Do I Have to Take Antidepressants Forever?

If you are taking antidepressants, you might wonder just how long you'll need to keep taking them. Will you need to take antidepressants forever? The short answer is not necessarily, but it's complicated.

According to the Centers for Disease Control and Prevention (CDC), more than 60% of patients aged 12 and up who were prescribed antidepressants have been taking them for two years or more. Of that population, 14% have been taking them for over 10 years, leading many to question whether these medications are being overprescribed and over-relied on as a standalone treatment.

"In the attempt to normalize depression, I believe the mental health community did a disservice to clients," said Dr. Emily Donald, a mental health practitioner and counselor at Aligned Counseling and Supervision. "We made it all about brain function, and we focused heavily on antidepressants as the primary intervention. However, there is evidence coming to light that depression is more complex than that."

Why Do We Still Use Antidepressants?

Most existing FDA-approved antidepressants are designed to either increase the availability of serotonin or norepinephrine (or both) in the brain. But, in a widely reported study published in Molecular Psychiatry in July 2022, researchers revealed that there is no consistent evidence to support the idea that low serotonin levels cause depression.

That doesn’t mean that antidepressants don’t work. Decades of clinical research on the FDA-approved antidepressants available right now along with other studies investigating how and why antidepressants work confirm that antidepressants can provide symptom relief. A 2018 systematic review in The Lancet, for example, examined 522 clinical trials comprising over 116,000 patients and found that all antidepressants were more effective than placebo in patients with major depressive disorder (MDD).

Part of the confusion stems from the delayed response to the standard antidepressants that work by changing neurotransmitter levels. While the changes they make to the brain begin within hours of taking the first dose, patients often don’t feel any difference until two to four weeks of continuous treatment.

Some researchers have explained this delayed response as a placebo effect or just a general numbing of emotions. However, those theories don’t explain the consistency of results or the synaptic changes that happen in the brains of patients taking antidepressants.

Antidepressants May Rewire Brains to Think More Positively

In a 2017 article in Lancet Psychiatry, researchers suggested that antidepressants aren’t just numbing emotions or acting as a placebo for depressed patients. Instead, the benefits might come from changes to brain circuitry.

Specifically, "depression is associated with the tendency to perceive social cues as more negative, to preferentially attend to aversive information, and to recall negative more than positive information concerning oneself," the researchers wrote in the Lancet Psychiatry article.

Chronic stress, whether caused by a psychiatric disorder or by negative life events, can essentially rewire the brain to become more alert to negative or adverse information (while ignoring positive information). This kind of adaptation is meant to be protective: your brain is becoming hypervigilant to possible threats. But it can contribute to the sense of hopelessness, helplessness, and general discontent associated with depression.

Researchers discovered that at the beginning of treatment, both depressed patients and healthy participants show an increase in the prioritization of positive over negative emotional information when given antidepressants.

Ketamine May Soon Fill Gaps in Standard Antidepressant Treatment Outcomes

The synaptic rewiring hypothesis might also partially explain why not all patients seem to respond to standard antidepressants. "Conventional antidepressants change only positive processing of incoming information," researchers explained.

But if there is no positive information incoming—perhaps because years of chronic depression have resulted in lost friends, lost hobbies, and lost career opportunities—this newfound ability to perceive positive information might not make you feel much different.

That's where some of the newer antidepressants derived from ketamine might be able to help. While they don’t seem to rewire the brain for positive information processing like SSRIs or SNRIs do, the researchers argued they might help individuals deal with existing negative memories and reduce the negative emotional response that comes with recalling them.

Other research shows that ketamine-derived drugs can immediately and significantly reduce suicidal ideation along with many other distressing symptoms of depression in some patients. Ketamine and ketamine-derived treatments can induce a noticeable antidepressant effect within two hours, and as much as 71% of patients experience a significant antidepressant response within 24 hours of a single dose.

All of its reported effects are short-lived, often wearing off in a matter of days, but they are still important. With a rapid (albeit short-lived) relief option, this might be a tool to help certain people to not have to be on ongoing SSRIs or SNRIs.

The Role of Therapy and Lifestyle Changes

Most clinicians suggest that antidepressants should, ideally, be used as just one piece of a multidimensional treatment plan that includes therapy and lifestyle changes. "[Antidepressants] are a very effective tool to help clients feel well enough (and safe enough) to access other, additional, interventions that can provide lasting results without significant side effects," Dr. Donald argued.

Dr. Stefan Ivantu, a consultant psychiatrist at the London Psychiatric Clinic, concurred and said, "People tend to feel more energetic and motivated after starting antidepressants, which can help them build healthier habits around exercise, diet, and sleep."

"We know that things like staying physically healthy, looking after your mental well-being, reducing stress levels, and social support can reduce the likelihood of depression returning, regardless of what type of depression it is," Dr. Ivantu explained.

The data supports these claims. In meta-analyses of studies comparing antidepressants on their own, in combination with therapy, and treatments using therapy alone, the findings consistently showed that the combination treatment yielded the most significant and most long-lasting results.

Some Cases of Depression Do Require Ongoing Antidepressant Treatment

Even with the advances in antidepressant research and the promising potential of therapy alongside diet and exercise, some patients with severe depression might still need more help.

That is, in part, because depression is not an illness that can be cured. Because so many questions remain about its causes and because it’s largely defined by its symptoms, the goal of treatment is not to 'cure' depression but to achieve symptom remission (make symptoms go away).

"But for some people, remission may not be possible," Dr. Hong explained. "In these cases, the focus shifts to symptom management. Even if symptoms can't be eliminated entirely, they can usually be significantly reduced with treatment."

Comorbidities Make Identifying Those Cases Complicated

Whether or not you have a severe, difficult-to-treat form of depression can be hard to say for certain. Even if you do need lifelong treatment, it may not necessarily need to involve antidepressants. "When treating depression," Dr. Ivantu argued, "it's also crucial to identify whether another undiagnosed mental health condition is actually causing the depressive symptoms."

"Recent studies have shown that approximately 30% of people with ADHD will also develop depression in their lifetime. Once these people receive a diagnosis and treatment for their undiagnosed ADHD, this can dramatically improve their depressive symptoms."

If you aren’t responding well to antidepressants—or you are, but you aren’t thrilled about the idea of taking them forever—you may want to talk to your doctor about other conditions that might be making it harder to get rid of stubborn depression symptoms.

Because of how many factors are at play, Dr. Donald argued, "Antidepressants as a lifelong treatment are an oversimplified answer to a complex systemic issue."

A recent study from the National Institute of Health and Care Research found that as many as 40% of patients taking antidepressants long-term (at least nine months) were able to stop taking them without their depression symptoms relapsing. Of those whose symptoms did relapse, some were able to manage the symptoms without taking medication again.

Of course, this doesn’t mean no one benefits from long-term antidepressant use or that antidepressants aren’t ever needed—but it does suggest that at least some of the people currently taking medication indefinitely could safely stop.

If You Do Have to Take Antidepressants Forever, You Will Be OK

Some recent studies suggest long-term antidepressant use may come with side effects previously unknown to scientists. "These risks include an increased risk of gastrointestinal bleeding, especially for SSRI users," Dr. Hong explained. "Some studies also suggest that compared to non-SSRI users, those taking the medication are at higher risk of dying from breast cancer." Less life-threatening side effects of long-term use include emotional numbing, weight gain, and sexual side effects.

While a study found that patients with breast cancer who also used antidepressants were more likely to die than those who didn’t, it didn’t find that antidepressants made people more likely to develop breast cancer in the first place.

In addition, the authors of this study cautioned against overly interpreting this, as there were many variables, such as depression itself, that may have been contributing to this finding. Moreover, the increased risk of gastrointestinal bleeding associated with SSRIs is small and may be complicated by the increased rates of alcohol abuse seen in patients with depression.

"My biggest concern with longer-term use of medications is discontinuation syndrome, which tends to be a more challenging problem the longer a patient has been taking medication," said Dr. Danielle Zito, a board-certified psychiatric nurse and mental health advisor at Illuminate Labs.

Some also report a return of depression symptoms, but researchers think this may be a relapse of the original depression symptoms rather than medication withdrawal. It is generally recommended that antidepressants be gradually tapered, and for those who do experience discontinuation syndrome, symptoms usually taper off within about two weeks.

What Does All of This Mean for People With Depression?

These mixed messages about how safe or effective long-term antidepressants are along with the overreliance on antidepressants as a standalone treatment may leave people with depression feeling even more defeated.

The reality is that the current SSRIs and SNRIs work for a lot of people, but they also don’t work for a lot of people. Ketamine-derived drugs are showing promise but might not offer the lasting results people with chronic depression need. While short and long-term side effects for all of these are an important consideration, many find the tradeoff worth it for the ability to better manage their depression.

Takeaways

Scientists are still a long way off from understanding exactly how antidepressants are affecting the brain and how they might harness that mechanism of action in a way that makes it more reliably effective for more people.

In the meantime, the best thing you can do if you’re dealing with depression is find a treatment plan that works for you. That will take some trial and error as you work out what type of medication—if any—and for how long, and what type of therapy is most helpful.

Be patient and kind to yourself as you work through this and remember that the decision about what treatment plan works best for you is ultimately yours. Your friends, family, and healthcare providers can provide important guidance and support but you get the final say when it comes to your own mental health.