Longterm medication use: Necessary or not?

One of the most common questions I get from patients with depression is a desire to know how long they will need to be on medication in order to effectively deal with their illness.

Most people with depression experience it as a recurrent disorder. A person does not usually experience only one episode of depression during a lifetime, but will have repeated bouts of the disorder over time. Often, symptoms get worse as time goes on and episodes last for longer periods of time.

Length of medication use was addressed in a study at the University of Pittsburg in the early 1990s. A group of patients who had experienced three or more episodes of depression were treated with an antidepressant until they were well. Only those who responded fully to the antidepressant continued with the study.

Next, participants were separated into five groups: one continued taking the antidepressant; another took the antidepressant and received psychotherapy; another received psychotherapy and no medication; another received psychotherapy and a placebo medication; and another received a placebo alone. Group assignment was random and medication assignment was also double-blind - meaning that neither patients nor doctors knew who continued their antidepressant or was assigned to placebo.

Over the next three years researchers watched to see which groups remained free of depression. Not surprisingly, those receiving a placebo medication alone did the worst - nearly all had relapsed by the end of the three-year period.

Those receiving active medication with or without psychotherapy did best and those receiving psychotherapy alone or with a placebo did better than those on placebo alone, but not as well as those on active medication. By the end of three years, two thirds of those receiving psychotherapy but no active medication had relapsed.

Similar studies conducted since the Pittsburg trial have examined the effects on overall outcome when original doses of antidepressant are lowered to half at any time in the 10 years following the original remission of symptoms.

Surprisingly, the results showed that when doses were lowered, people relapsed at the same rate as if they had been placed on a placebo. Until this time, the medical community believed that once a person had recovered from initial depression, they might only require a "maintenance" dose of medication.

In reality, the long-term medication dose should remain the same as the dose that was initially required to recover, although this does not guarantee that there will be no recurrent episodes - approximately 20% of patients relapsed by the end of the first 3 year period even while maintaining their original dose.

As a result of these and other studies, most doctors now recommend that patients with recurrent depression continue on long-term therapy even after initial recovery of symptoms. This is particularly important for those with frequent episodes.

However, as with any medical treatment, it is always the individual patient's choice whether they wish to continue on medication or not, but the choice should be made based on an understanding of likely consequences.

While psychotherapy was not shown in this study to improve the rate of relapse in patients with recurrent depression, it is still recommended for those who have obvious life problems that contribute to their depression.

Medication alone is not likely to be sufficient if the individual is going through severe marital or family problems or is under significant environmental stress of some sort. On the other hand, in the absence of such problems, psychotherapy may not add much to the effects of medication.

 

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