When Marjorie Isaacson first started taking medication for depression in her late 20s, she considered it lifesaving.
At the time, she had been dealing with a rocky marriage and struggling to eat. The drug, she found, helped her gain equilibrium. “I was really grateful just to be able to function,” she said.
But recently, Ms. Isaacson, 69, has been considering whether she wants to stay on antidepressants for the rest of her life.
Specifically, Ms. Isaacson wonders about the long-term effects of her medication, a serotonin-norepinephrine reuptake inhibitor that is known to raise blood pressure. And she feels unsettled by the emerging backlash against psychiatric drugs that has condemned their side effects and difficult withdrawal symptoms.
“As the years have passed, things have changed from ‘Take it and see how it goes, no need now to be concerned’ to ‘Well, it’s turning out things might be kinda complicated,’” she said. “That is worrisome.”
Antidepressants are among the most prescribed and easily accessible drugs in the United States, and many people take them for years.
But even though modern-day antidepressants have been around for decades — the Food and Drug Administration approved Prozac for depression treatment in 1987 — there is very little information about long-term use. The F.D.A. approved the drugs based on trials that lasted, at most, a few months, and randomized controlled trials of antidepressants have typically spanned only two years or less. Current clinical guidelines do not specify the optimal amount of time they should be taken for.
The lack of data can make it hard for people to know when — or whether — to quit. So we asked psychiatrists: How long should someone stay on antidepressants?
What factors should you consider?
Psychiatrists say it is a decision best made alongside your doctor. The answer depends on your symptoms, diagnosis, response to the medication, side effects and other factors — all things to discuss with a medical professional.
But oftentimes those conversations aren’t happening, said Awais Aftab, a psychiatrist in Cleveland.
And providers keep prescribing antidepressants to people at low risk of relapsing into depression “out of inertia,” he added. “That’s the problematic part, and it needs to be addressed.”
Antidepressants are known to have adverse effects that often fade as your body adjusts. But some side effects, like weight gain and sexual dysfunction, can linger.
Alice, 34, who lives in Massachusetts and asked to be referred to only by her first name to protect her privacy, stayed on citalopram for two years before deciding to quit.
She found it helpful for treating her panic attacks. But citalopram, a selective serotonin reuptake inhibitor, also caused her to gain weight and gave her a feeling of “artificial stability,” she said. Her therapist wanted her to continue taking it. Alice disagreed. So she stopped taking the drug cold turkey — a harrowing process — and now uses methods like meditation and journaling to manage her symptoms.
What do clinicians recommend?
For major depression, clinical guidelines suggest taking medication until patients feel “virtually back to themselves,” said Dr. Jonathan E. Alpert, chair of the department of psychiatry at Montefiore Einstein in New York.
After that, it’s important to continue treating them for at least four to nine months to “anchor in” their recovery, he added. Research suggests that going off the drugs earlier than this can increase the odds of relapsing.
Patients may then continue taking the medications for at least one or two additional years — what is known as maintenance treatment.
These recommendations are based, in part, on studies that have found higher relapse rates among those who stop taking the medication versus those who do not. And they represent a consensus among experts, distilled into guidance by the American Psychiatric Association and other professional societies like the Canadian Network for Mood and Anxiety Treatments.
When considering long-term use, Dr. Alpert thinks about several factors.
First, how long has the patient been ill for? Has that person had multiple depressive episodes? People who, like Ms. Isaacson, have had depression lasting two or more years or at least two depressive episodes are far more likely to have additional ones, research shows.
Second, he considers the severity of the illness. Was the patient admitted to the hospital? Did that person have trouble functioning in their daily life or need to try multiple drugs before landing on one that worked? An illness that is severe and tough to treat would suggest the need for long-term use, he said.
Finally, he looks at efficacy: Is the medication working? Some people get better, but still have residual symptoms. Continuing the medication often makes sense, Dr. Alpert said, to prevent “the risk of a flare-up.”
Antidepressants are also used to treat a wide variety of other conditions, such as anxiety, obsessive-compulsive disorder, post-traumatic stress disorder and chronic pain. For these issues, long-term treatment is often necessary, experts say.
Is it harder to stop antidepressants after prolonged use?
More data is needed, but some studies suggest that longer-term use can produce strong withdrawal symptoms.
In general, it is estimated that about one in six people who discontinue their antidepressant experiences adverse symptoms. These can include dizziness, fatigue and brain zaps. For one in 35 patients, symptoms can feel especially severe. In some cases, they are so problematic that trying to quit proves too difficult.
Gradually tapering your dose can help, doctors say.
Is there any danger in taking the drugs long-term?
It’s hard to say definitively.
Some observational studies suggest that antidepressants are generally safe. But no randomized controlled studies have been funded by drug manufacturers to examine decades-long use.
Given that large numbers of people take antidepressants (about 11 percent of U.S. adults), if there were additional problems connected to their use “it would be pretty hard to miss,” said Dr. Paul Nestadt, the medical director of the Center for Suicide Prevention at the Johns Hopkins Bloomberg School of Public Health.
The drugs are not without risks, which vary depending on the medication. Certain antidepressants have been associated with increases in blood pressure, heart rate and cholesterol. They can also lower sodium levels and increase the risk of blood clots.
A Danish study published in May found that people who took antidepressants for one to five years had a higher risk of suddenly dying from a heart condition than those who did not have a history of taking the drugs. However, it is unclear whether the deaths were driven by the medication or the psychiatric illness itself.
“I would love to have more studies to quantify those problems more,” Dr. Nestadt added.
Any downsides have to be balanced against the very real risks of avoiding medication, psychiatrists stress.
“I’m still of the opinion that, in people who have real depression, the benefits outweigh the risk,” Dr. Nestadt said.
Christina Caron is a Times reporter covering mental health.
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