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Referring Providers

[This post is a response to The New York Times article written by Victoria Toline entitled “Many People Taking Antidepressants Discover They Cannot Quit” (Carey, B. and Gebeloff, R, April 2017)]


When prescribing antidepressant medications, we as clinicians must have an understanding of the proper use of these medications, and the length of time the medications should be used. Unfortunately, the long-term use of antidepressants is increasing in the United States for various reasons. Many patients who have been on antidepressants long-term have a difficult time with the accompanying withdrawal symptoms that occur when a regimen in discontinued; patients also report a fear that their depression will reoccur if they attempt to wean off the antidepressant.

Patients who are currently taking medication often recall how difficult things were before the medication helped them achieve a level of wellness. They recall what their life was like suffering from symptoms of fatigue, lack of motivation, persistent feelings of hopelessness and worthlessness, poor sleep and appetite, being socially isolated, and being unable to function at work or in their daily home life. The fear of experiencing those difficulties again can keep patients on medication therapy for years. Often these patients are reluctant to even consider discontinuation of treatment.

As clinicians who prescribe antidepressant therapy, we should all be asking ourselves whether or not we have given our patients enough of an explanation about the timeline of medication therapy. Have we educated them enough on the side effects that can occur while beginning and ending that therapy? Unfortunately, in our field, patients often receive minimal information on how to taper off the medications. Likewise, as clinicians, we have to ask ourselves whether or not we are checking in with our patients at regular intervals to determine if they have the desire (and are ready) to attempt to get off a medication. This will depend on whether the depression, anxiety, and panic symptoms are under control.

Our reliance on antidepressants dovetails with the underuse of talk therapy in patient treatment. Talk therapy can significantly help patients address the anxiety and panic symptoms that can also contribute to depression. Are we asking the patients if they would consider talk therapy? Antidepressant therapy used in conjunction with talk therapy has been shown to help patients achieve a better response than using antidepressant therapy alone (Schneider. L.S., Small, G., Clary, C. 2001).

Discontinuing an antidepressant medication typically involves tapering the dose in increments, allowing two to six weeks between dose reductions. The specifics of a discontinuation plan will depend on what antidepressant the patient is taking, the length of time the patient has been taking the medication, and any symptoms or side effects that were present with previous medications (Harvard Health Publishing, Harvard Medical School, published 2010, updated 2018).

Obviously, we as providers need to rethink how we are treating our patients re: medication. First and foremost, we need to determine if antidepressant therapy is appropriate for our patients in the first place. Do they meet the criteria for MDD (major depressive disorder), and is the anxiety and/or panic severe enough to begin pharmacotherapy? Or would therapy and counseling alone be sufficient to meet the patients’ needs? (Below, for those who are interested, I’ve included a brief history of antidepressant medication and the details of MDD.)

If medications are prescribed, then education should be provided on the initial side effects and potential withdrawal symptoms if a patient chooses to discontinue the medication. It is my general recommendation that patients consider discontinuing medication after 6 months to one year, provided that their depression, anxiety, and panic symptoms are controlled. In every case, it is very important to discuss and assess every visit whether or not the patient should be taken off antidepressant therapy. While not every patient will decide to discontinue medication therapy, every patient should be given the proper knowledge, resources, and encouragement to do so.

If you need help managing your medication, click here to find a provider who can help.


Brief History of Antidepressants:

The 1950s saw the development of the first two antidepressants: iproniazid, part of a class of drug known as monoamine-oxidase inhibitors first used in the treatment of tuberculosis, and Imipramine, the first drug discovered in a class known as the tricyclic antidepressants (Lopez-Munoz, Alamo C, 2009).

1950's anti-stigma poster from the National Mental Health Foundation

These medications aided patients that suffered from depression by improving socialization and reducing depressive symptoms in those that otherwise suffered for years without any treatment options. But these medications were not without side effects: MAOIs could cause dangerously high blood pressure and cause hypertensive crisis (Mayo Foundation for medical education and Research, 1998-2018).

The late 1980s saw the introduction of Fluoxetine, a selective serotonin reuptake inhibitor that revolutionized treatment options for patients and became the first antidepressant in its class to pave the way for the next generation of SSRIs. In 1992, Zoloft was introduced for maintenance therapy for patients suffering depressive symptoms, with efficacy for up to 52 weeks in treating depressive symptoms. The US food and drug administration approved the use of Zoloft for the treatment of panic disorder after clinical trials with adult patients demonstrated significant reduction in frequency of panic attacks and anxiety (as well as the reduction in depressive symptoms) (Copyright 1995 Centerwatch).

Brief Overview of Major Depressive Disorder:

MDD is the most common mood disorder in the United States (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012). MDD is a chronic, recurring, and debilitating mental disorder that impairs occupational and/or social functioning. Most individuals suffering from MDD have recurrent depressive episodes (10.3%) rather than a single lifetime episode (4.1%) (Kessler et al, 2012).

man in session with a psychiatrist

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), 5th edition, an individual is required to exhibit a minimum of five depressive symptoms every day for a period of at least two weeks, which are newly presented or identified as worsened prior to the onset of the depressive episode, in order to be diagnosed with MDD (Kessler et al, 2013).

One of these five symptoms must include a depressed mood, which is described as being depressed, or having a loss of interest/pleasure in hobbies/activities that were previously enjoyable. In addition to one of these two symptoms, the individual must have four other depressive symptoms which may include changes in appetite or weight, sleep disruption and psychomotor activity, loss of energy or fatigue, feelings of worthlessness, difficulty in concentration levels, or suicidal ideation. All of these symptoms, with the exception of weight loss/gain and suicidal ideation, need to be present every day for the two week period to meet the DSM-V criteria for MDD; additionally, the depressive episodes must impair social or occupational functioning in the absence of substance abuse or other psychological disorders. (Hillhouse, Todd. M., Porter, Joseph, H. )

Sources:
Hillhouse, Todd. M., Porter, Joseph, H. 2015. A brief history of the development if antidepressant drugs: From monoamines to glutamate: Exp Clinical psychopharmacology, 2015, Feb.(1) 1-21
Mayo Foundation for medical education and Research, 1998-2018)
Harvard Health Publishing, Harvard Medical School, published 2010, updated 2018) How to Taper off Your Antidepressant, Response to Dosage Dictates Best Schedule to Sop Taking Medication
Lopez-Munoz, 2009. New Antidepressant Drugs-Beyond Monoaminergic Mechanisms
Schneider. L.S., Small, G., Clary, C. 2001) Estrogen Replacement Therapy and Antidepressant Response to Sertraline in Older Depressed Women
Carey, B. and Gebeloff, R, April 2017) New York Times Article Many People taking Antidepressants Discover They Cannot Quit

By: Bonnie Angelelli RN MSNed FNP-BC
Family Nurse Practitioner – Cary

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