Long-term drug treatment of unipolar depression

Depression is characterized by a recurrent course in many patients, and as a potentially chronic illness. It therefore often requires a long-term treatment strategy. This article proposes pragmatic answers to the questions involved in devising such a strategy, using the available literature. Cessation of treatment immediately after the observation of a response is associated with a high relapse rate, especially within the following 4 months, and all patients should therefore be treated for at least 3-6 months after the acute response to secure a stable remission. Patients at risk of recurrence should be considered for maintenance therapy thereafter. Such patients include those with prior episodes of depression within the last 5 years, those with a particularly severe or chronic depressive episode, those with residual symptoms scoring HAMD > 8 and also those whose age at onset was <25 or <60 years. Those who need maintenance therapy are likely to need it for a number of years, or indefinitely. SSRIs are better tolerated than TCAs or MAOIs and display similar efficacy in acute, continuation and maintenance treatment. They are less likely to be fatally toxic if taken in overdosage. There is growing evidence to support the use of a full therapeutic dose of antidepressant in maintenance treatment.