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ABOUT THE AUTHOR
LETTER FROM THE AUTHOR
TABLE OF CONTENTS
WHEN TO STOP TAKING YOUR ANTIDEPRESSANTS
ABOUT THE AUTHOR
Karen L. Swartz, M.D., is Director of Clinical Programs at the Johns Hopkins Mood Disorders Center and Assistant Professor of Psychiatry at the Johns Hop-kins University School of Medicine. She is also Co¬Director of the Women’s Mood Disorders Center, founder of the Adolescent Depression Awareness Pro-gram, and an attending psychiatrist at Johns Hopkins Hospital, with extensive clinical expertise in mood disorders, anxiety disorders, and eating disorders.
LETTER FROM THE AUTHOR
Dear Reader:
Welcome to the 2009 Depression and Anxiety White Paper—your personal guide to understanding the causes, symptoms, and management of a variety of mood disorders, including depression, seasonal affective disorder, and bipolar disorder, as well as numerous anxiety disorders, ranging from panic and generalized anxiety to obsessions and compulsions, post¬traumatic stress, and phobias.
This year’s highlights include:
- Learn why constant stress may leave you with a mood disorder.
- Can low testosterone levels increase your risk of depression?
- Treating insomnia—and how it can benefit your mental health.
- The link between mood disorders and heart problems.
- How to spot the warning signs of suicide in the elderly.
- Antidepressants don’t have to dampen the fires of sexual intimacy.
- A breast cancer drug that can help reduce mania?
- Is it safe to treat your mood disorder with dietary supplements?
- Put it in writing: When do you need a psychiatric advance directive?
- The vitamin deficiency that could be causing your depression.
- The most effective approach to facing fears and conquering phobias.
- On the horizon: Brain scans to predict your response to medication.
- How much is enough: When can you stop taking antidepressants?
If you have any depression or anxiety related queries you would like answered in the White Papers or comments about the White Papers in general, please email the editors at whitepapers@johnshopkinshealthalerts.com.
Sincerely,
Karen L. Swartz, M.D.
TABLE OF CONTENTS
Mood Disorders
Causes of Mood Disorders
Symptoms and Diagnosis of Mood Disorders
Major Depression
Dysthymia
Atypical Depression
Seasonal Affective Disorder
Grief Versus Depression
Depression in Older Adults
Effects of Depression on Physical Health
Bipolar Disorder
Suicide
Natural History and Prognosis of Mood Disorders
Depression
Bipolar Disorder
Treatment of Mood Disorders
Treatment of Depression with Medications
Treatment of Bipolar Disorder with Medications
Psychotherapy
Electroconvulsive Therapy
Light Therapy
Supplemental Treatments
Future Treatments
Anxiety Disorders
Symptoms of Anxiety
Effects of Anxiety on Physical Health
Panic Disorder
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Post-Traumatic Stress Disorder
Phobic Disorders
Treatment of Anxiety
General Medication Treatment
Treatment of Specific Anxiety Disorders
Chart: Antidepressant Drugs 2009
Chart: Drugs for theTreatment of Bipolar Disorder 2009
Chart:Commonly Used Antianxiety Drugs 2009
Glossary
Health Information Organizations and Support Groups
Leading Hospitals for Psychiatry
Index
Excerpt from page 68
Back to topWHEN CAN YOU STOP TAKING ANTIDEPRESSANTS
Discontinuing you medication takes careful planningWhen doctors first began prescribing antidepressant medications in the 1950s, the prevailing belief was that a short course of medication could cure depression — much like antibiotics wipe out an infection. But over time, physicians began to realize that depression required longer treatment regimens than originally thought.
Today, experts recognize that major depression and anxiety are long term, often recurrent ill¬nesses. But it isn’t necessarily permanent, and many people with mood disorders can even¬tually stop taking medication.
Although antidepressant medications aren’t addictive and, when discontinued, don’t cause the same type of withdrawal reaction as medications like opiates for pain, your body may still experience withdrawal-like symptoms. If you quit cold turkey, you could experience physical discomfort or a relapse of your condition. Some people can be tapered off medication after an extended period of stability, but these changes need to be timed carefully.How Long Is Enough?
Antidepressant medications usually produce a significant improvement in four to six weeks, although it may take 12 weeks or longer on a therapeutic dose to see the full benefit; this is known as the acute phase. If your condition has improved after this time, you move on to a continuation phase with the goal of preventing a relapse (the return of the same depressive episode).
Continuation treatment lasts anywhere from four months to a year, and you will continue to take the same dosage that worked in the acute phase. If you remain symptom free at the end of the continuation phase, you are recovered, and many people require no further treatment.
A maintenance phase focusing on preventing a new episode (a recurrence), lasting a year or more, may be required if you have any of the following:
a history of three or more episodes of major depression
a history of severe depressive symptoms
current dysthymia (chronic low-grade depression)
a family history of mood disorders
current anxiety disorder
substance abuse
incomplete response to continuation treatment
a pattern of seasonal depressive symptoms.
Your doctor may prescribe slightly lower doses of your antidepressant in the maintenance phase than during the acute or continuation phases. Maintenance treatment may be especially important for older adults, for whom research indicates high rates of recurrence: 50 to 90% over a two- to three-year period, as cited by a 2006 study in The New England Journal of Medicine. To assess whether maintenance treatment could ward off recurrence, this study found that people ages 70 and older who took the selective serotonin reuptake inhibitor (SSRI) paroxetine (Paxil) for two years after successful continuation treatment were almost two and a half times less likely to have a recurrence than those who took a placebo during this time.
Despite the above guidelines, there is no “one size fits all” when it comes to treatment length. However, recent evidence shows that many people require a year or more of antidepressant therapy to treat a major episode of de¬pression or anxiety adequately.
Stopping Safely
If you and your doctor agree that you no longer need an antidepressant, you’ll need to gradually lower the dose. Stopping too quickly can put you at risk for symptoms returning or for physical and mental “withdrawal,” a concern especially with SSRIs. About 20% of people who abruptly stop taking an antidepressant after more than six weeks of treatment experience “antidepressant discontinuation syndrome”—which is usually not dangerous or life threatening, but it can be distressing and can cause physical discomfort.
The most common symptoms are dizziness, nausea, lethargy, and headache. Other, more serious signs are irritability, nervousness, crying spells, flu-like symptoms (body aches, chills, and fatigue), and electric shock-like sensations in and around the head. Fortunately, symptoms are usually mild, begin within one week of stopping treatment, and go away within three weeks. Some people are quick to think their symptoms are a recurrence of their mood disorder, but any true recurrence is likely to happen a few months—not a few days— after stopping the medication.
Discontinuation syndrome isn’t well understood, but it’s likely due to the fact that the brain chemical serotonin regulates much more than just mood. It’s also involved in processes like sleep, digestion, and balance. So starting or stopping an SSRI can affect these functions as well.
Not all antidepressants are linked with the same types of discontinuation problems, because some take longer for the body to metabolize than others. For example, venlafaxine (Effexor) and Paxil are broken down in a few hours, so your body notices very quickly when you stop taking them. But fluoxetine (Prozac) takes about a week to metabolize, so its withdrawal effects are milder and delayed. In fact, some doctors have individuals gradually switch from Effexor or Paxil to Prozac, then taper off the Prozac, to minimize the withdrawal symptoms.
No matter which antidepressant you’re taking, you’ll need to slowly reduce the dose. Your doctor will give you specific instructions based on your individual treatment, but it will take time to wean your body off the medication.
For example, someone who has been taking an antidepressant for six to eight months may need to reduce the dose slowly over six to eight weeks. If you experience severe withdrawal-like symptoms or have a recurrence of symptoms, you may need to resume your normal dose and try tapering off more slowly.
Set the Stage for Success
Always talk to your doctor before discontinuing your antidepressant medication. And be sure to do everything you can to ensure that ending your treatment goes smoothly. Choose a time when you’re not engaging in a major life change or unusual stress. Try to follow a regular exercise program and eat a healthy diet. Turn to family and friends for support, and keep in regular contact with your doctor so he or she can monitor your progress.
Click here for the Mood Disorders Program at The Johns Hopkins Hospital.
