Length of continuation of antidepressant treatment

Continuation and relapse prevention

• support and encourage a person who has benefited from taking an antidepressant to continue medication for at least 6 months after remission of an episode of depression. Discuss with the person that:
  • this greatly reduces the risk of relapse
  • antidepressants are not associated with addiction
• NICE suggest that the clinician should review with the person with depression the need for continued antidepressant treatment beyond 6 months after remission, taking into account:
  • the number of previous episodes of depression
  • the presence of residual symptoms
  • concurrent physical health problems and psychosocial difficulties
• for people with depression who are at significant risk of relapse or have a history of recurrent depression, discuss with the person treatments to reduce the risk of recurrence, including continuing medication, augmentation of medication or psychological treatment (CBT). Treatment choice should be influenced by:
  • previous treatment history, including the consequences of a relapse, residual symptoms, response to previous treatment and any discontinuation symptoms
  • the person's preference

Using medication for relapse prevention

• if a person is at risk of relapse then continue antidepressants for at least 2 years if they are at risk of relapse. 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

Psychological interventions for relapse prevention

• if a person with depression is considered to be at significant risk of relapse (including those who have relapsed despite antidepressant treatment or who are unable or choose not to continue antidepressant treatment) or who have residual symptoms, then should be offered one of the following psychological interventions:
  • individual CBT for people who have relapsed despite antidepressant medication and for people with a significant history of depression and residual symptoms despite treatment
  • mindfulness-based cognitive therapy for people who are currently well but have experienced three or more previous episodes of depression.

Reference:

• 1) NICE (April 2018). Depression