Deciding When to Stop an Antidepressant

At next month's Psych Congress, cochair Charles Raison, MD, will speak to attendees about the challenges clinicians face when prescribing standard antidepressants and a new generation of emerging interventions for depression.

Here, in part 3 of a 4-part series, Dr. Raison discusses a common conundrum for mental health clinicians: deciding whether to stop or continue a patient's antidepressant treatment. Check back soon at DepressionCare360 for part 4, in which he talks about the risks associated with stopping an antidepressant then restarting it.

Dr. Raison is the Mary Sue and Mike Shannon Chair for Healthy Minds, Children & Families; Professor, Human Development and Family Studies, School of Human Ecology; and Professor, Department of Psychiatry, School of Medicine and Public Health, University of Wisconsin- Madison. He is also Director of Clinical and Translational Research for the Usona Institute, which conducts research on the therapeutic effects of psilocybin.

Dr. Raison's session, “Faded Love: A Critical Look at the Strengths and Weaknesses of Antidepressants for the Treatment of Major Depression,” will be held from 4:15 p.m. to 5:30 p.m. on Saturday, Oct. 5. 

Q: What factors should clinicians consider when deciding whether to continue or stop a patient’s antidepressant treatment?

A: Well, that's complex. In the old days, we used to say that you should stay on an antidepressant for at least a year or so and that if you have a couple episodes you should just stay on an antidepressant for the rest of your life. The data don't really support that. If you look at scientific literature ... there are not really clear guidelines on that. Some of these data suggest that maybe we should be thinking about this differently and with antidepressants we should be trying to treat people for the shortest period of time that we can and keep them well.

Not every study finds this, but it does appear that things like psychotherapy or some types of meditation and meditation-based psychotherapies can actually protect the person from getting depressed again when they stop an antidepressant. Several studies have seen this; not every one, but it's enough that it’s interesting. It suggests that while antidepressants are getting people well, what we really should be doing is then beginning to explore how can we responsibly taper the person off the antidepressant. Get people well enough to where they can get acclimated, so they can go to psychotherapy, so they can start exercising, eating healthier, dealing with the things in their lives that are contributing to the depression.

Go to Part 1: The Role of Antidepressants in the Treatment of Depression

These are old standard ideas— getting good sleep, going to psychotherapy, dealing with your interpersonal problems, challenging your negative cognition. These are things that we've known about for years. What's new here though is the idea that we need to take these a lot more seriously, because just leaving somebody on antidepressants and medications may not be anywhere near an optimal strategy.

Now that needs to be balanced against … if people who have had really chronic depression that's messed up their lives and they tend to have issues with collapsing when they stop an antidepressant. If you're treating that person and they get a really strong response to a standard antidepressant, you need to have a talk with them. It may not be optimal to be on an antidepressant for the rest of your life. But may be more optimal than being so depressed you can't function.

Go to Part 2: The Risks of Long-Term Antidepressant Treatment

This is not a lecture about abandoning antidepressants or not using them, by no means. I do not subscribe to that. I've seen too many people saved by these medicines. And as with all these things, there's a wide, wide range. There are people that take these medicines every day for years and years and years and do great, don't seem to have the acceleration of the illness, don't seem to be overly bothered by the side effects, don't seem to have this weird thing that so many people get, where they don't feel like themselves, or the medicine makes them feel different. For those people, especially if they really struggle without it, chronic antidepressant use may be very viable, may be the best option we have at this point. What I think we haven't done in the field is recognize that that scenario I've just described for you doesn't happen all that often. When it does in that context, I take it as fair trade. But if you chase the scenario that's overly unrealistic for many patients, then what do you do? You’ve got them on these chronic medicines, the medicines aren't helping, and might be hurting.

— Terri Airov