Clinician perspective on achieving and maintaining remission in depression

The majority of large-scale clinical trials of depression focus on response, typically defined as a 50% reduction in symptoms, as the endpoint. Response in the absence of remission places patients at greater risk for relapse, decreases their level of functioning, and erodes quality of life. Most importantly, both research and our clinical experience suggest that remission, or "getting well," is an attainable goal for patients with major depressive disorders. Pharmacotherapy, psychotherapy, and combination regimens are all treatment options. Recent studies across a range of patient populations have demonstrated the benefit of affecting multiple transmitter systems over a single antidepressant mechanism. Pooled data from more than 2000 patients comparing venlafaxine, a serotonin-norepinephrine reuptake inhibitor, and selective serotonin reuptake inhibitors suggest that the dual mechanism of action of venlafaxine provides significantly greater efficacy in achieving remission. Ultimately, achieving a good clinical outcome is desirable, but sustaining the mood state is, perhaps, more important. Studies of venlafaxine show it is possible to prevent more relapses and recurrences of depression with dual-mechanism treatment than with placebo. These data highlight the need for setting appropriately aggressive goals and working closely with our patients to achieve them. By doing so, we create the best opportunity for restoring patients to "wellness" and, ultimately, a normal and fulfilling life.