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."
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.