Letters Psychotic depression

Staying well has to be the main goal

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2307 (Published 16 April 2013) Cite this as: BMJ 2013;346:f2307
  1. Ian M Anderson, professor of psychiatry
  1. 1University of Manchester, Manchester M13 9PT, UK
  1. ian.anderson{at}manchester.ac.uk

I was heartened to read Rebecca Lawrence’s patient journey and admire her courage in being open about her illness.1 I hope that this will help others to do the same if they need to, because stigma and guilt or shame can be two sides of the same coin.

However, I was dismayed by the sentence in the clinician’s perspective that: “Once Rebecca has been well for 6-12 months, we could phase out medication.” A major clinical problem with recurrent depression, especially if severe or psychotic, is the risk of relapse and slow, incomplete, or even lack of recovery in a subsequent episode. There is good evidence that antidepressants reduce the risk of relapse substantially for as long as the treatment is continued.2 Unfortunately, without continuing treatment, Rebecca is at high risk of future relapse, given the duration and severity of episodes—at least four serious recurrences and perhaps a family history of depression. This article risks being read as an endorsement of routinely stopping prophylactic treatment. Of course, it is ultimately the patient’s choice, but choice must be informed by the best evidence, which in this situation is that indefinite prophylaxis provides the best hope of remaining in remission.3

In addition, I was disappointed that the “Useful resources” box did not include references to evidence based guidelines on treatment, such as those from the National Institute for Health and Care Excellence or the British Association for Psychopharmacology.3 4 It is extremely important to tackle the stigma associated with this disease, but it is vital to treat the illness as effectively as possible, because staying well has to be the fundamental goal.


Cite this as: BMJ 2013;346:f2307


  • Competing interests: IMA was first author of the British Association for Psychopharmacology guidelines on the use of antidepressants for depression and chaired the NICE clinical guideline group to update the depression guidelines (2009).