Q: Time to Remove the Antidepressant?
 
Hi Dr. Phelps...just ordered your book from Amazon. I started Effexor over two years ago after another bout of depression (have had several bouts with varying degrees of success with antidepressants alone). It relieved my depression, but I started having some hypomanic symptoms. My doctor basically DX'd me as BPII and prescribed Lamictal in addition to the Effexor. I've been more or less OK for over a year now. I do have some short periods of mild depression, but nothing major. I go in every 3 months to see my doctor and he just renews my scripts because I'm fairly stable. I don't think he wants to disrupt anything, and I really can't blame him, BUT...

Should I be considering removing the Effexor now that I'm stable? If nothing else, I'd save a significant chunk of change be getting off of Effexor. Thanks!


Dear Mr. V.' --

Short answer and long answer. The short answer: one can easily justify either approach -- stay on the Effexor, or taper it off. The research data most psychiatrists are familiar with, if they know any data at all on this question, derived from a study by (lead author, among many) Lori Altshuler. It suggested that staying on as better than coming off. However, what is much less known is why the structure of that study places the results in very significant doubt -- especially since now we have a much more sophisticated research design looking at the same question, which arrives at nearly the opposite conclusion. That one is by ((lead author) Nassir Ghaemi another very well-known mood disorders researcher.

You know you're in trouble when that was the short answer. 

For the long answer, I will refer you to the Antidepressants Controversies page on my website which addresses this particular issue specifically, and presents more detail from these two studies. The bottom line: if you have a prior history of "rapid cycling", more than four mood episodes in a year; or perhaps based on your current relatively mild but relatively rapid cycling; the Ghaemi paper suggests that you would be more stable (as well as slightly richer) by tapering off. In my view, if you and your psychiatrist (not you alone, of course) decide to taper at the Effexor, I think the key is to go very slowly, taking for months or even perhaps even more more, and going down by the smallest increments you can manage.

Dr. Phelps