Need for continuation and maintenance treatments

There has been widespread agreement on the finding that juvenile affective disorders tend to be recurrent. This finding is important because it has been taught for many years that while behavioural difficulties such as conduct disorders show strong continuity over time, "emotional" problems among the young tend to be short-lived. The studies described here suggest that this view is mistaken, at least so far as clinical cases of depressive disorders are concerned. They are associated with considerable impairment of psychosocial functioning, and in severe cases vulnerability extends into adult life.

It is apparent, then, that both assessment and treatment need to be viewed as extending over a prolonged period of time. Young people with severe depressive disorders are likely to have another episode, and so it is important that we develop effective prophylactic treatments. But for how long should these treatments continue? Research with depressed adults distinguishes between the need for continuation treatments and maintenance treatments. The idea behind continuation treatments is that although treatment may suppress the acute symptoms of depression, studies of the natural history suggest that the underlying illness process is continuing. Thus, for example, untreated major depression in adolescents often lasts for many months (see above). Treatment therefore needs to continue until the hypothesized underlying episode has finished. There have been no randomized trials of continuation treatments for juvenile depressive disorders. However, data from a non-randomized trial with depressed adolescents suggest that continuing psychological treatment for 6 months after remission is feasible and may be effective in preventing relapse (Kroll et al., 1996). Moreover, there is good evidence from randomized trials with depressed adults that continuation psychological and pharmacological treatments are effective (Kupfer, 1992). Most investigators therefore recommend that the treatment given during the acute episode of adolescent depression should be continued after remission, until the patient has been free of depression for around 6 months.

Maintenance treatments have a different objective, which is to prevent the development of a new episode of depression. Research with adult patients suggests that both phar-macotherapy and psychotherapy may reduce the risk of relapse if maintained for several years after the index depressive episode (Frank et al., 1990; Kupfer et al., 1992). Clearly, such treatments will be very time-consuming and expensive. At present, they cannot be contemplated for more than a small minority of depressed young people. Clinical experience suggests that indications for maintenance treatment include a history of highly recurrent depressive disorder, severely handicapping episodes of depression, and chronic major depression.

The form of maintenance treatment may vary from case to case. Since early-onset depressive disorders seem to have a significant self-perpetuating quality, there is clearly a need to help individuals to develop coping strategies that will enable them to deal with the illness in the long term. However, there is also evidence that relapses are linked to changes in environmental circumstances, especially family disturbances such as parenting difficulties and mental illness (see above). Accordingly, clinicians treating young people with depressive disorders need to assess the extent to which these factors are relevant. It may be possible to intervene therapeutically to improve patterns of family relationships. Parents who are depressed or suffering from some other form of mental disorder also need to be helped. In other words, there needs to be a concern with the family as a whole, and not just with the patient as an individual.

In patients with milder cases who are relatively well between episodes, it is important that we teach the child and his parents early recognition of the signs of a relapse, and encourage them to return to us when the first symptoms appear. Alternatively, it may be useful to see the young person from time to time for "check-ups", rather like going to the dentist.

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