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Psychiatric Times - Category 1 Credit
To earn AMA PRA Category 1 Credit(s)™:
Read the article "Diagnosing and Treating ADHD in Adults" from the May 2008 issue of Psychiatric Times, complete the posttest and the evaluation. (Note: A score of at least 70% must be achieved in order to be awarded credit.)

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You must keep your own records of this activity. Copy this information and include it in your continuing education file for reporting purposes.

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CME LLC designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

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The American Nurses Credentialing Center (ANCC) accepts AMA PRA Category 1 Credits™ toward recertification requirements.

The American Academy of Physician Assistants (AAPA) accepts AMA PRA Category 1 Credits™ from organizations accredited by the ACCME.

Educational Objectives

After reading this article, you will be familiar with:

• The difference between recovery and remission in major depressive disorder.
• How residual symptoms affect long-term outcomes.
• The clinical implications of relapse and recurrence.
• The reasons for the proposed changes in assessing recovery.

Who will benefit from reading this article?
Psychiatrists, primary care physicians, neurologists, nurse practitioners, and other health care professionals. Continuing medical education credit is available for most specialists. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing board.

Dr Belaise is a research fellow in the Affective Disorders Program of the department of psychology at the University of Bologna in Italy. Dr Fava is professor of clinical psychology at the University of Bologna and clinical professor of psychiatry at the State University of New York at Buffalo. The authors report that they have no conflicts of interest concerning the subject matter of this article.

In clinical medicine, the term recovery connotes the act of regaining or returning to a normal or usual state of health. However, there is lack of consensus about the use of this term (which may indicate both a process and a state), as well as of the related word remission, which indicates a temporary abatement of symptoms. Such ambiguities also affect the concepts of relapse (the return of a disease after its apparent cessation) and recurrence (the return of symptoms after a remission).

In an attempt to overcome these flaws, Frank and associates1 proposed a set of definitions that they developed after a review of longitudinal studies of mood disorders. The development of these criteria helped decrease inconsistencies among research reports, yet it did not touch some key issues in the conceptualization of these terms.

First, according to their definitions, recovery occurs when the number and severity of symptoms fall below the threshold used for defining onset. This subthreshold level of symptoms remains for a specified period. However, this state cannot be equated with being asymptomatic and provides room for a wide range of subclinical conditions.

Second, the definition of remission parallels the traditional medical concept of convalescence, a transitional period of reintegration after illness. The trajectory of the process is thus an important additional dimension that requires a longitudi- nal consideration of the development of disorders, encompassing prodromal, acute, and residual symptoms.2

Finally, the distinction between recovery and full remission is made on temporal grounds only. Neither recovery nor full remission differentiate whether active treatment is associated, even though recovery implies that therapy may have been discontinued. A depressed patient who has recovered and is currently drug-free is thus equated with another patient who is receiving long-term, high-dose antidepressant treatment.

The need to develop standardized criteria for remission has received increasing attention, in the study of mood disorders and other psychiatric illnesses, such as schizophrenia and obsessive-compulsive disorder.3-8 There is growing awareness of the importance of achieving full recovery, to avoid later adverse outcomes.4 After a review of the literature on residual symptoms as the most important target for full treatment of the depressive episode and a discussion of the clinical and theoretical implications of this topic, we will analyze the concept of recovery in unipolar major depressive disorder.

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