Antidepressant maintenance medications: when to discontinue and how to stop

Most depressive disorders, once developed, have a lifetime course. For the majority of patients, the risk for future episodes increases as the number of past episodes increases. The length of the well interval between episodes becomes progressively shorter with each new episode. Those who are older at onset often have higher probabilities of relapse during future years if not maintained on treatment. As the number of episodes grows larger and the patient becomes older, severity often intensifies, treatment responsivity to conventional antidepressants may diminish or even disappear, and the destructive consequences of the disorder progressively worsen. This destructive lifetime pattern can be prevented in many if not most patients since antidepressant and other maintenance medications are being shown to be efficacious in preventing most future episodes of depression, maintaining euthymia, and preserving quality of life. On the basis of these and other still-developing findings (and with the recognition that maintenance strategies have been inadequately tested in depressed children and adolescents), reasonable clinical wisdom might suggest that lifetime pharmacologic maintenance may be indicated for patients 50 years or older at first episode, 40 years or older with two or more prior episodes, or for those with three or more prior episodes. "Maintenance" dosages need to be comparable to established "treatment" dosages until it is proven that lower doses are efficacious; such data now are lacking. When medication is selected for long-term treatment, strong considerations should be given to the agent's side effect profile, since compliance is essential for success.(ABSTRACT TRUNCATED AT 250 WORDS)