Length of treatment/continuation of antidepressant treatment

• in both primary and secondary care, patients with depressive illness are being treated with antidepressants for longer
  
  
• antidepressants should be continued for at least 6 months after remission of an episode of depression, because this greatly reduces the risk of relapse (1,2)
  • when a patient has taken antidepressants for 6 months after remission, healthcare professionals should review with the patient the need for continued antidepressant treatment. This review should include consideration of the number of previous episodes, presence of residual symptoms, and concurrent psychosocial difficulties
  • treatment should be continued for a minimum of 12 months in the elderly following remission (2). The dose of antidepressant, used during the period following remission, should be the same dose as used during the acute phase (2)
    
    
• long-term maintenance therapy (on full treatment dose) has been shown to prevent recurrence of depressive illness in some hospital patients with severe recurrent depressive illness (2)
  • using medication for relapse prevention
    • NICE suggest that if a person is at risk of relapse then continue antidepressants for at least 2 years if they are at risk of relapse (1). Maintain the level of medication at which acute treatment was effective (unless there is good reason to reduce the dose, such as unacceptable adverse effects) if:
      • they have had two or more episodes of depression in the recent past, during which they experienced significant functional impairment
      • they have other risk factors for relapse such as residual symptoms, multiple previous episodes, or a history of severe or prolonged episodes or of inadequate response
      • the consequences of relapse are likely to be severe (for example, suicide attempts, loss of functioning, severe life disruption, and inability to work)
        
        
    • when deciding whether to continue maintenance treatment beyond 2 years, re-evaluate with the person with depression, taking into account age, comorbid conditions and other risk factors
      
      
    • people with depression on long-term maintenance treatment should be regularly re-evaluated, with frequency of contact determined by:
      • comorbid conditions
      • risk factors for relapse
      • severity and frequency of episodes of depression
        
        
    • people who have had multiple episodes of depression, and who have had a good response to treatment with an antidepressant and an augmenting agent, should remain on this combination after remission if they find the side effects tolerable and acceptable. If one medication is stopped, it should usually be the augmenting agent. Lithium should not be used as a sole agent to prevent recurrence

Reference:

1. NICE (April 2018). Depression
2. Anderson IM et al (2000). Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Association for Psychopharmacology guidelines. J Psychopharmacol, 14, 3-20.
3. Drug and Therapeutics Bulletin 1999; 37 (7): 49-52.