Medical Edge Newspaper Column

No Danger In Long-Term Use Of Antidepressants

July 9, 2006
DEAR MAYO CLINIC:
I've been taking doxepin for depression for 15 years. Is it safe to take antidepressant medications for such a long time? I've tried to wean myself off, but my symptoms return. -- Naperville, Ill.

ANSWER:
For patients who experience a single episode of depression, a six- to 12-month course of a suitable antidepressant will often suffice. But for those who experience more than one episode and whose depression may become a chronic condition, "maintenance treatment" is recommended. In such cases, efforts to wean oneself from the drug may result in the return of the depressive illness.

Patients with diabetes (who need insulin chronically) and patients with hypertension (who take antihypertensive drugs on a regular basis) are in a similar situation. Their medications, like antidepressants, do not merely mask symptoms but treat the underlying condition.

Antidepressants can produce side effects such as constipation, urinary retention, and sexual difficulties. Some side effects may be transient -- that is, they appear when the patient begins taking the drug and resolve after a few weeks, even though he or she continues taking the drug -- while others persist for as long as one is on the antidepressant. Side effects can usually be reduced by adjusting the dose, taking an alternative antidepressant, or adding an agent that counteracts the specific problem.

There is no evidence to date of any persistent side effect of antidepressants -- physical or cognitive -- caused by long-term use.

Until the early 1990s, the class of drugs called tricyclic antidepressants constituted the first line of drug treatment for depression. These medications include amitriptyline, nortriptyline (Pamelor) and doxepin (Sinequan). These agents act on more than one of the brain's neurotransmitters -- including serotonin, norepinephrine and dopamine -- that have been associated with depression. But because tricyclics affect multiple neurotransmitters, they typically have more side effects than other antidepressants.

The current first line of drug treatment is the class called selective serotonin reuptake inhibitors. They include citalopram (Celexa), sertraline (Zoloft) and fluoxetine (Prozac). SSRIs, which presumably act on fewer neurotransmitters, tend to have fewer side effects.

While most antidepressants have a similar level of efficacy, a medication that works for one person might not work for another. If a patient's response to a particular agent does not result in satisfactory progress after four to eight weeks, the doctor may suggest changing the dose or replacing it with another drug from a different chemical family. In your case, you might have tried more than one antidepressant and found that doxepin works best for you -- relieving depression while producing few or manageable side effects. As long as you don't develop a new medical problem for which this drug is contraindicated, you should continue it. If, on the other hand, you've been living with certain side effects that you'd prefer to live without, it might be worth trying -- in consultation with your doctor -- a different antidepressant.

Finally, it's worth noting that a major depressive illness is associated with more than depressed mood -- it is a biological illness, just as diabetes and hypertension are biological illnesses. As such, individuals cannot simply pull themselves up by their own bootstraps and move forward. They need to seek medical attention and receive appropriate treatment for relieving the symptoms associated with their condition.

-- Teresa A. Rummans, M.D., Psychiatry, Mayo Clinic, Rochester, Minn.