At therapy’s end
People come into Andrew Leuchter’s office, saying they’re better, saying they want to stop. “Oh, gosh, it happens all the time,” says Leuchter, a psychiatrist at UCLA’s Semel Institute for Neuroscience and Human Behavior. “They say they feel OK, that they don’t need drugs or any other help, and that they’ve recovered. On one hand that’s very encouraging, but on the other hand we have to be very careful, because the cost of being wrong -- if they are not ready -- can be very high.”
These are not drug addicts saying they want to go cold turkey. They are not alcoholics. These are people with depression who want to stop treatment.
Nearly 20 million Americans suffer from some form of depression, according to the National Institute of Mental Health. About 14% of adults now take antidepressants -- triple the percentage during the late 1980s -- and most stay on them for at least six months.
A study published in this month’s issue of the Archives of General Psychiatry estimated that mental disorders, largely depression, cost Americans 1.3 billion days of normal activity each year. Many people with such illnesses say they feel hopeless, helpless, unable to face life, unable to find solutions to their problems, and at times think of killing themselves. Some of them do.
Depression treatment, such as antidepressant drugs Prozac or some version of talk therapy, can help about two-thirds of sufferers. But as it does, patients start to ask: Am I better? Am I cured? Can I stop my therapy?
The answers are not simple. Measuring depression is hampered because there’s no physical marker that indicates whether a patient has it or does not. Information about that comes from behavior, thoughts and feelings, which can’t be assessed as easily as, say, blood pressure.
Rating scales can show how far symptoms, such as trouble sleeping, have receded, but psychiatrists say they put even more stock in a patient’s overall mood: whether he or she takes joy from life again and whether the person thinks he or she is back to a pre-depression emotional state. That too can be difficult to determine.
Now results from large, long-term studies are beginning to paint a clearer picture of the course of depression and are sharpening decisions about stopping treatment. If a person has had just one episode of depression, the chances of a long-lasting recovery are fairly good. But those chances go down with every subsequent episode.
Once people reach their third episode, Leuchter says, “then we need to discuss ongoing maintenance therapy, even if they are feeling better. I don’t like to use the phrase ‘lifetime treatment’ with patients. But, essentially, that’s what we’re talking about.”
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A lingering battle
One woman, a 41-year-old professional pet sitter who lives in Los Angeles, has been battling depression since she was a child. (She prefers to remain anonymous because, she says, depression is still a taboo subject.)
“I lost my dad when I was 10, and I never seemed to be able to get over it,” she says. She remembers crying on the school bus, crying a lot. At home, she didn’t want to get out of bed. Her body ached with a vague pain. She says at times she had to push herself to go to the bathroom. She had trouble seeing herself growing older. There didn’t seem to be any point. But it wasn’t until she was 22 that she got some help.
“I was working as an aide in a pediatrician’s office, and I was just crying all the time. It was over nothing, but it was uncontrollable,” she says. “One day the doctor took me aside. He said, ‘Look, we can’t help you here with something like this. But you can get help.’ And it was the first time somebody used the word ‘depression’ with me. It was the first time somebody took me seriously.”
The pediatrician referred her to a psychotherapist and to other doctors who prescribed antidepressants. She saw the therapist for a year and a half, “and I learned coping skills. I learned not to internalize things completely all the time.”
Medications were a rockier road. “I went through Paxil, and then Wellbutrin,” she says. “I would be fine for a time. Then I would go back to being depressed.”
It’s not unusual for patients to try multiple antidepressants and multiple dosages. There’s a lot of tinkering, because doctors still don’t understand precisely how these medications work. They have theories. The dominant one involves maintaining a balance in the brain of chemicals that seem to be involved in mood and emotions.
When Prozac, the granddaddy of modern antidepressants, was approved by the Food and Drug Administration in 1987, it was because taking the drug improved the moods of depressed patients. Doctors then knew the drug made more of the chemical neurotransmitter serotonin available in the brain. They assumed -- and still think -- the two things are connected.
Serotonin flows across tiny gaps from one brain cell to the next. Then the cell that originally released the chemical absorbs it again. The process is called reuptake. What Prozac appears to do is block that reuptake, so more serotonin lingers in the gap, ready to be taken up by other brain cells. If depression is indeed caused by low serotonin levels, this method -- while not increasing the absolute amounts of the chemical in the brain -- should leave more serotonin out in the open for more brain cells to use. Some antidepressants, such as Effexor, do the same thing with another mood-regulating brain chemical, norepinephrine.
Still, because no one really knows what a low, normal or high level of these neurotransmitters is, there’s a lot of trial and error involved in taking the drugs.
“We use many different doses and many different drugs because people seem to respond to them differently,” says Ellen Frank, a clinical psychologist at the Western Psychiatric Institute and Clinic at the University of Pittsburgh Medical Center. She has spent 25 years studying depression treatments. “Once we find something that works for a patient, we tend to stick with it,” she says. “The dose that gets you well keeps you well.”
That view is supported by results of a major study that followed 3,600 patients across the country for several years. One-third of them responded to the initial antidepressant treatment. People who did not respond were given a different drug, and some also got talk therapy. After that, non-responders got another combination. By the time the fourth combination was reached, 67% of the patients were no longer depressed.
That’s good news and not-so-good news, says A. John Rush, a psychiatrist at the University of Texas Southwestern Medical Center who led the study, which is known as STAR*D. The good news is that there’s hope for patients who can hang in there for multiple attempts at treatment. The not-great news, he admits, is that people who went through three or four treatment combos -- those with the toughest depressions to treat -- had the lowest chances of feeling better.
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The wellness factor
How, then, do patients know if they are well enough to stop therapy?
“That idea of ‘well’ is something patient and doctor have to agree upon,” says Leuchter, a specialist in the effectiveness of depression treatments. “They have to have a meeting of the minds on the definition. One real problem is that depressed patients often have a very low bar for what they would call feeling better. They’ve probably been depressed for years before they come to me for treatment. During this time they’ve lowered the bar: This, they tell themselves, is as good as it’s ever going to get.”
So a slight improvement in mood seems enormous, even if a depressed patient’s overall emotional state is one of apathy and general listlessness and little hope for the future, a condition few non-depressed people would describe as normal. Though it may seem good to the patient, most can do better.
There are scales of symptom severity, such as the Beck Depression Inventory or the Hamilton Depression Rating Scale, that Leuchter uses to rate individual symptoms, such as irritability or loss of appetite. “A 50% improvement on these scales is good,” he says. “But I don’t know anyone who would stop there. The acid test is getting back to full function. Are you able to work as you did before? Do you get enjoyment from life as you did before?”
Adds Frank: “If you are a schoolteacher, for example, how many papers could you grade in a week before you felt depressed, and how many can you grade now? How often do you get in a fight with your wife? If it was once a month before, and it’s once a month now, then you are probably back.”
Since “before” may be clouded in patients’ minds, Frank and Leuchter like to also get opinions from spouses or other people close to patients. After the end of a depressive episode, Leuchter says, it’s good to continue therapy for four to nine months. “It’s like the cast on a broken leg,” he says. “You need the continued support to be able to heal.” Coping skills need to be honed or a stressful incident might trigger another depression.
Then the patient begins to taper, whether it is drugs or psychotherapy or both, cutting the drug dose in half, or seeing a therapist every two weeks instead of every week. Then it’s wait and see. “If it goes well, then cut it in half again,” Frank says.
With drugs, if someone tries to taper too quickly or even go cold turkey, he or she often experiences a range of physical and emotional reactions. Some people complain of sleeplessness, dizziness, muscle aches or fatigue. Mentally, many feel anxious, nervous or, not surprisingly, depressed. Often, raising the drug back to the last effective dose alleviates the symptoms.
As with so many things regarding antidepressants, psychiatrists do not have hard-and-fast explanations for these effects. But it’s possible that the brain might reduce its ability to produce chemicals such as serotonin while the drugs enhance the supply. When the drugs are stopped, a lack of serotonin might cause side effects until the brain regains its balance.
Sometimes it doesn’t go well. For patients who have three episodes of major depression during their lives, particularly if the first one hit at a young age, chances of another relapse are high, about 90%.
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Long-term management
The woman who lost her father at age 10 fits that profile. After her initial treatment she got better and then worse. She changed drugs and doses, but the cycle continued for 18 years. She thought about killing herself; she also thought about killing others. At one point she committed herself to a hospital.
The last time she tried to wean herself off medication was a year ago. “I couldn’t do it,” she says. She felt herself falling back into a scary, dark place. So she went back on medication. “That’s frightening to me, a little. But I also know that there are meds that help. It’s a lot better knowing that I don’t have to go through life feeling like crap.”
She also credits psychotherapy with helping her identify situations that trigger depressive and anxious thoughts. It’s often periods of inactivity. So she keeps herself fully booked.
“I’m in L.A., I’m with dogs all day, and I’m walking them out in the sunshine, and all that feels good,” she says. “I like my life. I’m able to be depressed and crack jokes. As long as I keep going in this direction, I’ll be just fine.”
