Antidepressants: Deciding Appropriate Duration of Therapy

Gabriela D. Williams, PharmD, BCPS, BCPP
Clinical Pharmacy Specialist – Psychiatry
Eskenazi Health
CPNP Programming Committee Member

Within the past several decades, the United States and other countries around the world have seen an increased prevalence in long-term antidepressant use.^1-2 Continued treatment with antidepressant medications has been found to reduce the risk of relapse when compared to placebo, and treatment effects have often been found to persist for years.³ In particular, long-term use of antidepressants may be beneficial for patients with recurrent depressive disorder and in patients with other comorbid medical and/or psychiatric disorders.⁴

However, there is still a lack of robust data regarding the optimal use of long-term antidepressant therapy. Much of the information on relapse prevention with antidepressant medications is limited by the overall duration of most studies, and in particular, there is a lack of guidance on the optimal treatment duration for those patients not considered to be at high risk for relapse.⁵

Another key component in the discussion of antidepressant therapy duration is the risks associated with these medications. Studies have shown that long-term use of antidepressants may lead to common and persistent side effects for patients, including anticholinergic effects, weight gain, and sexual dysfunction.⁶ Also of important consideration is the risk of more serious side effects such as hyponatremia, bleeding, osteoporosis and fracture risk, diabetes, and cardiovascular effects.⁷

Given the need for a well-considered, evidence-based review of the risks and benefits of long-term antidepressant use, psychiatric pharmacists are well-suited to help treatment teams identify the particular situations and patient-specific factors that should be considered when making treatment decisions around the appropriate duration of antidepressant therapy. This program will enhance pharmacist’ knowledge on the risks and benefits of long-term antidepressant use and provide pharmacists with a foundation for making patient-specific decisions.

Specific objectives include:

• Recognize trends in the prevalence of long-term prescribing of antidepressant medications.
• Outline the potential benefits of long-term antidepressant medication management.
• Define the potential hazards in long-term antidepressant use.
• Identify key patient-specific factors that may warrant continuation of long-term antidepressant use vs. deprescribing of antidepressants.

We are very excited to have Glen Stimmel, PharmD, lead us through discussion on the appropriate duration of antidepressant therapy. Dr. Stimmel is a Professor of Clinical Pharmacy, Psychiatry and the Behavioral Sciences at the University of Southern California School of Pharmacy and Keck School of Medicine in Los Angeles, and also serves as the Associate Dean of Academic Affairs at the School of Pharmacy. Dr. Stimmel is a highly esteemed member of CPNP; he is both a founding member and Past President of CPNP and was awarded both the Judith Saklad Memorial Lecture Award from CPNP in 1998 and the Career Achievement Award from the CPNP Foundation in 2016. Dr. Stimmel has provided direct patient care in an adult psychiatric hospital and various psychiatric clinics for 25 years, and has, for 15 years, maintained an active clinical practice focusing on depression management at both the LAC/USC Geriatric Primary Care Clinic and Rheumatology Clinic. In addition to his clinical practice, Dr. Stimmel has authored over 230 articles and textbook chapters in the areas of clinical psychopharmacology, expanded scope of practice for pharmacists, sexual medicine, and pharmaco-economics of psychotropic drugs and teaches clinical psychopharmacology, sexual medicine, and patient medication counseling. He has been instrumental in pioneering efforts for the development of psychiatric pharmacy practice and was a key figure in investigating and securing prescriptive authority for pharmacists in California.

References

1. Mojtabai R, Olfson M.  National trends in long-term use of antidepressant medications: results from the U.S. National Health and Nutrition Examiniation Survey.  J Clin Psychiatry 2014;75(2):169-77.
2. Johnson CF, Macdonald HJ, Atkinson P, Buchanan AI, Downes N, et al.  Reviewing long-term antidepressants can reduce drug burden: a prospective observation cohort.  Br J Gen Pract 2012;62(604):e773-9.
3. Geddes JR, Carney SM, Davies C, Furukawa TA, Kupfer DJ, et al.  Relpase prevention with antidepressant drug treatment in depressive disorders: a systematic review.  Lancet 2003;361(9358):653-61.
4. American Psychiatric Association.  Practice guideline for the treatment of patients with major depressive disorder, 3^rd ed.  Available at: https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf.
5. Pies R.  Are antidepressants effective in the acute and long-term treatment of depression?  Innov Clin Neurosci 2012;9(5-6):31-40.
6. Bet PM, Hugtenburg JG, Penninx BW, Hoogendijk WJ.  Side effects of antidepressants during long-term use in a naturalistic setting.  Eur Neuropsychopharmacol 2013;23(11):1443-51.
7. Cartwright C, Gibson K, Read J, Cowan O, Dehar T.  Long-term antidepressant use: patient perspectives of benefits and adverse effects.  Patient Prefer adherence 2016;10:1401-7.