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Criteria for major depressive disorder in partial remission, lightheadedness and fatigue during pregnancy - For Begninners

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Several studies since the early 1990s have established that residual symptoms are common in treated depression, even in patients judged to be in remission. Remission, generally defined as the disappearance of the diagnostic criteria of depression for at least 2 consecutive months, has gradually ousted treatment response as the gold-standard end point for evaluating antidepressant efficacy in long-term controlled trials. In 1989 the MacArthur Foundation Research Network convened a task force to establish operational criteria for the terms treatment response, remission, relapse, and recurrence.
A clear distinction needs to be drawn between diagnostic criteria and rating scales or questionnaires. The Montgomery–Asberg Depression Rating Scale (MADRS)38 has attracted similar criticism, having been found to be sensitive to change but with an unstable factor structure. The Inventory of Depressive Symptomatology (IDS) was developed from 1986 onward,39 with the main validation study being published 10 years later. Depression questionnaires have yet to prove more sensitive to change than HAM-D, even if the Beck Depression Inventory (BDI)44 has been used to assess change primarily via its cognitive variables.
Several investigators have emphasized the importance of functional remission in conjunction with a return to premorbid cognitive function. Assessment of full remission is ultimately a simple matter, involving confirmation of the lasting disappearance of depressive symptoms and the return to previous functioning (complete with the date of the anticipated return to work, as applicable).
Functional remission in the presence of persistent residual symptoms is a trickier problem, requiring psychometric screening to pinpoint the residual symptoms concerned, given that these vary in their functional impact. Boulenger’s 2004 review55 of residual symptoms emphasized the heterogeneity among patients in partial remission. Analysis of patient responses revealed that “extreme responses (‘totally agree’ or ‘totally disagree’) to depression-related questionnaire items are the ‘tip of the iceberg’ reflecting underlying activity of mood-dependent, developmentally early, depressogenic schematic processing, uncorrected by subsequent reappraisal. Assessment of remission quality in depression needs to combine semistructured interviews to determine the degree of disappearance of the diagnostic criteria of depression, specialized scales to assess the extent of residual symptoms, duration criteria, and questionnaires that target subjective mood as well as more objective end points of return to the normal functional self, return to work and normal social activities, and quality of life. In 1992, Thase et al17 showed in 48 depressed patients receiving cognitive behavioral therapy (CBT) that the risk of relapse or recurrence in the year following the episode was much lower in full than in partial responders (9% vs 52%).
The difference was even more striking when taking into account not just major depressive disorder but all types of depression (minor, acute, and chronic [dysthymia]): 184 versus 33 weeks. Partial remission, defined as the persistence of residual symptoms, is a risk factor for early relapse and subsequent recurrence; it is a heterogeneous state, in which the persistence of even mild symptoms reduces the hope of full functional recovery. Its first publications, in particular by Ellen Frank, Robert Prien, David Kupfer, and others, were based on the review of 121 papers published in 1987-1988 in nine English-language journals.
The diagnostic criteria of depression must disappear for _8 consecutive weeks before a depressive syndrome can be considered to have resolved.
Remission came to be defined as the disappearance for at least 2 to 3 consecutive weeks of the main symptoms of depression (depressed mood, with loss of interest and pleasure) and the total or near dis- appearance of the nine DSM-IV diagnostic criteria of major depression. Proportion of patients with ( ) and without ( ) residual symptoms relapsing after remission from depression. The purpose of diagnostic criteria is to confirm the presence or absence of a diagnosis, usually after completing a semi-structured or structured interview. The Hamilton Rating Scale for Depression (HAM-D)30 remains the world’s most widely used depression scale and the subject of a still-extensive literature, not all of which is favorable. 40 A 16-item short form was produced in 2003,41 with further publications in 200642,43 comparing clinician and patient ratings.
The 2-year study in 219 depressives with psychotic characteristics published by Tohen et al52 in 2000 is a case in point. Most randomized consensitivity trolled trials reach over-optimistic conclusions in so far as the patients they include tend to be young, in good physical health, with little comorbidity, and no major risk of suicide.
In most cases some depressive symptoms persist; in other cases, symptoms predate the depressive syndrome.
Frequency of residual major depressive disorder symptoms in responders (215 patients with major depressive disorder received a fixed dose of fluoxetine 20 mg for 8 weeks).

The present paper reviews recent developments in the concept of remission, before discussing the various methods proposed for its assessment and the clinical implications of the variable nature of residual symptoms. Review of major depressive episodes showed that symptom-free patients had a risk of relapse that was less than one-third that of patients with residual symptoms. The best criteria of high-quality remission are the disappearance of the diagnostic criteria of depression for _2 months, a score of 1 on the Clinical Global Impression–Improvement scale, a score _3 on the Hamilton Rating Scale for Depression, and a return to premorbid general functional status. Their work differentiated the conventional efficacy measure, treatment response, from remission. Until that time, the depression can be considered as being in remission to a degree, dependent on the persistence of certain symptoms, provided these are insufficient in number and intensity to warrant rediagnosis as depression.
Thus Ferrier in 199926 combined the disappearance of the diagnostic criteria of depression and a Clinical Global Impression–Improvement (CGI-I) score of 1 to show that the serotonin norepinephrine reuptake inhibitor (SNRI) venlafaxine was more effective than selective serotonin reuptake inhibitors (SSRIs). DSM-IV criteria are the most commonly used, in combination with the Structured Clinical Interview for DSM-IV (SCID).27 This tool is used to confirm the absence of an ongoing depressive syndrome and to identify any residual symptoms.
Residual symptoms are sufficiently varied to justify a palette of therapeutic measures and sophisticated symptom analysis, without forgetting the physical symptoms45 that must always be taken into account before deciding treatment. Thus Zimmerman et al46,47 showed that the three items most frequently judged to be critical in determining remission were the presence of features of positive mental health such as optimism and self-confidence, a return to one’s normal self, and a return to usual level of functioning.
When general functioning remains impaired and there is a suggestion of personality disorder, assessment of the relationship between residual symptoms and personality becomes particularly important. Alongside conventional syndromal recovery, Tohen et al used the concept of functional recovery defined by the return to patients’ former vocational and residential status. In real life, however, half the patients prescribed an antidepressant stop taking it within the first month, and only one quarter continue treatment for more than 3 months.18,54 Hence the importance of assessing compliance during treatment and making the requisite effort to improve it as appropriate. Major depressive disorders: a prospective study of residual subthreshold depressive symptoms as predictor of rapid relapse. Remission and recurrence of depression in the maintenance era: longterm outcome in a Cambridge cohort. Longitudinal syndromal and sub-syndromal symptoms after severe depression : 10-year follow-up study. Depression- free days as a summary measure of the temporal pattern of response and remission in the treatment of major depression. The definition and operational criteria for treatment outcome of major depressive disorder. Toward an integration of psychologic, social, and biologic factors in depression: effects on outcome and course of cognitive therapy. Relapse after cognitive behavior therapy of depression: potential implications for longer courses of treatment. Outcomes in major depressive disorders: the evolving concept of remission and its implications for treatment. Relapse of major depression after complete and partial remission during a 2-year follow-up.
Definitions of antidepressant treatment response, remission, nonresponse, partial response, and other relevant outcomes: a focus on treatment-resistant depression. Remission, residual symptoms and nonresponse in the usual treatment of major depression in managed clinical practice. Improving the course of illness and promoting continuation of treatment of bipolar disorder. Remission and residual symptoms after short-term treatment in the Treatment of Adolescents with Depression Study (TADS).
Conceptualization and rationale for consensus definitions of terms in major depressive disorder. Measuring the severity of depression and remission in primary care: validation of the HAMD-7 scale.

Sensitivity to change, discriminative performance, and cutoff criteria to define remission for embedded short scales of the Hamilton depression rating scale (HAMD).
The 16- Item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression.
Comparison of self-report and clinician ratings on two inventories of depressive symptomatology.
Discordance between self-reported symptom severity and psychosocial functioning ratings in depressed outpatients: implications for how remission from depression should be defined. Two-year syndromal and functional recovery in 219 cases of first-episode major affective disorder with psychotic features.
A comparison of rates of residual insomnia symptoms following pharmacotherapy or cognitive-behavioral therapy for major depressive disorder. Relationship of variability in residual symptoms with recurrence of major depressive disorder during maintenance treatment. Four-year outcome for cognitive behavioral treatment of residual symptoms in major depression. A prospective test of criteria for response, remission, relapse, recovery, and recurrence in depressed patients treated with cognitive behavior therapy. Six-year outcome for cognitive behavioral treatment of residual symptoms in major depression. Effects of adding cognitive therapy to fluoxetine dose increase on risk of relapse and residual depressive symptoms in continuation treatment of major depressive disorder.
Effects of cognitive therapy on psychological symptoms and social functioning in residual depression.
Preventing recurrent depression using cognitive therapy with and without a continuation phase: a randomized clinical trial. Schedule for Affective Disorders and Schizophrenia for School- Age Children-Present and Lifetime Version: Initial reliability and validity data.
In a longitudinal study whose main results appeared in 2004, Kennedy et al3,4 showed that patients were only symptom-free for approximately half the mean 10-year follow-up; bouts of full depression occurred in 13% of follow-up months, bouts of minor depression in 15% of months, and bouts with residual symptoms in 20%. Careful evaluation of residual symptoms informs the choice of the most appropriate therapeutic strategy for achieving full remission. Response had generally signified a 50% reduction in overall score on a validated depression scale. In 1994, the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) officialized the terminology of total and partial remission: “Full remission requires a period of at least 2 months in which there are no significant symptoms of depression. A post hoc comparison of Hamilton Depression Rating Scale, Maier and Bech subscales, Clinical Global Impression, and Symptom Check-list-90 scores. Presented at the annual meeting of the Association for the Advancement of Behavior Therapy, Chicago USA, November, 1978. La persistance de symptomes residuels dans les remissions partielles represente un facteur de risque de rechute precoce puis de recidive. This end point gradually gave way to the remission end point following such studies as those by Bakish in 2001,21 Nierenberg and DeCecco the same year,22 Thase in 2003,11 and Cuffel et al23 and Keller24 in 2004.
Until recently, the scientific community more or less generally accepted the 1991 proposal by the MacArthur Foundation Task Force32 to define full remission as a maximum total score of 7 on the 17-item HAM-D (HAM-D17) and partial remission as a score of 7 to 13.
L’etat de remission partielle est lui-meme heterogene puisque l’esperance d’une recuperation fonctionnelle complete est moindre lorsque persistent plusieurs symptomes, meme d’intensite legere.
Alongside specialized tools such as the Modified Vocational Status Index and Modified Vocation Code Index, the main end point was simply a CGI-I score of 1 to 2 for at least 8 weeks.

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