Treatment
Antidepressants for the Long Haul
Get used to your antidepressant. You may be taking it for some time.
In an article published in The Lancet, investigators from Oxford, Nagoya City University (Japan), and the Western Psychiatric Institute (affiliated with the University of Pittsburgh) reviewed 31 placebo-controlled antidepressant trials comprising 4410 participants. The review involved depressed patients who had responded to treatment and had been randomized to continue or discontinue their antidepressants. Trials ranged from six months to three years. All classes of antidepressants were used, including SSRIs, tricyclics, MAOIs, and those with novel actions.
Staying on Your Antidepressant
Crunching the numbers from these studies resulted in an 18 percent average rate of relapse for those remaining on their antidepressant compared to 41 percent on a placebo. According to the authors of the study, this means continuing with antidepressants reduces the risk of relapse by 70 percent, a figure that held fairly steady in their review across all classes of antidepressants, condition of patient, and length of time on an antidepressant prior to a particular study. In absolute terms, the relapse numbers in both the antidepressant and placebo groups rose after two years (24 and 33 percent for two groups on antidepressants vs 62 and 65 percent for two groups on placebos), but remained constant relative to each other.
Long term studies represent the best proof of the efficacy of an antidepressant. Whereas short-term trial results are open to considerable interpretation about whether an antidepressant "gets" you well, these studies provide good evidence about their value in "keeping" you well.
The American Psychiatric Association's 2000 Practice Guideline for the Treatment of Patients with Major Depressive Disorder recommends four to five months of "continuation" treatment on an antidepressant following satisfactory resolution of symptoms, but has nothing to say concerning the subsequent "maintenance" phase, other than the treating physician should have regard to the risk of recurrence, the severity of symptoms, side effects, and patient preferences.
The British Association for Psychopharmacology's 2000 Evidence Based Guidelines for Treating Depressive Disorders with Antidepressants is far more specific, recommending that patients remain on their antidepressant at the same dose beyond six months and for as long as five years or indefinitely if: they: have had more than three major depressive episodes in the past five years or more than five episodes altogether, or if social or personality or other factors make a relapse or recurrence likely. The British Association also recommends 12 months of antidepressant therapy for elderly patients.
At the 2002 APA annual meeting, Maurizio Fava MD of Harvard observed that one episode of depression results in a greater than 50 percent probability of recurrence. With two episodes, the risk is greater than 70 percent, and three or more depressions makes another a virtual certainty at more than 90 percent.
Andrew Solomon in his National Book Award-winning The Noonday Demon: An Atlas of Depression wrote that his friends would react with, "Still? But you seem fine" to his disclosure that he was still on meds. In Andrew's words: "To which I would invariably reply that I seem fine because I am fine, and that I am fine in part because of medication ... they say, 'Surely you are strong enough to be able to phase out some of those drugs!' If you say to them this is like phasing the carburetor out of your car or the buttresses out of Notre Dame, they laugh."
Let them laugh. For many of us, going off our antidepressant is as unthinkable as a diabetic going off his insulin or a heart patient going off her beta blocker. Many patients quit on their antidepressant because they feel better and feel they don't need it any more. A good many of them discover it's the biggest mistake they ever made.
Published 2002, updated Feb 10, 2008
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