Dr. Bob's Psychopharmacology Tips

Antidepressant maintenance

From: Cdbojrab@aol.com (Christopher D. Bojrab, M.D.)
Date: Mon, 17 Mar 1997 09:35:43 -0500 (EST)
Subject: Antidepressant maintenance

I know that we have traditionally felt it was best to continue maintenance at active treatment doses with TCAs, but I have maintained people on lower doses of SSRIs than I treated them with initially. I have had generally good luck with this.

In a similar vein, I have my own ideas (listed below) about length of treatment with antidepressants.

Episode    Treatment
1st        For 9-12 months after depressive sx remit
2nd        For 18 months
3rd        For 24 months
4th        Discuss indefinite treatment

I do try to avoid discontinuing antidepressants in the winter months since I recall a few papers that suggest higher risk of relapse then.

Date: 17 Mar 97 22:58:41 EST
From: "John M. Rathbun" <73162.3513@compuserve.com>
Subject: Antidepressant maintenance

I'm old enough to recall when it was recommended that one should taper antidepressants after two months of remission. More recent research suggests we do more harm (relapse and treatment resistance) by premature tapering than by treating too long. Nonetheless, most people want to get off meds ASAP, and there are good reasons for this, including monetary cost and side effects, not to mention problems with self-esteem, insurability, and licensure. The FAA is notoriously sticky about any psychotropics in pilots, for example.

Many other factors weigh in the risk-benefit calculation: number of prior episodes, quality of remission between episodes, duration of episodes, severity of episodes, dangerousness during episodes, availability of psychosocial support, progress in psychotherapy, insight, ability to ask for help early in a developing episode, medical complications....

With good prognostic indicators, I would begin to taper after six good months; my experience is that a taper lasting another six months is safer than more abrupt ones, I think because relapses come on more slowly and can be more quickly reversed when medication levels are only a little subtherapeutic. I have no studies to quote, only more than 20 years of clinical experience with thousands of cases.

With poor prognostic indicators or a failure to sustain remission during a slow taper after six months, I advise two good years before the next try. Many patients will insist on going faster, and I would rather accede to their demands than abandon them. After a couple of mild relapses, they usually learn to trust my advice. If a slow taper after two years fails, I would wait five years to try again. After about three tries, I feel that it's silly to keep putting patients through the expense and risk and that lifetime maintenance is indicated.

I normally ask patients to keep a mood diary, because they often cannot recall accurately when they last felt depressed or how bad it was, especially if they feel good on the day they see me. Conversely, if they feel bad on the day of their appointment, they may recall with difficulty that they have had twice as many good days and half as many bad days over the past month as in the preceding month.

Finally, I always try to engage a responsible "other" as a safety net for the patient. This person should be specifically empowered and requested by the patient to intervene strongly if the patient is seen to be slipping. I feel this is wise because depression primarily attacks memory, judgment, and motivation, so I want an unimpaired person available to assure that the patient will get in to see me promptly in case of relapse. If a reliable monitor is not available, I have a lot more followup visits. Otherwise, the patient comes in only 3 months after relapsing, and that's bad medicine.

From: "M Cevdet Tosyali" <TOSYALIM@child.cpmc.columbia.edu>
Date: Mon, 17 Mar 1997 10:47:14 EST
Subject: Antidepressant maintenance

I am aware of the work done by Kupfer et al. with TCAs that prety conclusively demonstrated people should stay on acute treatment doses. I don't see why it should be different with SSRIs. I usually treat first episodes for at least 6 months. If there have been 2 or more episodes or chronic depression I try to keep people on for at least a year. I agree with not discontinuing in winter. I never rush to discontinue meds -- interestingly, most patients are more hesitant than I am to discontinue! (Actually, now that I think about it, in the clinic patients are eager to stop, in my private practice, more interested in staying on.)

Date: Mon, 17 Mar 1997 22:21:01 -0500 (EST)
From: David Tobolowsky <dmtmd@dc.seflin.org>
Subject: Antidepressant maintenance

The only antidepressant I know of which sometimes requires dose reduction between the acute treatment and continuation/maintenance phases is phenelzine; otherwise, I follow the dictum that the dose which makes someone recover is continued.

With the risk of recurrence of major depression around 50% after a first episode and higher after a second, I recommend lifetime maintenance treatment after a second episode, unless the episodes are mild, non-suicidal, and not disruptive to social or occupational functioning. Most experts seem to recommend lifetime maintenance after a third episode.

From: MKomrad@aol.com
Date: Mon, 17 Mar 1997 22:57:04 -0500 (EST)
Subject: Antidepressant maintenance

A big study out of Pittsburgh a few years ago, multicenter, showed that the best maintenance TCA doses are the same as the acute doses. Try to lower them and patients relapse. I am not familiar with similar references for SSRIs.

However, in my experience, since SSRIs don't have reliable blood levels and have few side effects, inpatient [impatient?] physicians will often acutely push the dose up higher than is necessary -- thinking that that will speed or enhance response. Hence, I believe, the phenomenon of finding that you can lower the SSRI dose after recovery and still have adequate maintenance. Supratherapeutic doses of TCAs are much less likely because of side effects (a narrower therapeutic index). Indeed, subtherapeutic dosing of TCAs is more likely.

A variety of review articles publish the following guidelines for depression:

Age    Lifetime maintenance treatment after...
>60    1 episode
>50    2
any    3.

A good study a few years back in the American Journal of Psychiatry on maintenance treatment for a single episode showed 9 months was optimal.

Date: Mon, 17 Mar 1997 23:47:20 -0500
From: William Braden <braden@brown.edu>
Subject: Antidepressant maintenance

Literature I've seen seems to focus on number of episodes and resulting implied probability of relapse. In practice I am more concerned about pattern and severity of episodes. I'll be more reluctant to discontinue meds in someone whose episode resulted in suicidal behavior or hospitalization, came on suddenly, was difficult to treat successfully and took months to recover from. In such a patient I lean towards a 24 month tx after the first episode, forever on subsequent episodes -- and I get upset if the patient doesn't listen. On the other hand, if the patient has milder episodes, which come on gradually, he goes back on meds as soon as the relapse has started, and he recovers quickly once treatment is re-started -- then I don't think it matters much.

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