SIR: In the course of a drug utilization review, we were struck by the observation that a large number of our patients had been taking antidepressant medication for many years. While there is some support in the literature for long-term antidepressant therapy (1, 2), administration of these drugs for more than 1 year is not usually recommended. The prescribing physicians insisted that numerous attempts had been made to discontinue the medications for these individuals but that patient resistance and recurrence of symptoms in some instances, had prevented discontinuation of the medication.
When we surveyed the literature we failed to find either an acknowledgement that long-term dependency on antidepressants is a problem or a systematic approach to its solution. We postulated that the dependency we found represented a multifaceted problem that included such factors as the patient's wanting to maintain a long-term relationship with a prescribing physician, the occurrence of withdrawal symptoms on dosage reduction (3, 4) that were misinterpreted as a recurrence of depressive symptoms, psychological dependence on placebo effect (5), and the correct recognition of recurring depressive symptoms.
We attempted to start a weekly group to address these issues. The major obstacle we encountered was difficulty in obtaining referrals. The prescribing physicians were largely convinced that their patients could not or would not do without the medication. Of the six patients we finally reviewed, two failed to keep all scheduled appointments and declined invitations to join in the group. The remaining four stayed involved in the group for most of the 7 months that it met. The participants were women ranging in age from 46 to 65 years who had histories of taking tricyclic antidepressants (or in one case, a monoamine oxidase inhibitor) for anywhere from 4 to 16 years. Each member expressed a desire to discontinue the medication, if possible, but was willing to accept the possibility that she might need to continue taking it. Our approach combined mutual support and problem solving with education, in which patients were taught about target symptoms that might be indicative of withdrawal from the medications.
At the end of 7 months one patient had successfully discontinued the antidepressant medication with no ill effects other than some mild gastrointestinal cramping attributed to withdrawal. The three others, while attempting to reduce medication, showed recurrence of depressive symptoms that included vegetative signs. In one case the symptoms recurred with such severity that the patient required hospitalization. At this time two of the three subjects are continuing to take antidepressants and one may need to be restarted on antidepressant treatment.
Our experience with this group has left us wondering whether there are, in fact, a large number of individuals with persistent depressive symptoms who require long-term treatment with antidepressants. We would be interested in hearing from others who may also have taken our approach or a different one to this problem.
1. Kleinman I, Ananth J: Tricyclic continuation and maintenance therapy in unipolar depression. Psychosomatics 22:1031-1036, 1981
2. Coppen A, Peet M: The long-term management of patients with affective disorders. in Psychopharmacology of Affective Disorders. Edited by Paykel ES, Copen A. New York, Oxford University Press, 1979
3. Dilsaver SC, Kronfol Z, Sackellares JC, et al: Antidepressant withdrawal syndromes: evidence supporting the cholinergic overdrive hypothesis. J Clin Psychopharmacol 3:157-163, 1983
4. Hodding GC, Jann M, et al: Drug withdrawal syndromes. West JMed 133:383-391, 1980
5. Gutheil TG: Improving patient compliance: psychodynamics in drug prescribing. Drug Ther 7:82-95, 1977