Abstract
Abstract
Background There are only few publications on long-term treatments for
major depressive disorder (MDD) lasting 5 years or longer. Most clinical
controlled trials lasted no longer than 2 years and some recent studies
suggested an advantage of cognitive behavioral therapy (CBT) over
antidepressants in relapse prevention of MDD.
Methods Exclusively outpatient "real world" treatment of severe
melancholia, prospectively documented over 10 years with different serial
treatment strategies, discontinuation phenomena and complications.
Methods Compared to CBT, agomelatine, mirtazapine, bupropion and high-dose
milnacipran, high-dose venlafaxine (extended-release form, XR) was effective,
even sustainably. Asymptomatic premature ventricular contractions (PVCs) were
found at the beginning of the treatment of the MDD, which initially led to the
discontinuation of high-dose venlafaxine (300 mg daily). Even the various
treatment strategies mentioned above were unable to compensate for or prevent
the subsequent severe deterioration in MDD (2 rebounds, 1 recurrence). Only the
renewed use of high-dose venlafaxine was successful. PVC no longer occurred and
the treatment was also well tolerated over the years, with venlafaxine serum
levels at times exceeding 5 times the recommended upper therapeutic reference
level (known bupropion-venlafaxine interaction, otherwise 2.5 to 3-fold increase
with high-dose venlafaxine alone). During dose reduction or after gradual
discontinuation of high-dose venlafaxine, rather mild withdrawal symptoms
occurred, but as described above, also two severe rebounds and one severe
recurrence happened.
Discussion This long-term observation supports critical reflections on the
discontinuation of successful long-term treatment with antidepressants in severe
MDD, even if it should be under "the protection" of CBT. The PVC
seemed to be more related to the duration of the severe major depressive episode
than to the venlafaxine treatment itself. A particular prospective observation
of this longitudinal case study is that relapses (in the sense of rebounds)
during or after previous venlafaxine tapering seemed to herald the recurrence
after complete recovery. Remarkably, neither relapses nor recurrence could be
prevented by CBT.
Conclusion In this case, high-dose venlafaxine has a particular
relapse-preventive (and "recurrence-preventive") effect with good
long-term tolerability.