TRATAMENTO DE MANUTENÇÃO DO TRANSTORNO DEPRESSIVO

Continuation and maintenance treatment:
Generally indicated for patients with unipolar major depression because the illness is highly recurrent. Standard treatments include pharmacotherapy, psychotherapy, or pharmacotherapy plus psychotherapy. Continuation treatment is administered after resolution of a major depressive episode to preserve and enhance remission, and prevent relapse of the presenting episode. Remission represents a period of time with minimal or no symptoms; the duration of this time period varies among different studies (eg, two to eight consecutive months). Continuation treatment is followed by maintenance treatment, which is provided after recovery from the presenting episode to prevent recurrence of new, subsequent episodes. Recovery is said to occur when patients remain well for a period of time exceeding the interval used to define remission. Many studies therefore use the terms "continuation treatment" and "maintenance treatment" interchangeably to describe treatment that is provided after patients respond to acute therapy.
INDICATIONS — Continuation treatment (lasting, for example, four to nine months) is generally indicated for patients who respond to acute treatment of unipolar major depression. Additional maintenance treatment (lasting, for example, one to three years) is indicated for patients with an increased risk of recurrence due to:
 Childhood maltreatment (physical or sexual abuse, neglect, or family violence or conflict)
 Early age of onset of unipolar major depression (eg, ≤18 to 21 years of age)
 A lifetime history of at least two or three major depressive episodes
 Persistent residual depressive symptoms, especially sleep disturbances
 Comorbid psychiatric disorders
 Psychosocial stressors or impairment (eg, marital conflict or inability to work)
 Negative cognitive style (eg, "I'm no good," "The future is hopeless," or "There’s nothing I can do")
 Family history of mood disorder
For patients with unipolar major depression who respond to acute therapy, continuation/maintenance treatment is consistent. However, patients with unipolar major depression who respond to acute treatment with cognitive-behavioral therapy (CBT) and are not at increased risk ofrelapse/recurrence may reasonably decline continuation treatment, provided the presenting episode was neither chronic nor severe.
Continuation/maintenance pharmacotherapy for unipolar major depression nearly always includes antidepressant medications, which should be used at the same dose that achieves remission. Although selective serotonin reuptake inhibitors (SSRIs) and tricyclics have been most widely studied, other reasonable options include serotonin-norepinephrine reuptake inhibitors (SNRIs), serotonin modulators (eg, trazodone and vilazodone), atypical antidepressants (eg, bupropion and mirtazapine), and monoamine oxidase inhibitors (MAOIs). Head-to-head randomized trials do not indicate that any one medication or medication class is superior.

DURATION
Continuation treatment
For patients with unipolar major depression who respond to acute therapy, multiple reviews and treatment guidelines recommend that clinicians administer continuation treatment for four to nine months to:
 Prevent relapse
 Eliminate residual symptoms (which are associated with relapse)
 Restore baseline psychosocial functioning
Evidence for the efficacy of continuation treatment includes a meta-analysis of five trials that compared antidepressants with placebo in 2000 patients who were treated with antidepressants for four to six months prior to random assignment. Relapse occurred in fewer patients who received antidepressants than placebo (18 versus 35 percent).
Maintenance treatment — Patients with risk factors for recurrence should receive at least one to three years of maintenance treatment following continuation treatment, as should patients who recover from a chronic (duration ≥2 years) or severe episode (eg, the episode includes a suicide attempt).

Patients with a history of multiple (eg, three) chronic or severe major depressive episodes, or with comorbid psychiatric and general medical disorders, are encouraged to maintain treatment indefinitely. Such patients may be discouraged by the prospect of treatment that lasts "forever." For these patients, it is important to emphasize the long-term nature of the relationship between the clinician and patient, and that the need for maintenance treatment will be reevaluated periodically (eg, annually) in light of the patient's progress in maintaining symptomatic and functional stability, as well as changes in risk factors for recurrence (eg, residual depressive symptoms or psychosocial stressors may resolve). It may be useful to help the patient conceptualize recurrent major depression as a chronic disease and to point out that other chronic illnesses such as hypertension, diabetes mellitus, and asthma often require life-time medications.
MONITORING PATIENTS — Patients receiving continuation and maintenance treatment for unipolar major depression should be regularly monitored for reemerging symptoms, with particular emphasis upon suicidal ideation. Patients treated with pharmacotherapy are also evaluated for adverse side effects. For patients who remit and remain stable, monitoring can be tapered, with progressively longer intervals between assessments. As an example, a patient who is seen every two weeks at the beginning of remission can be seen every two weeks for one to three more visits, and then every month for one to three visits. Continuously stable patients receiving pharmacotherapy can eventually be seen every three to six months. Stable patients receiving psychotherapy are typically seen once per month, following careful tapering from weekly to twice a month visits. More frequent visits should be scheduled for patients who develop symptoms or side effects; monitoring acutely ill patients is discussed separately.
For patients with unipolar depression who receive maintenance treatment, we suggest measurement based care using a self-report instrument. Measurement based care is discussed separately.
ADHERENCE — Many patients have difficulty adhering to (complying with) continuation and maintenance treatment.
REEMERGING SYMPTOMS DURING TREATMENT — If symptoms of unipolar major depression reemerge during continuation/maintenancepharmacotherapy, doses of medications should be optimized. If this does not control symptoms within four to eight weeks, or doses are already at the maximum of the therapeutic range, we suggest adding psychotherapy; this strategy is called sequential treatment. If a full blown episode occurs despite optimizing medication doses and adding psychotherapy, the treatment regimen should be switched.
If symptoms reemerge during continuation/maintenance psychotherapy, the frequency of sessions should be increased to that used during acute phase treatment. If a full blown episode occurs despite increasing the frequency of psychotherapy sessions, the treatment regimen should be switched.
DISCONTINUATION — Prior to discontinuing continuation and maintenance treatment for unipolar major depression, clinicians should discuss the potential for relapse and recurrence with patients, and the signs and symptoms that may arise. These discussions often include family members and generate contingency plans for seeking treatment should the need arise. In addition, the date for termination of psychotherapy should be discussed at the outset ofcontinuation/maintenance treatment.
We suggest tapering continuation/maintenance medications over two to four weeks prior to discontinuation to minimize the discontinuation syndrome, which includes gastrointestinal distress, headache, myalgia, insomnia, anergia, and dysphoria. Medications with shorter half lives (eg, venlafaxine) should be tapered over one month. The dose is generally reduced by the same amount for each step of the taper. As an example, sertraline 200 mg per day is decreased by 50 mg every three to five days. Additional information about discontinuing antidepressants is discussed separately.
In addition, tapering allows clinicians to detect recrudescent symptoms of major depression and reinstitute the full dose used initially to achieve remission. If a full-blown episode develops despite increasing the dose and does not improve within four to eight weeks, we suggest augmenting or switching treatment.
Following discontinuation of continuation/maintenance pharmacotherapy or psychotherapy for unipolar major depression, it is prudent to monitor patients for several (eg, three to eight) months, because the risk of relapse or recurrence is greatest in the first several months after stopping treatment. For patients who suffer a relapse or recurrence, we suggest restarting the same treatment that was discontinued.

REFERÊNCIA: UPTODATE - Unipolar depression in adults: Continuation and maintenance treatment