Ask the Pharmacist

Q) I have been on an antidepressant for awhile and I really think I’m feeling better. How long am I supposed to be on it for?

A) Upon being counselled on an initial antidepressant, it is often revealed that they have been dealing with their symptoms unaided for many months and sometimes even years. This is likely due to the many people who still feel stigmatized in admitting they are struggling and feel alone in their struggles.

Depression is widely acknowledged to be the single largest contributor to the global disability that we have and that the numbers affected continue to increase with the incidence rising nearly 20% from 2005 to 2015. The lifetime incidence of being diagnosed with a major depressive disorder is 16% in the U.S. and this does not include the many millions more whose depression does not rise to this particular level. And yet still, the decision to acknowledge there is a problem, and to accept a treatment, particularly in the form of a pill, is an extremely difficult one for many of us to make.

Almost as challenging a query for many people is how long they should stay on their drug, once they are feeling better. This last sentiment is key. If you are still struggling more than is normal (i.e. no individual is happy or energetic all the time, but when we are “well” these do not persist for too long nor do they prevent us from living our lives and enjoying ourselves soon thereafter) then stopping therapy just does not make sense. Perhaps a change in treatment should be considered, but battling this dreadful disorder unaided seems like an unwise course of action.

For many, there is a rush to get off the drug for a couple of main reasons. A commonly stated one is that many do not like relying on a pill to get better. However, “pills” do work for most people. About half of the individuals who do decide to take a medication will respond to just about any drug that is chosen by their physician.

Many of the other half will respond to a drug from a different class of antidepressant or a combination of more than one antidepressant. The vast majority of these responders will see at least a 50% reduction in their symptoms (improvement in mood, better sleep, more energy..) within 1-2 months. Psychotherapy also works very well for many and, in fact, probably just as well, but there is a brutal lack of trained specialists available, particularly in rural Ontario and this situation cannot have been helped by the pandemic.

As well, psychotherapy takes considerable amounts of time spent talking, waiting and perhaps driving quite a distance to the appointments that for many people trying to hold down a job, finish school and/ or support a family just isn’t feasible. Though cognitive behavioural therapy is definitely a great choice to include in the treatment plan, it may not be practical for many as stated above due to the time constraints it involves.

However, getting back to our original question regarding how long should you continue with therapy, you may not be surprised to learn that it differs for many people. Things to consider before coming up with an answer are:

  • Severity of your depression. For instance, if you were considering self-harm, a much longer remission while still being treated is absolutely recommended and many would suggest lifetime treatment as it’s just not worth the risk in coming off a medication that has been proven to be safe.
  • Side effects can also play a role on length of treatment, especially if they are affecting your quality of life.
  • Other stressors or events going on concurrently. If you are going through or about to be going through a major stressor, it is probably best to stay on the medication for awhile longer.
  • Whether this is your first bout with depression or one of many. For people with multiple reoccurrences, the consensus opinion is that there is more harm in stopping the drugs than in continuing them throughout your life
  • How you feel about stopping therapy. If you’re ready to quit perhaps it is time consider a plan for getting off the medication but if you’re not certain about stopping, there are no long-term issues with continuing therapy indefinitely.

One does not become addicted to antidepressants nor do they appear to cause long term harm to your brain, kidneys or any other vital organ that we possess. All that being said, the general consensus as to when to consider stopping an antidepressant, once remission has occurred (note: a response to medication is defined as a noticeable improvement in symptoms while remission is defined by the near absence of symptoms), seems to range from a low of four months to a year.

It should be noted that the vast majority of guidelines push for at least 6 months rather than 4. This is because depression, like so many other disorders, has a nasty tendency to reoccur and this is particularly more likely in those that stop therapy shortly after they start to feel better.

Studies have found that the greatest risk of relapse occurs within the first six months of remission. Patients, whose remission has lasted for six months, are said to have recovered but, even in these people, once they stop taking the medication, they run a risk of having another depressive episode in their lifetime that is three to five times greater than that of a member of the general population. This is not to counsel all patients to stay on these drugs forever, but rather to be patient if they are doing well before deciding to come off them.

Once you and your health care team decide it is indeed time to come off of the drug, most antidepressants should be slowly reduced in dose (we call this process tapering) to help prevent withdrawal side effects. Withdrawal is nasty for two reasons.

One it can make you feel really crappy which none of us really need.

Two it can fool you into believing your depression has come back and subsequently causing you to stay on the drug for a longer period of time than was necessary. Most antidepressants (note that bupropion (Wellbutrin) is far less likely to do this as it has only a minimal impact on serotonin systems) can cause withdrawal effects due to the fact that they alter the levels of neurotransmitters in the brain and the brain cells (neurons) adapt to these new levels and do not enjoy sudden alterations to them. Withdrawal effects are uncomfortable, but not dangerous to your health.

It can be difficult to determine if symptoms are related to a withdrawal versus a resumption of your depression since both can make you feel anxious and depressed but there are a few guidelines that can help. Discontinuation symptoms tend to emerge within days to weeks of stopping whereas relapse symptoms develop later and come on more gradually.

Withdrawal symptoms often include physical complaints that are not typical of depression such as dizziness, flulike symptoms, an upset stomach, excessive sweating or flushing, mood swings, poor control of body movements (e.g. tremors, restless legs, uneven gait, difficulty in coordinating speech…), nightmares and weird sensations such as electric shocks to the head. Discontinuation symptoms also disappear quickly if you take a dose of the antidepressant whereas a relapse often takes weeks of treatment to improve again.

Lastly, withdrawal effects tend to resolve as your body readjusts while a case of recurrent depression continues or may even get worse. In general, if symptoms last longer than a month and are worsening, it is probably that you are in fact dealing with a reoccurrence. As far as coming off the drug, the key is patience.

One suggestion is to reduce your dose by a quarter every 4 to 6 weeks. This is more cautious than most other recommendations but in the long run, are you really going to care three years from now if you stopped a drug in November versus February? Studies have shown that those who stopped the drug within a week are more likely to relapse than those who gradually reduced their dose over at least a few weeks. As well, there are certain lifestyle choices that can absolutely aid in avoiding withdrawal symptoms or from having a depressive relapse.

You likely already know what some or all of them are but it is a good idea to be reminded of them.

· Eat well
· Schedule plenty of time for sleep
· Stay active with exercise
· Seek support during and after not just from your health professionals but also from a trusted loved one or two.

For more information about this or any other health related questions, contact your pharmacist.