Andrew Lee, 29, was diagnosed with major depressive disorder seven years ago while he was pursuing his engineering degree. Since his diagnosis, he’s taken a combination of two antidepressants, fluoxetine (Prozac) and bupropion (Wellbutrin), at high doses of 60 milligrams and 300 milligrams respectively, to keep his symptoms at bay. “I’ve always sort of had this idea in my head that the ultimate goal is to be medication-free,” Lee says. “Sometimes I disagree with myself on that."
It doesn’t help when people question his meds. He says some of the most stigmatizing comments he’s received have come not from friends or family, but from healthcare providers. He’s faced judgment from his primary care physicians and pharmacists about his high dose and whether or not it’s appropriate.
“When I get my prescriptions at pharmacies, the pharmacist will say something about the dose, and will make a comment about how I shouldn’t be on this dose, how it’s too high,” Lee says. “And every time I hear something like that, I just think ‘It’s none of your business, it’s not your place to comment on what my dosage is, or what works for me.’ Every time I come out of that situation, I start to second-guess myself, thinking ‘Is this too high? Should I be weaning myself off these drugs?’”
According to a 2017 report from the National Center for Health Statistics, 13 percent of Americans older than 11 said they’d taken an antidepressant in the last month. Of those people, two-thirds took the medications for more than two years, and a quarter took them for at least ten years.
Of course, antidepressants aren’t just for treating depression. “The list is very long for why people take antidepressants,” as Roger McIntyre, a professor of psychiatry and pharmacology at the University of Toronto, and head of the Mood Disorders Psychopharmacology Unit at the University Health Network, explains. It includes anxiety disorders, pain, sleep problems, binge eating, attention-deficit/hyperactivity disorder (ADHD), plus off-label uses.
But when people with depression are using antidepressants for years, or even decades, how long is too long?
McIntyre says "long-term use" (for which there is no specific definition) is appropriate in the right clinical context and with ongoing assessment by a physician, meaning visits typically as often as every three to six months for someone whose condition is stable. “We have multiple-year data—two to three-year data which is randomized and controlled—that demonstrates that if you stay on treatment rather than stopping the treatment or getting switched to placebo, the people who stay on medication have a much better outcome,” he says. “That is, they are less likely to have relapse, and more likely to stay well.”
When it comes to figuring out treatment duration, the main goal is preventing relapse, explains Joshua Nathan, an assistant professor of clinical psychiatry at the University of Illinois at Chicago and president-elect of the Illinois Psychiatric Society. Practice guidelines from the American Psychiatric Association (APA) recommend that for a first depressive episode, people prescribed an antidepressant should stay on their medication for four to nine months after they’ve achieved remission. It can take six to 12 weeks for antidepressants to improve symptoms to the point of remission, and that’s if the medications work for that person, and don’t cause side effects bad enough to make them want to stop.
“After that it’s really about, to some extent, patient preference,” says Nathan, who notes that the risk of relapse increases with each subsequent episode of depression (at baseline, it’s about a 20 percent risk within the first 6 months after remission). “Are you willing to risk another episode in the next, say, five years? Or would you rather stay on the medication? And different people will answer that differently,” Nathan says. “For some people, the depression was bad enough, and they don’t want to take a chance, they had no problems with [the medication], so they don’t mind taking something every day.”
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The APA guidelines recommend multi-year treatment, or a “maintenance phase,” for people with chronic major depressive disorder, or for those who’ve had three or more depressive episodes. Longer treatment is also warranted when the risk of relapse is high, where risk factors include higher severity, persistent depressive symptoms during recovery, earlier age at onset, family history of mental illness, and having another psychiatric or chronic general medical disorder. (Relapse is more likely for people who are still facing stressors or have persisting sleep problems.)
Theoretically, Nathan explains, it’s possible to take antidepressants for a lifetime. “There is some data linking certain antidepressants to osteoporosis, but also some linking them to preventing or delaying the onset of dementia, so there may be some risk and some benefit to chronic antidepressants,” says Nathan. “So if, on balance, someone’s anxiety is well-controlled or there is a high risk of depression relapse, and known side effects are absent or insignificant, long-term use may prevent significant suffering with no other clear health impact.”
Nathan says that while some of his patients will bring up discontinuing their antidepressants, others are hesitant. “Many are afraid to stop their medication,” Nathan says. “The symptoms were severe enough, and they very much recall the improvement, and don’t want to take the chance of the illness coming back.” For those who do decide to stop, they should first discuss doing so with a doctor, and stopping should never be done abruptly, according to the APA guidelines. Tapering down takes several weeks, and requires close monitoring from a physician to check for relapsing symptoms.
There can also be a role for starting or continuing psychotherapy during a medication taper if there are residual symptoms or stressors in the person’s life, Nathan explains. “The therapist may be treating a problem that cannot be addressed with medication—such as a interpersonal issues, grief, or cognitive distortions and low self-esteem,” he says.
Lee remembers trying to taper down his medications a year and a half after he’d started them. “I tried going from 60 to 40 mg of fluoxetine, and that ended up triggering a depressive episode… After that, I decided that I was going to resume the full dosage that I was on before.”
Some doctors have argued that people with depression are taking antidepressants for too long, saying the drugs aren’t that effective and that they could actually be counterproductive by disincentivizing people from learning coping strategies. But criticizing antidepressant prescribing and use also comes with a risk of stigmatizing those who take the medications to stay healthy and keep functioning.
“The notion that antidepressants are overprescribed is hyperbole,” McIntyre says. “It’s disrespect to the psychiatric patient and their suffering.”
McIntyre explains that appropriate antidepressant prescribing is crucial because of depression’s impact on disability and mental and physical health. Depression is linked to medical problems like heart disease, diabetes, and obesity and people can lose many years of life from these conditions, he says. “In Canada and the United States, depression is the most common reason why people fail out of school, they’re not able to complete their education, they’re not able to go to work, perform at work,” he adds. “This is a very serious disease.”
Still, there’s the question of safety when people take antidepressants long-term—a question Todd Koch gets on a weekly basis in his practice as a clinical pharmacist specializing in mental health. “There’s no evidence that they cause any problems in the long term,” says Koch, who also works as an educator in the Department of Psychiatry at the University of Toronto.
Koch also notes that a common worry among patients is whether the medications are addictive. Tapering off the drug can lead to temporary symptoms that can be very uncomfortable, although they’re not life-threatening. These symptoms, dubbed “discontinuation syndrome” include flu-like symptoms, hypersensitivity, insomnia, vivid dreams, and the sensation of electric shocks.
Still, Koch assures, antidepressants are not addictive. “For a substance to be considered addictive, there are three criteria,” he says. “Withdrawal is definitely one of them, but the other two criteria are tolerance and craving. And antidepressants don’t have these three criteria.” In some cases, Koch says, people may still experience an urge to continue taking their medications, out of fear of having their depression relapse.
“People think that antidepressants are a crutch,” Koch says. “People think that depression is some kind of moral failing or lack of resilience, and why should this problem require propping up with a pill—‘why can’t I just get through it?’ And then people don’t think of the depression as something as serious as acute kidney injury, or a heart problem, which it really is.”
As widely as antidepressants get prescribed, they’re not a panacea for mental health. They don’t work for everyone’s depression, and when they do work, they can also cause side effects like sexual difficulties, sweating, weight gain, and gastrointestinal problems like nausea, vomiting, and bloating.
“Unfortunately [antidepressants are] not perfect, and they don’t cure depression,” McIntyre says. “The conclusion is not that antidepressants are overprescribed. The conclusion is not that antidepressants don’t work. The conclusion is that they do work extremely well, but they work extremely well for a smaller percentage of people than we’d like. And unfortunately, it continues to be trial and error.”
And for some people, that trial lasts for years.
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