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US National Guideline: Discontinue antidepressants after 4-9 months


Altostrata

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The 2010 APA Practice Guideline for the treatment of patients with major depressive disorder is summarized for all physicians by the National Guideline Clearinghouse of the US government as follows:

 

To reduce the risk of relapse, patients who have been treated successfully with antidepressant medications in the acute phase should continue treatment with these agents for 4–9 months . In general, the dose used in the acute phase should be used in the continuation phase [iI]. To prevent a relapse of depression in the continuation phase, depression-focused psychotherapy is recommended , with the best evidence available for cognitive-behavioral therapy.

 

....

Maintenance Phase

 

In order to reduce the risk of a recurrent depressive episode, patients who have had three or more prior major depressive episodes or who have chronic major depressive disorder should proceed to the maintenance phase of treatment after completing the continuation phase . Maintenance therapy should also be considered for patients with additional risk factors for recurrence, such as the presence of residual symptoms, ongoing psychosocial stressors, early age at onset, and family history of mood disorders [iI]. Additional considerations that may play a role in the decision to use maintenance therapy include patient preference, the type of treatment received, the presence of side effects during continuation therapy, the probability of recurrence, the frequency and severity of prior depressive episodes (including factors such as psychosis or suicide risk), the persistence of depressive symptoms after recovery, and the presence of co-occurring disorders [iI]. Such factors also contribute to decisions about the duration of the maintenance phase [iI]. For many patients, particularly for those with chronic and recurrent major depressive disorder or co-occurring medical and/or psychiatric disorders, some form of maintenance treatment will be required indefinitely ....

 

This recommendation is graded as having the top level of empirical evidence backing it up:

 

....

Definitions:

 

Categories of Endorsement

 

Recommended with substantial clinical confidence.

 

[iI] Recommended with moderate clinical confidence.

 

[iII] May be recommended on the basis of individual circumstances.

http://www.guideline.gov/content.aspx?id=24158

 

 

Now, this recommendation is for Major Depressive Disorder (MDD). Many people with situational depression or mild-to-moderate depression are misdiagnosed with MDD. (I have no idea what might be called "the acute phase" in those situations. Maybe when you went to the doctor and asked for a drug?)

 

Still, even if you did have MDD, even in the most conservative evaluation, if you have responded to the medication, discontinuing is justified in 4-9 months -- not years and years later.

 

(If the medication never did anything for you, if I were you, I might ask: "Why am I taking this anyway?" For most people, taking psychiatric medication is elective -- if you don't want to take it, you don't have to agree to it. But -- you must take responsibility for your own emotional welfare, and stop looking to drugs as the answer.)

 

Also from the Guidelines http://www.guideline.gov/content.aspx?id=24158 :

 

Discontinuation of Treatment

 

When pharmacotherapy is being discontinued, it is best to taper the medication over the course of at least several weeks . To minimize the likelihood of discontinuation symptoms, patients should be advised not to stop medications abruptly and to take medications with them when they travel or are away from home . A slow taper or temporary change to a longer half-life antidepressant may reduce the risk of discontinuation syndrome [iI] when discontinuing antidepressants or reducing antidepressant doses. Before the discontinuation of active treatment, patients should be informed of the potential for a depressive relapse and a plan should be established for seeking treatment in the event of recurrent symptoms . After discontinuation of medications, patients should continue to be monitored over the next several months and should receive another course of adequate acute phase treatment if symptoms recur .

 

For patients receiving psychotherapy, it is important to raise the issue of treatment discontinuation well in advance of the final session , although the exact process by which this occurs will vary with the type of therapy.

Also see this topic 2010 APA Practice Guidelines: About discontinuation.

Edited by Altostrata
updated and expanded

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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  • Moderator Emeritus

Thanks for posting... now if we can only get psychs/PCs to take note.. and get some interest for Benzos. The psychotropic orphan. :(

As always, LISTEN TO YOUR BODY! A proud supporter of the 10% (or slower) rule.

 

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Read my intro thread here, and check the about me section.  "No matter how cynical you get, it's almost impossible to keep up." Lily Tomlin

 

 

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brighteningup

Does anyone know where the 4-9 months comes from? Why can't it be 8-12 weeks, for example, a lot of clinical trials seem to be for this period.

 

When I started taking an SSRI I was told I had to take it for 6 months minimum, or I was at risk of relapse, but I'm not sure where this comes from, it seems to be a current view in the UK NHS. I had some benefit in the first 4 weeks, actually from the first week onwards (as well as pretty unpleasant side effects) I wonder could I have taken them for just 2-3 months, then tapered off over the next 3-4?

 

Anyone know if there is any strong evidence base for the 4/6 month minimum?, and if there is, does it take account of the confounding effects of withdrawal for some people? (eg what looks like relapse is actually withdrawal from CT at end of the drug trial?)

 

Bright.

Citalopram for 6 months

Since then tapering off over last 4 months

20mg -> 15mg -> 10mg -> 5mg (roughly every 3-4 weeks)

Stayed at 2.5mg for approx 6 weeks

As of 9 Sept 2011 off citalopram

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Barbarannamated

RE: 4-6 month minimum.... have you read any rationale for that? Seems like a rather arbitrary timeframe although I must admit it's good to see anything short of 'life therapy'.

Interesting that you responded so quickly, Bright. Any theories on that? I know a psychiatrist who firmly believes that if people don't respond in a few days, it is not a drug for them. Unfortunately, he continues trying all others. Martin Jensen is somewhat of a pariah esp after writing a text on his unorthodox approach (hearsay from another psychiatrist in S Ca area where Amen also happens to be based).

Pristiq tapered over 8 months ending Spring 2011 after 18 years of polydrugging that began w/Zoloft for fatigue/general malaise (not mood). CURRENT: 1mg Klonopin qhs (SSRI bruxism), 75mg trazodone qhs, various hormonesLitigation for 11 years for Work-related injury, settled 2004. Involuntary medical retirement in 2001 (age 39). 2012 - brain MRI showing diffuse, chronic cerebrovascular damage/demyelination possibly vasculitis/cerebritis. Dx w/autoimmune polyendocrine failure.<p>2013 - Dx w/CNS Sjogren's Lupus (FANA antibodies first appeared in 1997 but missed by doc).

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brighteningup

No I haven't read any rationale for the 4-6 month minimum - I was wondering if anyone else has.

 

Re why I responded so quickly, well I do have a view on this, but I'm not a medical professional, or any kind of expert so it's just a view.

 

1) It was actually rapid placebo effect, by the weekend I felt high - probably a side effect from the SSRI, and this reinforced the placebo effect, as did the feeling I was finally getting some help.

 

2) I had low cortisol levels and the ssri I was taking - citalopram (Celexa, Cipramil) - is known to raise cortisol levels within 4hrs in some cases. - It may be that in my case the low cortisol may have been due to the side effects from long term prolonged use of topical corticosteroids; I had recently in the last 6 months, unwittingly increased dosage of, and then suddenly dropped dosage of the topical steroid I was using, which may have led to low cortisol levels which caused achiness, fatigue, insomnia and depression - all recognised symptoms of low cortisol. (I didn't have the cortisol levels checked or monitored in any way at the time, so can't say for sure - I had had standard blood tests for thyroid problems, diabetes etc which had showed up nothing). So if my cortisol levels were low maybe raising my cortisol levels may have started to help quite quickly. Also there seems to be some evidence that prolonged periods of anxiety and depression of itself may affect cortisol levels, maybe citalopram quickly helped with this. - I had been experiencing mild to moderate anxiety for years (over 30) and had depression on and off for about 2.

 

Don't know for sure

 

Bright

Citalopram for 6 months

Since then tapering off over last 4 months

20mg -> 15mg -> 10mg -> 5mg (roughly every 3-4 weeks)

Stayed at 2.5mg for approx 6 weeks

As of 9 Sept 2011 off citalopram

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brighteningup

Just to clarify further two different GPs and a psychiatrist told me I'd need to take the SSRI for 6 months minimum.

 

Incidently the UK patient informaton website NHS Choices says this:

"Once your depression lifts , your doctor will advise you to continue taking the SSRI for at least a further four to six months, as this reduces the chance of a relapse of

your depression after you stop taking the SSRI."

www.nhs.uk/Conditions/SSRIs-(selective-serotonin-reuptake-inhibitors)/Pages/Introduction.aspx

 

 

I've no idea what research this is based on so still no idea where this minimum comes from.

 

And I do agree it's good to see lifetime drug taking being discouraged

Citalopram for 6 months

Since then tapering off over last 4 months

20mg -> 15mg -> 10mg -> 5mg (roughly every 3-4 weeks)

Stayed at 2.5mg for approx 6 weeks

As of 9 Sept 2011 off citalopram

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You would have to trace the citations for that information.

 

There are some studies that conclude antidepressants should be taken for 6 months after "initial response" to prevent relapse. This recommendation is probably based on that. I believe some of the studies are in the Journals section.

 

Of course, the validity of the studies is open to interpretation.

 

If you feel up to providing the citations, please post them here.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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If I remember correctly, I thought that people were advised to take an AD for 6 months after starting the med on the theory that doing so for that long changed the brain chemistry that would then prevent the relapse. Of course, that is a bunch of BS.

 

Barabarannamated, my former psychiatrist said that in his experience, the folks who responded the most quickly on meds did the best on the meds.

 

Regarding Martin Jensen, during my "career" on psych meds, when I was desperate to find the right med, I actually purchased his book. But I never said anything to my psychiatrist about it because it was so unconventional.

Drug cocktail 1995 - 2010
Started taper of Adderall, Wellbutrin XL, Remeron, and Doxepin in 2006
Finished taper on June 10, 2010

Temazepam on a PRN basis approximately twice a month - 2014 to 2016

Beginning in 2017 - Consumption increased to about two times per week

April 2017 - Increased to taking it full time for insomnia

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brighteningup

This 2001 study mentions either 6 or 9 months as an ideal period to take antidepressant medication

 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181183/

 

(study is primarily about antidepressant withdrawal

 

And here is the 2011 study again arguing for continuous treatments for 6 months to prevent relapse

http://www.ncbi.nlm.nih.gov/pubmed/21402412

 

I haven't been able to access the full text version of this yet, so don't know whether relapse and withdrawal were considered separately.

 

Seems there is an established view in the literature for a 6 month minimum still holds.

 

I also looked at the UK NICE [NHS National Institute for Health and Clinical Excellence] (guidelines on adult depression last updated in October 2009, and the 6 month minimum recommendation is in there too - but no references as where this is from in the version I looked at. [NICE is an independent body which makes recommendations on appropriateness of treatments for various conditions to the England and Wales NHS - there is a separate similar body for Scotland; this includes assessing effectiveness of treatments from available scientific literature] NICE guidelines are very influential in UK medical treatment.

The pdf can be downloaded from here http://www.nice.org.uk/CG90

 

Haven't had chance to look into this further, may do at later date

Citalopram for 6 months

Since then tapering off over last 4 months

20mg -> 15mg -> 10mg -> 5mg (roughly every 3-4 weeks)

Stayed at 2.5mg for approx 6 weeks

As of 9 Sept 2011 off citalopram

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Having a completely personal reaction to this article - would to God I had stopped after nine months - in 1989-90.

 

1989 - 1992 Parnate* 

1992-1998 Paxil - pooped out*, oxazapam, inderal

1998 - 2005 Celexa - pooped out* klonopin, oxazapam, inderal

*don't remember doses

2005 -2007   Cymbalta 60 mg oxazapam, inderal, klonopin

Started taper in 2007:

CT klonopin, oxazapam, inderal (beta blocker) - 2007

Cymbalta 60mg to 30mg 2007 -2010

July 2010 - March 2018 on hiatus due to worsening w/d symptoms, which abated and finally disappeared. Then I stalled for about 5 years because I didn't want to deal with W/D.

March 2018 - May 2018 switch from 30mg Cymbalta to 20mg Celexa 

19 mg Celexa October 7, 2018

18 mg Celexa November 5, 2018

17 mg Celexa  December 2, 2019

16 mg Celexa January 6, 2018 

15 mg Celexa March 7, 2019

14 mg Celexa April 24, 2019

13 mg Celexa June 28, 2019

12.8 mg Celexa November 10, 2019

12.4 Celexa August 31, 2020

12.2 Celexa December 28, 2020

 

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My Gp told me I would have to take them for the rest of my life!

Started Seroxat(Paxil) for panic attacks in 1997 stopped the drug in 2005 tapered over 3 months ( doctors advice)

Suffered severe and protracted withdrawl ever since.

No other medication taken.

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Having a completely personal reaction to this article - would to God I had stopped after nine months - in 1989-90.

 

 

So do I! That's the time frame when I started taking them also.

 

 

Charter Member 2011

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Barbarannamated

This 2001 study mentions either 6 or 9 months as an ideal period to take antidepressant medication

 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181183/

 

(study is primarily about antidepressant withdrawal

 

And here is the 2011 study again arguing for continuous treatments for 6 months to prevent relapse

http://www.ncbi.nlm.nih.gov/pubmed/21402412

 

I haven't been able to access the full text version of this yet, so don't know whether relapse and withdrawal were considered separately.

 

Seems there is an established view in the literature for a 6 month minimum still holds.

 

I also looked at the UK NICE [NHS National Institute for Health and Clinical Excellence] (guidelines on adult depression last updated in October 2009, and the 6 month minimum recommendation is in there too - but no references as where this is from in the version I looked at. [NICE is an independent body which makes recommendations on appropriateness of treatments for various conditions to the England and Wales NHS - there is a separate similar body for Scotland; this includes assessing effectiveness of treatments from available scientific literature] NICE guidelines are very influential in UK medical treatment.

The pdf can be downloaded from here http://www.nice.org.uk/CG90

 

Haven't had chance to look into this further, may do at later date

 

Shelton

Pristiq tapered over 8 months ending Spring 2011 after 18 years of polydrugging that began w/Zoloft for fatigue/general malaise (not mood). CURRENT: 1mg Klonopin qhs (SSRI bruxism), 75mg trazodone qhs, various hormonesLitigation for 11 years for Work-related injury, settled 2004. Involuntary medical retirement in 2001 (age 39). 2012 - brain MRI showing diffuse, chronic cerebrovascular damage/demyelination possibly vasculitis/cerebritis. Dx w/autoimmune polyendocrine failure.<p>2013 - Dx w/CNS Sjogren's Lupus (FANA antibodies first appeared in 1997 but missed by doc).

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Barbarannamated

6-9month=Richard Shelton @Vanderbilt.

Sorry, computer locking up

Pristiq tapered over 8 months ending Spring 2011 after 18 years of polydrugging that began w/Zoloft for fatigue/general malaise (not mood). CURRENT: 1mg Klonopin qhs (SSRI bruxism), 75mg trazodone qhs, various hormonesLitigation for 11 years for Work-related injury, settled 2004. Involuntary medical retirement in 2001 (age 39). 2012 - brain MRI showing diffuse, chronic cerebrovascular damage/demyelination possibly vasculitis/cerebritis. Dx w/autoimmune polyendocrine failure.<p>2013 - Dx w/CNS Sjogren's Lupus (FANA antibodies first appeared in 1997 but missed by doc).

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  • Administrator

Yes, Shelton is very prominent in journal articles about antidepressant withdrawal.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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Barbarannamated

And advising AD treatment be DCd after 6-9months

Pristiq tapered over 8 months ending Spring 2011 after 18 years of polydrugging that began w/Zoloft for fatigue/general malaise (not mood). CURRENT: 1mg Klonopin qhs (SSRI bruxism), 75mg trazodone qhs, various hormonesLitigation for 11 years for Work-related injury, settled 2004. Involuntary medical retirement in 2001 (age 39). 2012 - brain MRI showing diffuse, chronic cerebrovascular damage/demyelination possibly vasculitis/cerebritis. Dx w/autoimmune polyendocrine failure.<p>2013 - Dx w/CNS Sjogren's Lupus (FANA antibodies first appeared in 1997 but missed by doc).

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