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Ask the Mental Health Expert Archives 2001-2004

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Antidepressant Discontinuation

Q. How do you determine when an anti-depressant is no longer needed? How can you tell if the lifting of the major depression is totally caused by the medication, or if the medication is no longer necessary? What is the average length of time people stay on antidepressants?

A. There is no magic formula for deciding when an antidepressant is no longer needed, but there are some clinical guidelines that psychiatrists usually apply. It depends, in large part, on the patient's time of recovery from the most recent depressive episode; on his or her risk for recurrence of depression; the severity and duration of any previous depressive bouts; and the side effects (if any) of using an antidepressant.

In general, after the patient has recovered from a first bout of major depression, it's necessary to continue the antidepressant for at least 4 months after remission. This is a period in which, without medication, the patient is highly vulnerable to a relapse. (Many psychiatrists would advise continuing the antidepressant for at least 6-9 months). When patients have had 3 or more episodes of major depression, many experts believe they require indefinite maintenance antidepressant medication--the so-called "3 strikes and you're on" rule developed by Dr. John Greden.

However, some patients may have such widely-spaced depressive episodes (e.g., 4 episodes over 30 years) that they may elect to treat any new episode if and when it occurs. Psychotherapy alone might help stave off a recurrence of depression for many of these patients. Still, several studies have shown that if a patient has had two previous episodes of major depression, there is almost a 90% chance of having future episodes after medication is discontinued (see Hirschfeld RM et al, JAMA 1997;277:333-340).

As to how you can tell that the lifting of the major depression is totally caused by the medication--you can't. There are always other variables in the patient's life--changes in family relations, job changes, moves to a new home, etc., not to mention the role of counseling or psychotherapy. Still, many studies looking at response to antidepressants versus psychotherapy versus waiting list or other controls strongly indicate that medication is effective for major depression. I don't know the average length of time people stay on antidepressants, but I can tell you that most patients with major depression probably don't stay on their medication long enough.

For example, in one study (Dunn et al, J Psychopharmacol 1999;13(2):136-43), the researchers examined whether subjects were prescribed at least 120 days of antidepressant therapy at an adequate average daily dose, within the first 6 months after initiation of therapy. Only 6.0% of patients initiating therapy on a tricyclic antidepressant, and 32.9% of patients initiating therapy on an SSRI were prescribed antidepressant treatment that was consistent with these treatment guidelines. Thus, major depression is often undertreated. For more information on this topic, you may want to contact the National Depressive and Manic Depressive Association (800-826-3632).

August 2001

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