Clinical Review

Long term treatment of depression with selective serotonin reuptake inhibitors and newer antidepressants

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c1468 (Published 26 March 2010) Cite this as: BMJ 2010;340:c1468
  1. Steven Reid, consultant psychiatrist1,
  2. Corrado Barbui, lecturer in psychiatry2
  1. 1Department of Liaison Psychiatry, St Mary’s Hospital, London W2 1PF
  2. 2Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, University of Verona, 37134 Verona, Italy
  1. Correspondence to: S Reid steve.reid{at}nhs.net

    Summary points

    • The rise in the prescribing of antidepressants is largely accounted for by an increase in long term treatment

    • Half of people with a diagnosis of major depression will go on to have a further episode, and risk of recurrence increases with each episode

    • Evidence for the benefits of long term prescribing of antidepressants comes almost exclusively from secondary care settings

    • Continuing antidepressant treatment roughly halves the absolute risk of relapse

    • The increased risk of suicidal behaviour associated with selective serotonin reuptake inhibitors (SSRIs) is restricted to people aged under 25

    • People with risk factors for relapse of depression should be advised to continue with SSRIs for at least 12 months and consider long term treatment

    The introduction of fluoxetine in 1987 marked the arrival of the selective serotonin reuptake inhibitors (SSRIs) for the treatment for depression. In the United States antidepressant prescriptions accounted for 2.6% of primary care visits in 1989, rising to 7.1% in 2000.1 This pattern was reflected across Europe, where SSRIs are now the most commonly prescribed antidepressants. Newer antidepressants, such as the serotonin norepinephrine reuptake inhibitors, including venlafaxine and duloxetine, also contributed to the remarkable increase in antidepressant prescribing.2

    Several reasons were put forward for this trend: improved tolerability; reduced lethality in overdose; the aggressive marketing of newly patented drugs; the wider range of available antidepressants; and ease of prescription. An analysis of the UK general practice research database showed that prescriptions almost doubled from 1993 to 2005.3 However, the increase in antidepressant prescribing was not accounted for by new diagnoses but rather a rise in the number of prescriptions given for long term treatment: although the proportion of patients receiving short term treatment declined, the proportion of patients receiving continuing prescriptions for over five years increased. Another primary care study found that …

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