The efficacy of anti-depressants is a debate that has raged for decades and shows little sign of abating. At its heart lies the broad range of experiences of those prescribed drugs such as fluoxetine, sertraline and citalopram: for some they have proven no less than a lifeline during a period of intense emotional upheaval, providing much-needed stability. But for others, the experience may be very different, anti-depressants seeming to have little effect or, in rare cases, appearing to exacerbate their depression. Predicting who will benefit and targeting medication accordingly is, somewhat predictably, a major goal of medical research that might help reduce dependence on drugs and avoid unnecessary costs.
But for those who find anti-depressants to be a helpful tool to managing their depression, there are other challenges to navigate, not least of which is how and when to end their use. Having found relief from the impact of depression on their daily lives, many are understandably reluctant to risk a relapse by altering their daily routine. Such reticence has, however, contributed significantly to the progressive rise in prescriptions of anti-depressants which have doubled over the past 15 years. For those contemplating ending their medication, there is, however, some hope from a recent study published in the New England Journal of Medicine (385:1257-1267). In this double-bind trial, 478 patients were recruited, all of whom had expressed a desire to end their anti-depressant medication. Patients were randomly assigned to one of two groups: the first continued to receive their routine prescription while the other gradually came off anti-depressants over a two-month period as their normal drugs were progressively replaced with a placebo. Interestingly, of those in the ‘discontinuation’ group, 44% showed no signs of relapse over the following 12 months. Although encouraging, the corollary is, of course, stark: namely that 56% suffered a period of depression lasting at least two weeks. It is, however, significant that 39% of those whose medication was unaltered, also relapsed, a testament to the inexact science behind the use of anti-depressants.
If nothing else, this study may provide comfort to those contemplating ending their use of anti-depressants by reassuring them that to do so need not precipitate a relapse: there is nothing inevitable about a return to depression. Nevertheless, it emphasises the need to plan withdrawal carefully by doing so only in the knowledge and with the full support of a GP and perhaps by seeking alternative support during the transition period, a role that counselling may possibly fulfil. Needless to say, the ability to distinguish those at risk of relapse from those less likely to succumb, continues to be a high priority for medical science and may greatly facilitate the difficult decision to end medication in the future.