In Search of Recovery in Depression

When we talk about the treatment of depression, the goal we have in mind from the beginning is to achieve complete remission of symptoms; that is, for the clinical symptoms of depression (sadness, loss of interest or pleasure in things, etc.) to disappear. However, there is increasing evidence that we should go further and also treat residual symptoms to restore the patient to their pre-morbid level of functionality.

What does this mean? It means returning the patient to their previous state before the onset of depression. In clinical practice, it’s often easy to overlook the fact that beneath the sadness, apathy, or disinterest in things, there are also other symptoms, frequently more difficult to detect and more persistent over time, known as residual symptoms. These residual symptoms might include fatigue, sleep disturbances, or cognitive symptoms (memory impairments, processing speed changes, reaction time alterations, complex attention deficits, or cognitive flexibility impairments).

It has been demonstrated that these residual symptoms can lead to the individual’s deterioration, even after what we have traditionally understood as “complete remission” of symptoms.

Furthermore, cognitive symptoms can interfere in several aspects that need to be considered, such as: Increased therapeutic non-compliance (e.g., errors in medication adherence). A higher number of recurrences of depressive episodes. Lower rates of response to pharmacological treatment.

Lower rates of complete remission. Impairment in social, occupational, and family life. For these reasons, it is essential for psychiatrists to always explore cognitive symptoms, either through clinical interviews or by using scales (such as the Sheehan or the RDQ), self-report questionnaires (such as the COBRA or the PDQ-D), or even apps (such as THINC-it, which includes a condensed version of the PDQ-D along with other neuropsychological tests).

Certain medications in the pharmaceutical industry have been shown to have pro-cognitive effects in addition to their antidepressant effects. Examples of these drugs include vortioxetine or tianeptine, which are undoubtedly molecules to be considered, especially in patients where depressive symptoms partially remit but these other cognitive symptoms persist, affecting the individual’s functionality.

References:

VII GETBA Teaching Course, March 2019. Romera, I., Pérez, V., & Gilaberte, I. (2013). Remission and functionality in major depressive disorder. Actas Esp Psiquiatr 2013;41(5):263-8. XVI Lundbeck Seminar “Turn the Tide on Depression” (Progress in mind).