At what point do you decide to stop SSRI treatment?

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Blitz2006

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Just wondering, when you treat GAD or MDD and you have a patient on SSRI, and they are fine after a few months (no symptoms, etc.). Do you stop after 6 months? 12 months? 2 years? What are the stats on chances of relapse if you stop? If it is 2nd episode, do you not stop at all?

Thanks,

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Well for me it depends on what the source of the patients depression or anxiety is. I explain to patients that after achieving our tx goal, symptom remission, which will take at least 3 months but could take much longer than that, one should continue therapy for an additional 6 to 9 months before a trial off medication. If symptoms return then they may need medication for longer (another year at least).

Qualifiers I consider is if the patient has had multiple (>3) untreated lifetime episodes of depression, or if they have had more than 1 episode that was severe or difficult to treat, that it may take even longer to treat. If their mood symptoms are mostly situational, related to increasing life stressors, or began as an isolated event as an adult then I think of shorter trials once life is going better for them. If they have no clear reason for their depression, that lets say began as a teen and continues, I think they may need medication longer term. I look at family hx and treatment responses. I also consider if they are doing therapy or not, eating, sleeping and having sex normally ect.

With anxiety, anymore I see it as a symptom related poorly treated mood disorders and personal issues not being addressed as other wise it would respond better to medications. So I just focus treatment on the underlying mood disorder or situational issue (using therapy not benzos) and try to get them off of medications asap so they don't develop a medication crutch to cope with feeling "anxious". I know their are always outliers in which case I tell them to do DBT. :)
 
I'm going to ignore the GAD bit because I don't believe in it as DSM defines it. but MDD - for a single episode you continue for 6 month following remission if you follow the guidelines. In practice, whatever the patient wants. For 2 episodes, the guidelines would say continue for 2 years (there is a 70% chance of relapse). For 3 episodes, the guidelines would say indefinitely as there is a 90% chance of relapse. Once you stop, chance of relapse is the same as if they never took an antidepressant, and in fact probably higher due to physiological and psychological dependence on the drug, which is a real phenomena. OTOH with CBT there is a significant reduction in risk of relapse for bout 2.5 years, and then risk of relapse increases to pre-therapy levels (which is why booster or maintenance sessions are a good idea). MBCT is also pretty good for reducing relapse in patients with recurrent depression. long-term psychodynamic therapy has been shown to continue to lead to improvements after the therapy has finished. In fact, most of the benefits of long-term therapy occur in the years following termination.

Let's face it, antidepressants are vastly overprescribed in the treatment of depression and many people continue on them for years. This, imho is why the chronicity of depression has increased in recent years (at least part of the explanation). Contrary to popular belief, the incidence of depression has been decreasing, but the prevalence of depression has been increasing (i.e. reduction in new cases of people becoming depressed, but fewer people are getting better). This is due to our flawed approach to the treatment of "depression" as if it were a "thing", a "disease" when it is neither.
 
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With anxiety, anymore I see it as a symptom related poorly treated mood disorders and personal issues not being addressed as other wise it would respond better to medications.
It sounds like you're saying you don't believe in anxiety disorders on their own that don't respond quickly and significantly to meds. Am I reading this incorrectly?
 
It sounds like you're saying you don't believe in anxiety disorders on their own that don't respond quickly and significantly to meds. Am I reading this incorrectly?

No, sorry if that is how it reads, I meant in the context of a pt w/ MDD and GAD. I don't try to treat the depression and anxiety with separate medications (unless as a bridge). This is mostly in reference to pts put on benzos for anxiety (which overtime can make anxiety worse unless you keep increasing the dose) in addition to being on an SSRI. Minimizing medications and maximizing therapy. There are certainly anxious people who are not depressed.
 
I tell people a year of very good results and strong desire to make it work without meds are needed. I don't think we really know how antidepressants work; I see SSRI's especially fizzle out after a year or more of good results. I also see people stopping meds that work well, getting depressed or anxious again, and not having as good a result the second time.
Take Splik's advice with a grain of salt, he/she has a whole different paradigm of psychiatry than what you learn in school.
 
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As a rule of thumb I’d advise most patients that they should stay on antidepressants for 9-12 months after stabilisation, and a taper could be considered after this point if there have been no signs of a relapse. If patients have had multiple depressive relapses in the context of non-compliance, then a longer period on medication is likely to be indicated.

Patients who want to stop earlier will probably do so regardless of what advice you give them, even if you make them aware that if they stop and relapse, it doesn’t necessarily mean the same medications will work again.


Much of the analysis in this article is more concerned with managing bipolar depression. Most predominantly present with depressive cluster symptoms, and patients will often get trialled on multiple antidepressants before the correct diagnosis is picked up. Bipolar depression can be hard to treat at the best of times, but the study is suggesting that antidepressant trials makes lithium less effective – however, we know that while lithium is a very good treatment for mania, it doesn’t stack up as well in the acutely depressed bipolar patient which makes me question the treatment resistance links.
 
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I tell people a year of very good results and strong desire to make it work without meds are needed. I don't think we really know how antidepressants work; I see SSRI's especially fizzle out after a year or more of good results. I also see people stopping meds that work well, getting depressed or anxious again, and not having as good a result the second time.
Take Splik's advice with a grain of salt, he/she has a whole different paradigm of psychiatry than what you learn in school.
I've heard this before too. Do you know what the mechanism is?

Also does anyone know of a primer on how SSRIs interact with the HPA axis? It's something I've seen mentioned here and there but more frequently throughout the years.
 
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