Depression is estimated to affect 25% of Americans. According to the Centers for Disease Control and Prevention, one in ten will be treated with an antidepressant medication, making antidepressants the most common class of medications prescribed today.
Of the 2.8 billion medications prescribed by doctors and in hospitals, nearly 118 million were for antidepressants (Mojtabai R, Olfson M. J Clin Psychiatry. 2008; 69: 1064–1074), and primary care physicians prescribe 74% of all antidepressants, more than any other group of health care providers (Olfson M, et al. Am J Psychiatry. 2006; 163:101-108).
The standard recommendation for antidepressant treatment is 9-12 months. While there are no published figures on the average duration of antidepressant treatment, there are data to suggest that more people are staying on them for longer than the recommended 9-12 months (Nierenberg AA, et al. J Clin Psychiatry 2003; 64[suppl 15]:13–17).
Clinicians who prescribe antidepressants are often faced with a difficult question from patients: “How and when do I come off my medication?” Many have serious reservations about taking antidepressants in the first place, despite the fact that they are so prevalent and considered standard care. In fact, people seem to be more averse to taking antidepressants than other classes of prescription drugs for other medical conditions.
Reasons for this include longstanding stigmas regarding mental illness and its treatment; lack of objective quantitative tests to confirm the diagnosis; a concern that antidepressants simply mask symptoms but do not treat root causes; concerns about the overuse, safety, short-term side effects, and long-term impact (read, Wellbutrin for Mommy, ADHD for Baby? from HPC’s Fall 2010 edition).
How Do You Stop This Thing?
Many people taking antidepressants wish to stop. This presents big questions: Is there a good reason to stop? Do the potential benefits of cessation outweigh the risk of symptom relapse? If it makes sense to stop, how do you go about it?
Drug manufacturers provide clear guidelines for safely starting medications but little guidance on how to safely discontinue them. Package inserts warn against abrupt cessation and suggest tapering slowly, but neither the drug companies, the Food and Drug Administration (FDA), nor psychiatric organizations offer specific suggestions on when and how to stop antidepressants. There are no published, proven methods that work consistently. As clinicians, we are left to our own experience to guide us.
Why Come off an Antidepressant?
When deciding to take a patient off an antidepressant, the first step is to ascertain the motivation for cessation. With some exceptions, good reasons fall into one of three categories: 1) The patient no longer needs the drug to stay well; 2) The side effects or risks of the drug outweigh any benefits the patient is receiving; or 3) The drug never really helped much in the first place.
In any of these situations, consider diet or other lifestyle changes, exercise, homeopathic remedies, or psychotherapy. Encourage patients to initiate these approaches before stopping drug therapy, unless there is a specific contraindication such as the potential interaction between serotonin reuptake inhibitors and St. John’s Wort.
Carefully assess a patient’s compliance with and response to the non-drug alternatives before risking a depression relapse by stopping the drug prematurely. Look thoroughly at current risk factors to determine whether the patient will likely be successful in discontinuing treatment. Some risk factors are not modifiable. These include:
- Three or more prior depressions
- Significant residual symptoms
- Shorter periods of “doing well” between depressive episodes
- A severe prior depression
- Onset of first episode prior to age 17 or after age 65 years
- History of melancholic or psychotic depression
- Depression with significant functional impairment (Shelton RC. J Clin Psychiatry. 2001; 3(4):168-174)
When to Stop Medication?
Stopping too early in a course of treatment may put someone at a higher risk for recurrence (Frank E, et al. Arch Gen Psychiatry 1991;48:851–855). Some researchers have suggests that having three or more episodes of depression indicates the need for indefinite maintenance therapy (Warner, C, et al. Am Fam Physician. 2006;74(3):449-456). This can be discouraging to someone eager to come off a drug.
Be aware that this recommendation is from large-scale, grossly inadequate studies evaluating the statistical likelihood of one group as a whole relapsing after drug cessation versus another group that stays on their meds. This type of research does not account for special circumstances or individual variations.
If a patient has been doing well for an extended period and wants to stop, you can help them by encouraging them to reduce any factors that might impede success.
- Avoid cessation during “difficult” periods. For example, in someone who typically does worse in the winter, wait until springtime to begin tapering.
- Avoid excessive alcohol consumption or illicit drug abuse.
- Determine current stress level and whether the patient will be undergoing any major life changes (divorce, job change) or personal loss. Remember that even a good change can be stressful.
- Ensure the patient is physically stable and without any other health problems or other medication changes.
How to Stop Antidepressants
In most acute- and continuation-phase antidepressant studies, participants are tapered off drugs over 1-2 weeks. High relapse rates may be partially explained by this accelerated taper.
There are several books and internet sites that recommend specific titration schedules as well as nutritional supplement support protocols, but none of these have been studied carefully. The British National Formulary recommends tapering over 4 weeks if a patient has been on treatment for more than 4 weeks. Some practitioners go very slowly, with dose reductions every four to six weeks. Unless there are specific reasons to taper rapidly, many will use a conservative approach and make small dose adjustments based on available medication strengths every 4-6 weeks.
Patients may experience discontinuation symptoms when tapering off a drug. Some are easy to identify: nausea, flu-like symptoms, dizziness, or “electric shocks” like sensations in the head or extremities. Discontinuation symptoms may also mimic depression symptoms such as mood swings, depression, anxiety, poor concentration, and insomnia (Paykel ES, et al. Arch Gen Psychiatry 1999;56:829–835). Discontinuation symptoms almost always improve after 1-2 weeks, though they can be very uncomfortable, even disabling for some patients.
If symptoms worsen over time, they are indicative of a true relapse and the need to continue drug therapy either at a partial or full dose. Some clinicians have observed a “honeymoon phase” during which patients feel pretty well when they first come off a drug, but then the depression returns within a few weeks.Before beginning to taper, instruct patients to be vigilant for symptoms of depression relapse.
Encourage patients to take proactive steps to reduce their risk of relapse. Often, small lifestyle modifications, such as reducing stress, taking care of themselves physically, engaging in meaningful work, hobbies, or social activities can go a long way in nurturing emotional health. Many types of psychotherapy have been shown to prevent depression relapses and recurrences.
Exercise is well-validated for “treating” depression, but little is known about whether it can prevent relapses (Dunn AL, et al. Am J Prev Med. 2005; 28(1):140-1).
There is a growing body of good science supporting the use of omega 3 fatty acids, vitamin B12, folate, SAMe, and St. Johns Wort in treatment of depression (Banov M. Taking Antidepressants: Your Comprehensive Guide to Starting, Staying on, and Safely Quitting. Sunrise River (2010): 111-113). Unfortunately, there’s little science on relapse prevention or maintenance and prevention dosing. Since these nutraceuticals are fairly benign, it is reasonable to utilize them, so long as you ensure that your patients take high quality products and there are no potential interactions with other drugs.
Given how many people are put on antidepressants indefinitely, we need more research on strategies for cessation, and on possible non-drug alternatives to treat and prevent future depressive episodes. Until then, we must depend on the art of medicine rather than the science to help patients become and stay medication-free.
Michael Banov, MD is Medical Director of the Northwest Behavioral Medicine and Research Center, Roswell, GA (www.psychatlanta.com). He is the author of, Taking Antidepressants: Your Comprehensive Guide to Starting, Staying on, and Safely Quitting (www.takingantidepressants.com).