Friday, September 24, 2004

Off meds by the holidays?

In our clinic, more patients are asking about stopping antidepressants. Some are well informed about the "discontinuation syndrome" that can make stopping certain meds difficult. (See Public Service Announcement.") I try to explore with them: why stop them, and why now? Is there a side effect that we should try to deal with? Has their mood improved, how long have they been stable, do they know that depression is often recurrent? How will we recognize if their depression is returning? For many patients, the advice will be: it's not a good idea to stop the med.

Have they been unhappy with the meds, or with seeing a psychiatrist in the first place? Have they accidentally missed some pills, and felt terrible? Some decide unilaterally, "I'm reducing these, I'm stopping these pills." A host of physical and emotional symptoms may ensue. The symptoms may signal that the depression is returning, or that withdrawal is occurring, or both. We try to sort it out. (Note! Note! I am only talking about certain antidepressants here! Not tranquilizers, not other drugs!)

How should most of these antidepressants be tapered? It should happen very slowly, and with monitoring by the doc. I tell them, "This never happens as fast as we'd like." But how many patients relapse, and are advised to resume the meds? The APA guidelines say: "Depression is, for many, a recurrent disorder. Among those suffering an episode of major depression, between 50% and 85% will go on to have at least one lifetime recurrence, usually within 2 or 3 years." Many patients choose to stay on the meds. For some, it's not an easy choice to make.


Blogger shrinkette said...

Will you look at that....I've been so worried about confidentiality, I've even kept the names of the antidepressants confidential, in my post. Maybe I'm taking this confidentiality thing too far.

1:16 PM  
Blogger shrinkette said...

This comment has been removed by a blog administrator.

1:16 PM  
Blogger Modulator said...

After more than 10 years on SSRIs I chose (unilaterally) to begin a slow, gradual descent in dosage, because (through therapy, and reading books, and Other Stuff On The Internet) I began to realize that the positive effect (the boosting of mood) was somehow combining with my underlying personality structure and beginning to have more of a numbing effect on my affective life. By numbing I mean a subtle effect of that "whatever" feeling, whatever, as in "I can go on like I'm living now because who the fuck cares anyway and I'm functioning normally, aren't I" stance towards my mental self.

Anyway, it all has kept making sense, and I'm still in talk therapy, and my therapist is quite supportive.

My goal is to lower the dose to as low as is feasible -- if I remain on a tiny maintenance dose for a long time still, that still counts as progress.

I also note that there aren't really any published data on the effective long-term maintenance dose and efficacy of antidepressants -- all the long hard work that goes into bringing these great medications onto the market is (still) rather focused on proving that the meds have a targeted effect in the here and short-term "now"; i.e. x mg of medication y over z weeks causes a 27% reduction in whatever metric is used to measure depression these days. And the number z is never greater than 52, it seems.

2:05 PM  
Anonymous Anonymous said...

Personally, i don't believe that you cure depression nor most mental illnesses with meds. I have had a severe depressive episode that i consider passed and surmounted. I have been on drugs briefly and stopped them very fast, as i knew they were altering me too much, my perceptions and the way i interact with the world in a too chemical way. My mum has been depressive for decades and on many drugs yet they have no effects. I think therapy yes but also books, philosophy, growing up, traveling, music, animals, work, connectedness/ a social net, seeing how others live and finally perspective helps you get through. I don't believe in Big Pharma. I find it does more harm and confusion to people that need all their strength and clarity of mind.
But yes i know it's also a personal choice of course for each person. Some feel it works. But they are not the ones who want to stop the medication. And the industry is way too drug friendly. So i prefer to err on the side of no-drugs.

2:24 PM  
Blogger shrinkette said...

Dear Anonymous, I'm sorry to hear about your mom's experience, and I'm sorry that you had a bad experience with meds. I'm always happy when people recover and meds aren't necessary. Some people don't get better without the meds. Sometimes when people don't respond to the meds, we have to ask, do we really have the diagnosis figured out? And have we thought through the treatment enough? This would be a good topic for another post. I wish all our treatments were more effective than they are, and had fewer side effects.

8:20 PM  

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