The question of whether or not you should start taking antidepressants is complex and difficult to answer. But even fuzzier is the question of when or if you should stop. Last May, NPR ran a piece called "Coming Off Antidepressants Can Be Tricky Business."
Joanne Silberner writes:
Several top psychiatrists say there's just not enough data to say for sure when to try coming off an antidepressant. Drug companies generally test their new products for a few months or up to a year. They don't spend much time looking into how to taper off their products. The dense informational inserts that come with prescription drugs have a lot of information on how to take the product, but no information on how to stop.
According to the Johns Hopkins Depression and Anxiety White Papers, antidepressant use involves three phases:
- The acute phase, which is when a person first begins antidepressants until she feels full benefit, usually four to 12 weeks after.
- Then, she goes on to a continuation phase, with the goal of preventing a relapse or a return to the depressive episode. This can last anywhere from four months to a year, usually taking the same amount of the drug as was figured out in the acute phase. If a person is symptom free after this, she may go off her antidepressants.
- However, for people who meet the following criteria, a maintenance phase, lasting a year or longer, is needed, either at the regular dose or a smaller dose:
- A history of three or more episodes of major depression
- A history of severe depressive symptoms
- Current dysthymia (chronic low-grade depression)
- A family history of mood disorders
- Current anxiety disorder
- Substance abuse
- Incomplete response to continuation treatment
- A pattern of seasonal depressive symptoms
The decision of when to go off is highly individualized. There is no "one size fits all" rule of thumb. Although many studies indicate that a year or more of an antidepressant is needed to treat a major episode of depression or anxiety, there are certainly patients that have needed only a few months of drug therapy.
Says Silberner of NPR:
There's enormous variation among people when they stop antidepressants. A person whose depression kicked in after a major life tragedy may do OK without drugs once life stabilizes. A person whose depression came out of the blue is likely to be at higher risk of chronic depression. And within all that, there's basic biology -- people react differently to drugs and to withdrawing from drugs.
The only rule that all doctors hold is that a person does not go off medication cold turkey, but by gradually lowering the dose. Stopping too suddenly puts you at risk for symptoms returning or for physical and mental withdrawal. Several of the newer antidepressants especially, including Paxil, Luvox, Effexor, trazodone, Remeron and Serzone will produce symptoms of dizziness, nausea, lethargy, headache, irritability, nervousness, crying spells, flu-like illness and sleep or sensory disturbances -- known as the "discontinuation syndrome" that occur within 24 to 72 hours after stopping the medication.
About 20 percent of people who abruptly stop taking an antidepressant after more than six weeks of treatment experience the discontinuation syndrome.
Whitney Blair Wyckoff of NPR lists these six suggestions from Dr. Richard Shelton, professor of psychiatry at Vanderbilt University, to keep in mind when considering coming off medication:
- Consider the severity of your illness. Those with the best odds are people who were mildly ill, who haven't been ill many times in their lives and whose symptoms didn't affect their ability to function in a meaningful way.
- Never come off cold turkey. That's a bad idea under most circumstances, and that's, unfortunately, where doctors tend to see people having the most trouble. Shelton recommends that people always consult with whoever is prescribing drugs for them.
- Don't be in a hurry. To be able to taper off an antidepressant medication successfully, you want to do it slowly. And by slowly, there are no absolute rules. So, it can take a month or six weeks or two months.
- Try to start coming off during the spring or summer. Withdrawing during the fall and winter can be a big problem -- especially for people living in Northern states.
- Choose a time that isn't significantly stressful. For example, people who are going through a divorce should wait a while before thinking about starting to ease off antidepressants.
- Be realistic. According to Sheldon, about 80 percent of patients discontinue their antidepressants in actual practice settings. But most of these patients relapse, and half restart their medications.