After people have responded to an antidepressant and are no longer in the grips of the depression, it’s common for them to wonder “how long should you take antidepressants?”
After all, with many medications, once they’ve worked you can stop taking them.
This guide should help answer this question for many people with depression.
First get completely well
if you feeling quite a bit better but you still have some mild depression, it is far too early to think about stopping your antidepressant. Doing so would almost certainly be associated with a return of depression.
The clock starts ticking once you’re in something called “complete remission.” That means that you don’t have any persistent and significant symptoms of depression.
Joanne came in very seriously depressed after her adult son died in a car accident. She was not able to work effectively in a job that she had help for 20 years and was having suicidal thoughts herself. Initially she was reluctant to take a medication but eventually she agreed to and her mood improved significantly. In fact her symptoms of depression fell by 50% which qualifies as a good response. However, she still noticed that her concentration wasn’t quite as good as it had been and she didn’t have the same level of motivation to do things, and she felt sad, especially in the morning, most days. She had gone from being severely depressed to only mildly depressed.
We would say, as you can see in the chart to the right, that she had had a clinically significant response, but had not achieved remission, or a return to how she was when she was not at all depressed.
Since she had always been reluctant to take medications, once she noticed that she was feeling better again she asked when it would be time to stop the medications.
I explained that if she stopped the medication before she had a full recovery she would be very likely to go back to the depression that she was experiencing before she started the medication.
This is why we check depressive symptoms using standard instruments that allow us to compare your symptoms with those of many other patients and determine whether you’ve reached remission or not.
Now allow your brain to heal
Once you are no longer depressed your brain can begin to heal from the effects of depression. We can now show that depression reduces something called brain derived neurotrophic factor (growth hormones for brain cells) and that brain connections are reduced during extended periods of depression.
The process of healing the brain takes quite a bit longer than recovery from the acute symptoms. In fact, our best estimates are that it takes 6 to 9 months after you are no longer symptomatically depressed for your brain to entirely recover cognitive function and resilience.
Factors to consider
Previous episodes of depression
If you have never had an episode of depression before then it is reasonable to begin to taper off the medication gradually after you have been free from depression for nine months. If you have had three or more episodes of depression then the likelihood of having another episode at some point in the future is roughly 90% and therefore, for many people, long-term treatment with an antidepressant makes sense. If you have had one or two previous episodes of depression your risk of recurrence is somewhere between 30% and 90%. Factors such as a family history of depression, current stress, etc. will influence your risk of recurrence.
Severity of your depression
Severity of depression not only increases the risk of recurrence but also needs to be considered when assessing the implication of having another episode. If you have had very severe episodes of depression and if it came on suddenly without a lot of warning then you may want to be more conservative about tapering off of the medication.
Advice from the Harvard Health Watch
If you’re thinking about stopping antidepressants, you should go step-by-step, and consider the following:
Take your time. You may be tempted to stop taking antidepressants as soon as your symptoms ease, but depression can return if you quit too soon. Clinicians generally recommend staying on the medication for six to nine months before considering going off it. If you’ve had three or more recurrences of depression, make that at least two years.
Talk to your clinician about the benefits and risks of antidepressants in your particular situation, and work with her or him in deciding whether (and when) to stop using them. Before discontinuing, you should feel confident that you’re functioning well, that your life circumstances are stable, and that you can cope with any negative thoughts that might emerge. Don’t try to quit while you’re under stress or undergoing a significant change in your life, such as a new job or an illness.
Make a plan. Going off an antidepressant usually involves reducing your dose in increments, allowing two to six weeks between dose reductions. Your clinician can instruct you in tapering your dose and prescribe the appropriate dosage pills for making the change. The schedule will depend on which antidepressant you’re taking, how long you’ve been on it, your current dose, and any symptoms you had during previous medication changes. It’s also a good idea to keep a “mood calendar” on which you record your mood (on a scale of one to 10) on a daily basis.
Consider psychotherapy. Fewer than 20% of people on antidepressants undergo psychotherapy, although it’s often important in recovering from depression and avoiding recurrence. In a meta-analysis of controlled studies, investigators at Harvard Medical School and other universities found that people who undergo psychotherapy while discontinuing an antidepressant are less likely to have a relapse.
Stay active. Bolster your internal resources with good nutrition, stress-reduction techniques, regular sleep — and especially physical activity. Exercise has a powerful antidepressant effect. It’s been shown that people are far less likely to relapse after recovering from depression if they exercise three times a week or more. Exercise makes serotonin more available for binding to receptor sites on nerve cells, so it can compensate for changes in serotonin levels as you taper off SRIs and other medications that target the serotonin system.
Seek support. Stay in touch with your clinician as you go through the process. Let her or him know about any physical or emotional symptoms that could be related to discontinuation. If the symptoms are mild, you’ll probably be reassured that they’re just temporary, the result of the medication clearing your system. (A short course of a non-antidepressant medication such as an antihistamine, anti-anxiety medication, or sleeping aid can sometimes ease these symptoms.) If symptoms are severe, you might need to go back to a previous dose and reduce the levels more slowly. If you’re taking an SRI with a short half-life, switching to a longer-acting drug like fluoxetine may help.
You may want to involve a relative or close friend in your planning. If people around you realize that you’re discontinuing antidepressants and may occasionally be irritable or tearful, they’ll be less likely to take it personally. A close friend or family member may also be able to recognize signs of recurring depression that you might not perceive.
Complete the taper. By the time you stop taking the medication, your dose will be tiny. (You may already have been cutting your pills in half or using a liquid formula to achieve progressively smaller doses.) Some psychiatrists prescribe a single 20-milligram tablet of fluoxetine the day after the last dose of a shorter-acting antidepressant in order to ease its final washout from the body, although this approach hasn’t been tested in a clinical trial.
Check in with your clinician one month after you’ve stopped the medication altogether. At this follow-up appointment, she or he will check to make sure discontinuation symptoms have eased and there are no signs of returning depression. Ongoing monthly check-ins may be advised.
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