response have estimated that approximately two-thirds of patients fail to achieve full remission (2). More recent findings from the National Institute of Mental Health’s Sequenced Treatment Alternatives to Relieve Depression (STAR*D) suggest that in a community sample of patients with depression, approximately 40% of patients failed to “respond” to an adequate trial of a selective serotonin reuptake inhibitor (SSRI) and over 65% failed to achieve remission (3). This study went on to show only modest improvement of response or remission and high rates of residual symptoms, even when patients were given a chance to switch antidepressants or augment their treatment to a set sequence of treatment choices (4,5). Furthermore, acute and long-term studies show that high rates of “residual symptoms” persist even after remission is achieved in the treatment of depression (1,6), and these residual emotional or physical symptoms of depression jeopardize achieving remission and can also significantly increase the risk of relapse and recurrence (7). In addition to increased risk of relapse and recurrence, there are several other possible consequences of failing to achieve remission, including continued psychosocial impairments, increased use of medical services, potential worsening of prognosis of any comorbid medical/psychiatric illnesses, ongoing risk of suicide, and at least the theoretical possibility of the patient becoming “treatment resistant” (8,9).
