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TIME TO QUIT ANTI-DEPRESSIVES?

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Dr. Orlanda Varela, Psychiatrist at Sinews, Madrid responds to frequently asked questions about how to quit anti-depressives.


Taking anti-depressives is increasingly becoming more frequent and even more so the fact that a friend or family member may think that they are not able to quit them.  What is happening?


We live in a world that pretends to negate that pain and discomfort is part of life.   The use of anti-depressives has skyrocketed as one of the top 10 most prescribed pharmaceuticals.  There are various anti-depressives within the 10 drugs most prescribed in primary care.  They are also amongst the medicines in which the greatest number of bottles are sold in this country. 


In my opinion, they are overprescribed.  The proof is that some studies write their efficiency in between lines and I believe that this is because when they are not well indicated, they do not work correctly. 


It´s also very common that doctors believe that maintaining the anti-depressive prevents relapses in people who have suffered depressive episodes and never attempt to remove the medication for fear of suffering again.  However, there is no scientific evidence that prolonging treatment more than a year after total remission, in the case of DEPRESSION has a preventative effect.  Very few cases of depression require maintenance of the medication in a larger time frame.  Fortunately, “real” depression is an illness that can be cured and reappears periodically throughout one´s life. 


Is there a reason for a patient to take anti-depressives for many years or is that always negative or useless?


Yes, there are good reasons for long treatments in the case of patients who suffer other problems besides depression.


Today, the most utilized anti-depressives are from the ISRS family (which act over our level of Serotonin.)  For example, Prozac which its main ingredient is Fluoxetina, Sertralina, Paroxetina, or Escitalopram is used as well to treat other problems besides depression.  Some of these problems such as Social Phobia, Bulimia, or Obsessive Compulsive Disorder can be chronic and the patients who suffer them require a very prolonged treatment in order to live a normal life. (I speak, of course, of the most severe cases because there are different levels of severity.) In the case of ANXIETY disorders, in which the treatment is longer, there is a high percentage of patients who take anti-depressives in order to reduce their anxiety level, obsession or compulsion (not because they are dependent on them.) 


One question that many of you may be asking: How do I know when it is the right moment to stop taking anti-depressives?  Yes, it´s the million dollar question, of course, and it is not so easy to answer.  The first thing to have in mind is the reason for why you are taking it.  Here, there are three big groups:


1) People who take them for DEPRESSION
Generally, if it is the first episode of your life, the doctor will tell you to take them a minimum of six months after you reached remission (usually patients respond within a month or month and a half after beginning medication.)
If it was your second episode (or have had more than two in your life), the minimum time is stretched and it should be at least one year.  The objective of these time frames is to reduce the minimum probability of relapse when we take away the medication.  If it is done well, the probability of relapse is very small. 
As important as estimating the minimum amount of time is deciding when.
It´s obvious that if we reach the year mark and someone close to you passes away or lose a job… It will be more sensible to wait.  A good time is a time when you are stable and in a certain routine without situations where we may anticipate stress in the near future.   


2) People who take it for STRESS, which is a time of your life where complicated situations accumulated and you felt worn.  The more reactive the symptoms are and the more transitory the stress that caused it, the shorter the duration of treatment will be.  There could even be cases where less than half a year has passed after the situation that caused the discomfort resolved and you´ve gained a better understanding (through therapy) as to why you got into this state as well as strategies to deal with stress.  In these cases, the combined treatment of medicine and psychotherapy is much more effective than taking medication alone.
I should clarify here that simply one stressful event, as painful as it may be, should not automatically lead us to take an anti-depressant.  We have to feel loss, abandonment, pain, and put to use our resources and time in order to accept and adapt.


3) Chronic problems such as OBSESSIVE COMPUSIVE (OCD) and other variants of severe CHRONIC ANXIETY. 
People who suffer from these types of problems are the ones who should follow longer treatments, including sometimes, for many years or their whole life (in more severe cases.)  Especially if you find yourself limited in your daily functioning after experiencing a few supervised attempts (by a specialist) to remove medication.  These are very few cases- it should not be more than 10% of the people who have taken at an anti-depressant at some point in their lives. 


Perhaps in order to give more clues over when it would be a good moment to stop taking the anti-depressive, we can use the rule five of ten.  If you believe that you satisfy five of the following ten criteria, perhaps you should ask your doctor about the possibility of quitting medication under his or her supervision in treatment.  


1) You have spent more than 9 months without symptoms that made you take it at least not habitually or not every week.
2) You have analyzed the reasons that led you to that discomfort and you understand them and have them in mind. 
3) You have developed strategies in therapy that allow you to cope with discomfort and reduce the pain.
4) You find yourself in a stable phase, nothing out of the ordinary is happening, and your routines are in order. 
5) In the near future, there is no stressful event or important change in your life in which you will need to adapt (an international move, changing jobs, having your first child…)
6) You have recovered your previous level of functioning.  You don´t need to avoid things that you used to do nor do you feel limited by fear. 
7) You live a healthy lifestyle, you eat relatively healthy, you do some exercise and sleep relatively well. 
8) The people who know you best think that you look well. Nobody insists that you should not stop taking medication (it´s possible that they are not right in insisting, of course, but this is just one factor out of ten)
9) Although you can be somewhat scared of leaving the medication, you are motivated to find alternatives in order to manage the unlikely event that it may reappear. 
10) You’ve reached a point where the balance between what the medicine offers you and the disadvantages of taking it, are not positive.  There are more cons than pros (this could also be a reason to change medications if you are still not ready to quit.) 


Will I suffer any withdrawal symptoms?


No, no anti-depressive causes physical dependence, therefore, there cannot be “withdrawal.”
However, physical symptoms may appear during removal in 10-20% of the cases.  This is called Antidepressant discontinuation syndrome. It deals with a special sensibility that some people have to a sudden change of dosage and consists of dizziness as if your head was floating and possible cramps and electrical sensations in the muscles.  It can be avoided and solved by deceiving the body with a slow, soft reduction of the dosage.


How do I distinguish the symptoms of withdrawal from relapse?


It´s very simple, because the initial symptoms are not very similar and they reduce with time.  In general, a mix of physical discomfort that appears two to three days after quitting the medicine and that reduces after the second week and has disappeared after a month is not a relapse. 

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