Can cognitive behavioral therapy reduce relapse rates of depression after ECT? a preliminary study

OBJECTIVE: The goal of this study was to explore the potential of providing cognitive behavioral therapy (CBT) after an index course of electroconvulsive therapy (ECT) for depression to improve long-term outcome. METHOD: The Beck Depression Inventory (BDI) and Clinical Global Impression (CGI) scale were used to assess depression and treatment outcome for 6 patients who received 12 weeks of CBT after an index course and concurrent with a continuation course of ECT. RESULTS: Patients either maintained their response or showed decreased depressive symptoms at the 6-month post-index ECT evaluation. At the 9-month follow-up, 5 of 6 patients had BDI scores below their post-index ECT scores. The CGIs were rated "much improved" or "very much improved" by 5 patients at the termination of CBT. All 6 patients maintained or improved their CGIs at the 6-month follow-up. CONCLUSIONS: These results provide preliminary evidence that CBT after ECT is feasible and may extend the antidepressant effects ofECT.     

Changes in adverse events reported by patients during 6 months of fluoxetine therapy.

BACKGROUND: Although a period of 6 to 12 months of antidepressant therapy is recommended for most patients with depression, systematic examinations of the course of adverse events over time, the resolution of early-onset events, and the possible emergence of later-onset events are limited. We examined the safety of fluoxetine, 20 mg/day, in a large, prospective, long-term treatment trial, and we report a comparison of early- and late-onset adverse events and the course of adverse events over 26 weeks of treatment. METHOD: Adverse events were recorded at each visit in a uniform format by open-ended questioning, regardless of perceived causality. New or worsened events reported in either the first 4 weeks of treatment (early-reporting interval) or weeks 22 through 26 of treatment (late-reporting interval) were compared. RESULTS: Patients (N = 299) whose depression (DSM-III-R) remitted with 12 weeks of fluoxetine treatment entered continuation therapy, and 174 completed 26 weeks of therapy. All events that occurred in > or =5% of patients early in treatment decreased in frequency over time (p<.05), and no events occurred significantly more frequently during continuation therapy. No previously uncommon adverse events became common during long-term treatment. CONCLUSION: Common adverse events associated with initiating fluoxetine treatment in depressed patients, including nausea, insomnia, nervousness, and somnolence, resolve in the majority of patients and become significantly less frequent with continued treatment over a 6-month period. No adverse events present initially become more frequent late in treatment. Therapy with fluoxetine, 20 mg/day, is well tolerated over 6 months, and most adverse events observed early in treatment resolve.     

Frontal cerebral perfusion after antidepressant drug treatment versus ECT in elderly patients with major depression: a 12-month follow-up control study

BACKGROUND: Little is known about the evolution of brain perfusion alterations in patients with major depression, and still less about the changes in functional neuroimage produced by different antidepressant biological treatments. METHOD: Between January 2001 and December 2003, long-term follow-up frontal brain perfusion was compared in 2 subgroups of elderly patients (>or= 60 years) treated for severe unipolar major depression (DSM-IV): one subgroup of 16 patients administered electroconvulsive therapy, and another of 26 patients receiving pharmacologic treatment. All patients were remitters. A medication-free brain single photon emission computed tomography was performed in baseline conditions and after a minimum period of 12 months of euthymia. Twenty-eight age- and sex-matched healthy controls were also assessed. RESULTS: No significant differences were found between the 2 subgroups in frontal uptake ratios after a 12-month follow-up period of euthymia. During the acute episode, patients presented significant anterior hypofrontality; 12 months later the hypofrontality had disappeared. CONCLUSION: The long-term evolution of frontal perfusion in elderly major depressives who respond to antidepressant biological treatment is essentially the same in those who receive electroconvulsive therapy and in those who receive medication.     

Efficacy of continuation ECT and antidepressant drugs compared to long-term antidepressants alone in depressed patients

OBJECTIVE: The purpose of this study was to evaluate the efficacy of continuation ECT in depression. METHOD: The authors used retrospective chart review to identify 29 patients who received continuation ECT plus long-term antidepressant treatment after a positive response to acute treatment with ECT for a depressive episode (continuation ECT group). A retrospective case-controlled approach was used to ascertain a matching group of 29 patients who received long-term antidepressant treatment alone after responding positively to acute ECT (antidepressant-alone group). All 58 patients (46 with unipolar depression, 12 with bipolar disorder) had been chronically depressed before receiving acute ECT. Data from medical records were analyzed by using survival analysis and proportional hazards regression to determine outcome and risk factors. RESULTS: The mean duration of the follow-up period for all patients was 3.9 years (5.4 years for the continuation ECT patients and 2.4 years for the antidepressant-alone patients). Outcome was significantly better in the continuation ECT group. The cumulative probability of surviving without relapse or recurrence at 2 years was 93% for continuation ECT patients and 52% for antidepressant-alone patients. At 5 years, survival declined to 73% for continuation ECT patients, but fell to 18% for antidepressant-alone patients. Mean survival times were 6.9 years for the continuation ECT patients and 2.7 years for the antidepressant-alone patients. CONCLUSIONS: The findings provide strong support for the efficacy of continuation ECT plus long-term antidepressant treatment in preventing relapse and recurrence in chronically depressed patients who have responded to acute treatment with ECT.     

Which elderly depressed patients remain well on maintenance interpersonal psychotherapy alone?: report from the Pittsburgh study of maintenance therapies in late-life depression

The aim of this study was to identify elderly depressed patients who can remain well on maintenance Interpersonal Psychotherapy (IPT) alone, after discontinuation of antidepressant medication. Using Cox proportional hazards models, increased severity of depression at pretreatment was associated with increased recurrence rates, to an extent greater in patients maintained on monthly IPT than in those maintained on nortriptyline. The long-term response to maintenance IPT was correctly identified in 20/25 cases by a pretreatment Hamilton score of > or = 20. Fourteen of sixteen patients with pretreatment scores of > or = 20 experienced recurrence of major depression on maintenance IPT, while 6/9 patients with pretreatment scores of less than 20 did not. (Fisher exact P = .01). The same pattern of recurrence in relation to severity was not evident in maintenance placebo, nortriptyline, or combination treatment. In addition, Hamilton scores during continuation treatment were lower (< or = 7) among those who remained well on maintenance IPT than among those who had recurrences. Elderly patients whose depressions are milder at baseline and who show excellent symptomatic remission during acute and continuation therapy may be good candidates for monthly maintenance IPT after initial successful treatment with antidepressant medication and psychotherapy.     

Comorbidity in generalized anxiety disorder: prevalence and course after cognitive-behavioural therapy]

OBJECTIVE: To evaluate the prevalence and course of Axis I concurrent disorders in a population of patients who underwent cognitive-behavioural therapy (CBT) to treat their generalized anxiety disorder (GAD). METHOD: This study is a secondary analysis combining patients from 3 treatment studies done at Université Laval. A total of 90 patients with a DSM-IV consistent GAD diagnosis received from 12 to 16 CBT sessions to treat GAD. Symptomatology was assessed at pretest, posttest, and 6 months after treatment, with the Anxiety Disorders Interview Schedule, a structured diagnostic interview. RESULTS: Seventy-three per cent of patients had both GAD and a concurrent diagnosis. The most common diagnoses were simple phobia, social phobia, panic disorder, and major depression. CBT applied to GAD decreases the number of concurrent diagnoses. A panic disorder or a greater number of concurrent diagnoses at pretest is associated with a less efficient treatment at follow-up 6 months later. CONCLUSION: Patients with GAD have a high comorbidity rate with other Axis I disorders, but these significantly decrease after a short CBT aimed at GAD. Implications for GAD treatment and mechanisms that might explain these findings are discussed.     

Pramipexole in treatment-resistant depression: an extended follow-up

We evaluated the long-term antidepressant safety and response of adjunctive pramipexole, a D2-D3 dopamine agonist, in the course of drug-resistant depression. Twenty-three patients with treatment-resistant major depressive episode (MDE) were followed up after a 16-week pramipexole add-on trial. Pramipexole was added to current treatment with TCA or SSRI, at increasing doses from 0.375-1.500 mg/day. The LIFE scale was administered at baseline of the acute trial, at Weeks 16, 32, and 48. Patients were analyzed for sustained remission (score= <2 at LIFE for at least 8 weeks) and recurrence (after remission score > =3 at LIFE for at least 2 weeks) of depression. Of 23 patients, 12 had major depression and 11 had bipolar depression (16 women; mean age=52.8 years). Mean age of onset and median duration of current MDE were 35.1 years and 6 months, respectively; all subjects had at least two prior MDEs. Mean pramipexole dose was 0.990 mg/day. Median duration of follow-up was 28 weeks. Mean baseline MADRS and CGI-S scores were 33.7+/-8.4 (sd) and 4.6+/-0.8, respectively. Median time to sustained remission from baseline was 10 weeks and overall 60.9% (14/23) of subjects recovered within Week 22. Recurrence of depression occurred in 35.7% (5/14) of remitters after Week 24 and within Week 28 from remission. Although there were no sleep attacks, two cases of hypomania and one case of psychotic mania occurred at Weeks 22, 24, and 30, respectively. Pramipexole augmentation of antidepressant treatment was relatively safe and presumably effective in the long-term course of treatment resistant depression.     

Cognitive-behavioral therapy to prevent relapse in pediatric responders to pharmacotherapy for major depressive disorder

ObjectiveWe present results of a feasibility test of a sequential treatment strategy using continuation phase cognitive-behavioral therapy (CBT) to prevent relapse in youths with major depressive disorder (MDD) who have responded to acute phase pharmacotherapy. Method: Forty-six youths (ages 11-18 years) who had responded to 12 weeks of treatment with fluoxetine were randomized to receive either 6 months of continued antidepressant medication management (MM) or antidepressant MM plus relapse prevention CBT (MM+CBT). Primary outcome was time to relapse, defined as a Childhood Depression Rating Scale-Revised score of 40 or higher and 2 weeks of symptom worsening or clinical deterioration warranting alteration of treatment to prevent full relapse.ResultsCox proportional hazards regression, adjusting for depression severity at randomization and for the hazard of relapsing by age across the trial, revealed that participants in the MM treatment group had a significantly greater risk for relapse than those in the MM+CBT treatment group (hazard ratio = 8.80; 95% confidence interval 1.01-76.89; X² = 3.86, p = .049) during 6 months of continuation treatment. In addition, patient satisfaction was significantly higher in the MM+CBT group. No differences were found between the two treatment groups on attrition rate, serious adverse events, and overall global functioning.ConclusionsThese preliminary results suggest that continuation phase CBT reduces the risk for relapse by eightfold compared with pharmacotherapy responders who received antidepressant medication alone during the 6-month continuation phase. J. Am. Acad. Child Adolesc. Psychiatry, 2008;47(12): 1395–1404.     

Long-term follow-up after successful electroconvulsive therapy for depression: a 4- to 8-year naturalistic follow-up study

OBJECTIVES: A long-term follow-up of depressed patients responsive to electroconvulsive therapy (ECT) with intensive pre-ECT pharmacotherapy treatment failure who also participated in a 6-month trial directly post-ECT in which imipramine was compared with placebo for relapse prevention. METHODS: A total of 26 patients responsive to ECT who participated in the 6-month continuation trial were invited 4 to 8 years later to assess their follow-up status. The groups with and without relapse within 6 months were compared with regard to recurrence of depression up to 8 years later. Recurrence was defined as a new episode of depression that needed antidepressant medication and/or readmission in hospital and/or a new ECT course. RESULTS: At the time of follow-up (mean duration, 6.8 years), the recurrence rate of depression for the total sample was 42.3%. There was no significant difference in the recurrence rates and number of recurrences between the nonrelapse and relapse groups.The small study population limits generalization of the results; the design of the study is naturalistic and retrospective. CONCLUSION: In our small sample of depressed patients with pharmacotherapy treatment failure, recurrence is not influenced by relapse after terminating ECT. Continuation of medication started immediately after ECT seems to be an important factor in preventing recurrence.     

Venlafaxine versus placebo in the preventive treatment of recurrent major depression

BACKGROUND: Major depression is often chronic and recurrent, yet most long-term therapeutic trials are not adequately designed to assess antidepressant efficacy in recurrence prevention. Long-term efficacy and safety of prophylactic venlafaxine treatment were evaluated in outpatients with recurrent major depression. METHOD: Patients with a history of recurrent DSM-III-R major depression received open-label treatment with venlafaxine, 100 to 200 mg/day, for 6 months. Those who responded to treatment (Hamilton Rating Scale for Depression [HAM-D(21)] score < or = 12, day 56) and remained relapse-free (no more than 2 HAM-D(21) scores > 10 and no Clinical Global Impressions-Severity of Illness [CGI-S] score > or = 4, months 2-6) either continued taking venlafaxine, 100 to 200 mg/day, or were switched in a double-blind fashion to placebo for 12 months. The primary efficacy outcome was the number of patients experiencing a recurrence of major depression (CGI-S score > or = 4). The cumulative probability of recurrence was calculated using the Kaplan-Meier method of survival analysis. Data were collected from November 1992 through December 1995. RESULTS: Of the 235 patients who enrolled in the recurrence-prevention period, 225 (N = 109, venlafaxine; N = 116, placebo) provided efficacy data. Survival analysis determined a 22% cumulative probability of recurrence in venlafaxine-treated patients after 12 months compared with 55% for the placebo group (p <.001). More than twice as many placebo-treated patients (48%) as venlafaxine-treated patients (21%) discontinued treatment because of lack of efficacy (p <.001). CONCLUSION: Twelve-month maintenance venlafaxine treatment was significantly more efficacious than placebo in preventing major depression recurrence in patients who had been successfully treated with venlafaxine for 6 months.     

Psychosocial outcomes following long-term,double-blind treatment of chronic depression with sertraline vs placebo

BACKGROUND: Chronic forms of depression are associated with significant functional and psychosocial impairments. To date, no study has measured psychosocial functioning in this population during long-term maintenance antidepressant treatment or following the double-blind discontinuation of treatment. METHODS: Patients with chronic major or double depression completed 12 weeks of short-term treatment followed by 16 weeks of continuation treatment with sertraline hydrochloride. Responders at the end of the continuation phase were randomized, double-blind, to 18 months of maintenance therapy with either sertraline (n = 77) or placebo (n = 84). Multiple domains of psychosocial functioning were assessed during double-blind therapy. RESULTS: Substantial worsening in psychosocial function measures occurred in patients taking placebo compared with sertraline during maintenance. Patients with reemergence of depression lost psychosocial gains regardless of treatment. In the subsample of patients who remained in remission throughout maintenance, most of the observed improvement in psychosocial functioning occurred during short-term treatment. By maintenance end point, normalization of functioning was achieved by 58% to 84% of remitters, depending on the outcome measure used. CONCLUSIONS: These results indicate that long-term treatment of chronic forms of depression can result in sustained psychosocial benefits. Discontinuation of treatment results in frequent reemergence of symptoms and loss of psychosocial gains. Long-term treatment resulted in only modest further improvement of psychosocial measures over that achieved in the short-term phase.     

Impact of antidepressant discontinuation after acute bipolar depression remission on rates of depressive relapse at 1-year follow-up

OBJECTIVE: While guidelines for treating patients with bipolar depression recommend discontinuing antidepressants within 6 months after remission, few studies have assessed the implications of this strategy on the risk for depressive relapse. This study examined the effect of antidepressant discontinuation or continuation on depressive relapse risk among bipolar subjects successfully treated for an acute depressive episode. METHOD: Eighty-four subjects with bipolar disorder who achieved remission from a depressive episode with the addition of an antidepressant to an ongoing mood stabilizer regimen were followed prospectively for 1 year. The risk of depressive relapse among 43 subjects who stopped antidepressant treatment within 6 months after remission ("discontinuation group") was compared with the risk among 41 subjects who continued taking antidepressants beyond 6 months ("continuation group"). RESULTS: A Cox proportional hazards regression analysis indicated that shorter antidepressant exposure time following successful treatment was associated with a significantly shorter time to depressive relapse. Furthermore, patients who discontinued antidepressant treatment within the first 6 months after remission experienced a significantly shorter period of euthymia before depressive relapse over the length of 1-year follow-up. One year after successful antidepressant response, 70% of the antidepressant discontinuation group experienced a depressive relapse compared with 36% of the continuation group. By the 1-year follow-up evaluation, 15 (18%) of the 84 subjects had experienced a manic relapse; only six of these subjects were taking an antidepressant at the time of manic relapse. CONCLUSIONS: The risk of depressive relapse in patients with bipolar illness was significantly associated with discontinuing antidepressants soon after remission. The risk of manic relapse was not significantly associated with continuing use of antidepressant medication and, overall, was substantially less than the risk of depressive relapse. Maintenance of antidepressant treatment in combination with a mood stabilizer may be warranted in some patients with bipolar disorder.     

Multiple sclerosis,interferon beta-1b and depression A prospective investigation

The objectives were twofold: a) to explore a possible association between major depression and treatment with interferon beta-1b in patients with multiple sclerosis; and b) to investigate whether putative antecedent risk factors such as a previous psychiatric history and a family history of affective illness influence the prevalence of major depression post-treatment with interferon beta-1b. Forty-two patients with relapsing-remitting MS underwent neurological examination and were interviewed with the Structured Clinical Interview for Axis 1 DSM-IV Disorders prior to starting interferon beta-1b and thereafter at 3, 6 and 12 months. Ethical considerations dictated that patients diagnosed with major depression received anti-depressant medication. At index assessment, 21.4 % of the sample were diagnosed with a major depression, the figures falling to 17.5 %, 11.4 % and 6.3 % at 3, 6 and 12 months respectively. The majority of subjects with a major depression had a history of psychiatric illness prior to treatment with interferon beta-1b. A family history of affective disorder was not associated with a significantly increased rate of major depression either before or after treatment with interferon beta-1b. While the study's methodology did not address causality, the data demonstrate that major depression post-treatment with interferon beta-1b is linked to a history of psychiatric illness prior to starting treatment. The threefold decline in prevalence rates for major depression over the course of a year demonstrates a good response to anti-depressant medication and possible beneficial effects of interferon beta-1b on mood.     

Clinical issues in long-term treatment with antidepressants

Historically, the emphasis in treating depression has been focused on the acute phase of treatment, with few published data on the continuation and maintenance phases of treatment. Yet the risk of depression increases with each episode, with a 50% to 90% chance of developing another episode after 1 or 2 prior episodes of depression. Moreover, subsequent episodes of depression are often of longer duration, more severe, and less responsive to treatment. Most patients with major depression require some form of long-term antidepressant treatment, and many need lifelong treatment. Optimizing efficacy and minimizing side effects are essential during both the acute and long-term phases of antidepressant treatment. Antidepressant side effects, including insomnia or somnolence, weight gain, asthenia, and sexual dysfunction, can significantly decrease patient compliance with long-term treatment for depression. Identification and management of side effects, combined with early and ongoing educational messages to the patient about treatment issues and the importance of sustaining illness remission, help improve compliance and reduce the potential for premature discontinuation of an otherwise optimal antidepressant.     

Adequacy of antidepressant treatment in Spanish primary care: a naturalistic six-month follow-up study

OBJECTIVE: This study evaluated the adequacy of pharmacological antidepressant treatment in major depressive episodes prescribed in 16 Spanish primary care centers, both during the acute phase of treatment and after the first three months of the continuation phase, under real-world naturalistic conditions (usual care). Factors that could be associated with adequacy of care also were explored. METHODS: A total of 333 patients from primary care who began pharmacological antidepressant treatment were followed up for six months. Treatment adequacy and associated factors were evaluated. RESULTS: Between 27% and 32% of patients received adequate antidepressant treatment during the acute phase. Percentages of adequacy were between 21% and 25% when considering the acute phase and the first three months of the continuation phase. Psychiatric consultations were found to be associated with treatment adequacy. CONCLUSIONS: In state-funded Spanish primary care centers, antidepressant treatment adequacy was poor during both the acute phase and the first three months of the continuation phase. Primary care physicians prescribed suggested antidepressants, mostly as recommended (99%) and at adequate dosages. However, they did not perform the recommended number of follow-up sessions and treated patients with depressive disorders other than major depression as if they had a major depressive episode. Collaborative interventions between primary and specialized care could improve treatment adequacy.     

Paroxetine versus nortriptyline in the continuation and maintenance treatment of depression in the elderly

Elderly depressed patients are vulnerable to recurrence of depression and benefit from long-term antidepressant therapy. Physicians increasingly use selective serotonin re-uptake inhibitors (SSRIs) as maintenance therapy, although in the absence of data showing that SSRIs are as efficacious as tricyclic antidepressants (TCAs) in the prevention of depression relapse and recurrence. Our objective was to evaluate, in an open trial, the efficacy of paroxetine versus nortriptyline for preventing recurrence of depression in the elderly. Elderly patients with major depression were randomly assigned in a double-blinded fashion to receive either paroxetine or nortriptyline for the acute treatment of depression. Patients who did not respond or tolerate their assigned medications were crossed over openly to the comparator agent. Patients whose depression remitted continued antidepressant medication (paroxetine n = 38; nortriptyline n = 21) during an open 18-month follow-up study. We examined the rates of and times to relapse and to termination of treatment for any reason. Paroxetine (PX) and nortriptyline (NT) patients had similar rates of relapse (16% vs. 10%, respectively) and time to relapse (60.3 weeks vs. 58.8 weeks, respectively) over 18 months. A lower burden of residual depressive symptoms and side effects during continuation and maintenance treatment was evident in nortriptyline-treated patients. Paroxetine and nortriptyline demonstrated similar efficacy in relapse and recurrence prevention in elderly depressed patients over an 18-month period.     

The Pathways Study: a randomized trial of collaborative care in patients with diabetes and depression

BACKGROUND: There is a high prevalence of depression in patients with diabetes mellitus. Depression has been shown to be associated with poor self-management (adherence to diet, exercise, checking blood glucose levels) and high hemoglobin A1c (HbA1c) levels in patients with diabetes. OBJECTIVE: To determine whether enhancing quality of care for depression improves both depression and diabetes outcomes in patients with depression and diabetes. DESIGN: Randomized controlled trial with recruitment from March 1, 2001, to May 31, 2002. SETTING: Nine primary care clinics from a large health maintenance organization. PARTICIPANTS: A total of 329 patients with diabetes mellitus and comorbid major depression and/or dysthymia.Intervention Patients were randomly assigned to the Pathways case management intervention (n = 164) or usual care (n = 165). The intervention provided enhanced education and support of antidepressant medication treatment prescribed by the primary care physician or problem-solving therapy delivered in primary care. MAIN OUTCOME MEASURES: Independent blinded assessments at baseline and 3, 6, and 12 months of depression (Hopkins Symptom Checklist 90), global improvement, and satisfaction with care. Automated clinical data were used to evaluate adherence to antidepressant regimens, percentage receiving specialty mental health visits, and HbA1c levels. RESULTS: When compared with usual care patients, intervention patients showed greater improvement in adequacy of dosage of antidepressant medication treatment in the first 6-month period (odds ratio [OR], 4.15; 95% confidence interval [CI], 2.28-7.55) and the second 6-month period (OR, 2.90; 95% CI, 1.69-4.98), less depression severity over time (z = 2.84, P = .004), a higher rating of patient-rated global improvement at 6 months (intervention 69.4% vs usual care 39.3%; OR, 3.50; 95% CI, 2.16-5.68) and 12 months (intervention 71.9% vs usual care 42.3%; OR, 3.50; 95% CI, 2.14-5.72), and higher satisfaction with care at 6 months (OR, 2.01; 95% CI, 1.18-3.43) and 12 months (OR, 2.88; 95% CI, 1.67-4.97). Although depressive outcomes were improved, no differences in HbA1c outcomes were observed. CONCLUSION: The Pathways collaborative care model improved depression care and outcomes in patients with comorbid major depression and/or dysthymia and diabetes mellitus, but improved depression care alone did not result in improved glycemic control.     

Continuity of antidepressant treatment for adults with depression in the United States

OBJECTIVE: Continuation of antidepressant treatment for depression beyond the first months helps to consolidate treatment response and to reduce the risk of early relapse. The authors sought to characterize the rate and pattern of antidepressant discontinuation among adults initiating antidepressant treatment for depression. METHOD: Data were drawn from the household component of the Medical Expenditure Panel Survey for 1996-2001. Analysis was limited to data for adults age 18 years and older (N=829) who initiated antidepressant treatment for depression and who 1) discontinued treatment during the first 30 days of treatment, 2) completed the first 30 days of treatment and then discontinued treatment during the following 60 days, or 3) continued treatment for more than 90 days after treatment initiation. RESULTS: A majority of the patients discontinued antidepressant therapy during the first 30 days (42.4%). Only 27.6% of the patients continued antidepressant therapy for more than 90 days. Antidepressant discontinuation during the first 30 days of treatment was significantly more common among Hispanics (53.8%) than non-Hispanics (41.3%); patients with fewer than 12 years of education (50.8%), compared with those with 12 or more years (39.3%); and patients with low family incomes (50.2%), compared with those with medium or high family incomes (38.6%). Patients were significantly more likely to continue antidepressant treatment beyond 30 days if they received psychotherapy (68.0% versus 43.7%), completed 12 or more years of education (64.8% versus 52.0%), or had private health insurance (60.1% versus 50.8%). Among those who continued antidepressants beyond 30 days, antidepressant continuity during the subsequent 60 days was significantly associated with fair or poor pretreatment self-rated mental health and physical health, treatment with a selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor, and psychotherapy. CONCLUSIONS: Early discontinuation of antidepressant therapy is widespread in the community treatment of depression, especially among socioeconomically disadvantaged patients. Provision of psychotherapy and selection of an appropriate antidepressant medication may reduce the risk of discontinuation during the first 3 months of antidepressant treatment for depression.