Should Depression Be Considered a Lifetime Disorder: Evidence from the Pittsburgh Studies of Maintenance Therapy

Abstract

A series of studies carried out at the University of Pittsburgh point strongly to the lifetime nature of recurrent unipolar disorder and to the need for a long-term perspective in the development of treatment strategies. In our initial investigation (Frank et al., 1990), remitted recurrent unipolar patients were randomly assigned to full dose ≈220 mg imipramine) maintenance pharmacotherapy, monthly maintenance psychotherapy, the combination or placebo for a period of three years. Full dose medication was highly effective (p < 0.0001) in preventing new episodes, with maintenance psychotherapy showing a modest protective effect (p = 0.05). In a second investigation (Kupfer et assignment. A third investigation (Frank et al., 1993), focused on those patients in the original study who had experienced a recurrence in the absence of active pharmacotherapy. Following successful treatment of their recurrence and a 20-week continuation treatment phase, these subjects were randomly assigned to either full or half-dose pharmacotherapy for a three-year period. Full-dose imipramine was associated with fewer recurrences and longer survival time than the half-dose strategy (p < 0.07). Taken together, these studies of recurrent unipolar patients present a picture of a disorder requiring long-term (if not life-long) prophylaxis in a manner similar al., 1992), subjects who survived the initial three-year trial in one of the two active medication conditions, were randomly assigned to an additional two years of full-dose pharmacotherapy or placebo. Once again, active medication was significantly superior to placebo (p < 0.006) in protecting against new episodes, this time in a group of patients who had all previously sustained a remission of almost 3.5 years prior to random to that apparently required in manic-depressive illness. What remains to be elucidated is: (1) whether more frequent maintenance psychotherapy can provide adequate protection against recurrence and (2) whether there are subgroups of recurrent unipolar patients who can ultimately discontinue treatment without adverse consequences.