Last week, Health Secretary Robert F. Kennedy Jr. announced initiatives aimed at getting more people to stop using antidepressant drugs, particularly a class known as selective serotonin reuptake inhibitors, or S.S.R.I.s.
“Let me be clear: If you are taking psychiatric medication, we’re not telling you to stop,” Mr. Kennedy said at a mental health summit organized by the MAHA Institute, a group that supports the goals of the Make America Healthy Again movement. “We are making sure that you — and your clinician — have the information and support to make the right decisions for you.”
Experts emphasize that antidepressants like S.S.R.I.s are very safe drugs with few serious health risks. But Mr. Kennedy’s comments may have some people questioning when it is appropriate to stop taking them and how to do so safely. Here’s what psychiatrists had to say.
Who can consider going off their antidepressant?
“The decision to stop is quite a difficult one and a nuanced one, which every individual and their physician has to take quite seriously,” said Dr. Glyn Lewis, a professor of epidemiological psychiatry at University College London.
The American Society of Clinical Psychopharmacology recently published recommendations about “deprescribing” psychiatric medications. They include the suggestion that doctors re-evaluate “the utility of continuing any particular psychotropic medication” on at least an annual basis.
There are several factors to take into account when deciding whether to stop.
As a general rule, experts said people could consider going off their antidepressants when they felt they were back to their normal selves.
“That would include feeling their moods are stable, that they’re motivated and engaged in life again, that they are functioning fully compared to how they were when they were depressed,” said Dr. Jonathan E. Alpert, chair of the department of psychiatry and behavioral sciences at Montefiore Einstein in New York.
However, he and other experts advised waiting another six months or so after that point before actually stopping the medication. That extra time “appears to help consolidate the recovery they’ve made” and lowers the risk of relapse, Dr. Alpert said.
Dr. Mark Rapaport, the president-elect of the American Psychiatric Association, said he also took into account whether the person had a good support network in place and if they would be experiencing any major life changes in the near future, like moving or starting a new job. “Even good change is associated with stress,” he said.
Another consideration is a person’s odds of relapsing. Experts say that after a first depressive episode, people have a roughly 50-50 chance of becoming depressed again. After two episodes, the odds rise to about 70 percent; after three, they’re close to 90 percent. The more depressive episodes a person has had, the longer that person is typically advised to stay on medication.
Experts also think about what might happen if the person does relapse. “If the depression’s been mild to moderate, the consequences of a relapse may not be life-changing,” Dr. Alpert said. But if somebody has been severely suicidal or disabled (like they’ve had to stop work or school) each time they get depressed, “then the consequences of a relapse are very high.”
Side effects are another reason people might want to stop taking an antidepressant. In those cases, the experts advised, patients should talk to their doctor about switching medications instead of stopping outright, or trying nonpharmaceutical options like therapy, transcranial magnetic stimulation (T.M.S.) or transcranial direct-current stimulation (tDCS).
How do I stop safely?
The experts emphasized the importance of tapering.
“Stopping medication slowly — and this applies to pretty much all medication — is a better idea than stopping it quickly because it gives the body time to adjust to the absence of the drug,” said David Taylor, a professor of psychopharmacology at King’s College London.
Many, but not all, people experience withdrawal symptoms when they stop taking an S.S.R.I. or other antidepressant; for some, they can be severe. Symptoms can include feelings of anxiety, irritability, tearfulness, fatigue, insomnia, nausea, muscle aches or even a zapping sensation on the scalp.
“They’re not dangerous,” Dr. Alpert said, “but they can be very uncomfortable.”
Gradually lowering the dose over time can help reduce the likelihood of going through withdrawal. The precise timeline depends on the individual and the type of antidepressant being taken. But a general guideline is to reduce the dosage by 25 percent each week, stopping over the course of a month.
If people start to experience uncomfortable withdrawal symptoms, the experts said they should consult with their doctor about going back up to the last dose when there weren’t symptoms, and reducing more slowly from there.
Because the symptoms overlap, it can sometimes be difficult to tell whether feeling anxious or tearful, for instance, is a sign of withdrawal or an indication that someone’s depression or anxiety is returning.
The time frame is the most telling factor, Dr. Taylor said. “Depression tends to return insidiously over a period of weeks or months, whereas withdrawal symptoms come in with a bang almost immediately.”
Is there a risk to staying on antidepressants long-term?
Most clinical trials have looked only at short-term antidepressant use, but people have been taking the drugs for years without evidence of widespread harm, Dr. Rapaport said.
However, the side effects are something to consider. Weight gain and sexual dysfunction are most commonly reported, but some drugs have been found to increase heart rate or blood pressure. There is also a greater risk of internal bleeding, particularly if the person is also taking a nonsteroidal anti-inflammatory or anticoagulant drug. A few studies have found that people who take antidepressants have an increased risk of blood clots and cardiovascular disease, but the connection could be related to other health factors. For example, people with depression are more likely to smoke and less likely to be physically active.
There is also a general guiding principle in medicine that people “should be on the fewest number of medications that allow them to stay healthy,” Dr. Alpert said. “And so if we think that somebody no longer requires the benefit of an antidepressant, then it makes sense to reassess and consider coming off the antidepressant.”
Perhaps most important to keep in mind, though, is that “depression is not trivial by any means,” Dr. Taylor said. If people with recurrent depression have found a medication that “allows them to have a happy life and productive life, then with some minor exceptions and with some caution, those people probably should continue, because a relapse could be disastrous.”
