While in the past, alleviating the symptoms of depression during the acute phase was the main objective of any therapeutic management, specialists today pay particular attention to the quality of their patients’ recovery. The goal: to prevent any relapse, which could be fuelled by the presence of residual symptoms. Explanations.
Curing depression is often a long road, punctuated by phases of remission and relapse. In recent years, specialists have paid increased attention to the quality of patients’ recovery from a major depressive episode. The reason is simple: individuals with residual depressive symptoms (30 to 50% of cases), such as loss of pleasure and interest, anxiety or somatic concerns (pain, etc.) in particular, would be more fragile in the medium term than those in whom symptoms disappear completely. The risk of relapse is even three times higher than in people who have become asymptomatic.
Persistent signs of depression
Another important fact is that these residual symptoms, as specialists call them, can have a significant impact on a person’s psychosocial functioning, if they do not affect their quality of life. Other difficulties, whether or not related to the use of antidepressants, may also hinder the healing process: sleep disorders, cognitive or sexual difficulties, for example. As for the loss of interest and lack of pleasure, they seem to play a major role in the risk of relapse
Accompaniment towards healing
Thus, when a patient is in remission, the practitioner will seek to identify and treat anything that could compromise complete remission. To this end, he or she will take care of all aspects of the patient’s life, including social functioning, professional integration and well-being. To best accompany him on the path to recovery, he will reassess his diagnosis and be alert for the possible presence of other psychiatric illnesses, such as anxiety disorder, addiction or somatic problems, that may be associated with depression. Drug treatment can be adapted (increase in doses, change of substances, addition of a second antidepressant) provided that individual patient tolerances are respected. Finally, to best manage the presence of these symptoms suggestive of recent depression, psychological support may be offered, knowing that cognitive psychotherapy or the interpersonal approach are particularly appropriate treatments in these circumstances.
When the disease course is resistant to conventional treatments and does not indicate remission, other treatments are considered. For many years, it has been recognized that sleep deprivation has dramatic, but transient, outcomes in depressed patients. Whether partial or total, it quickly leads to an improvement in mood. Today, thanks to scientific advances in chronotherapy, we know that it must be combined with other types of treatment (light therapy, antidepressants or mood stabilizers, phase advance) for the antidepressant effect to persist.
There are also approaches to brain stimulation that are used in some countries but are not first-line treatments: transcranial magnetic stimulation, deep brain stimulation and vagus nerve stimulation. They are considered promising in the treatment of resistant depression, but must still prove themselves in order to be reimbursed by health insurance in Switzerland.
Transcranial magnetic stimulation has been approved in the United States by the Food and Drug Administration (FDA) for the treatment of major depression in adults in the event of non-response to conventional drugs, but not in Europe or Switzerland for this indication. Its antidepressant effect has certainly been identified, but its clinical utility is being discussed within the scientific community. In our country, however, its so-called “off-label” use remains possible under the responsibility of the doctor who prescribes it and with the informed consent of the patient.
Vagus nerve stimulation, on the other hand, has obtained the indication for the treatment of chronic depression in the European Union. Its use is very rare in Switzerland. Deep brain stimulation, which is associated with a higher risk of side effects, is mainly recognized in the treatment of obsessive-compulsive disorder, as an additional treatment to medication in very specific cases. For depression, studies have shown convincing results.