Will I need to stay on my depression meds forever?

Mental Health Expert Dr. Charles Raison Psychiatrist,
Emory University Medical School

Expert answer

Dear Ally, let me start by applauding your very accurate understanding of depression, terrible illness that it is. Your question is an interesting one because, of course, you could get off the medications any time you like simply by ceasing to take them. But what you mean, of course, is whether you will ever be able to stop taking the medications and not have to worry about falling back into another depressive episode.

This brings up a very important point about psychiatric disorders: Anything is possible. So anytime someone asks a question that starts with some variation of "Is it possible ...?" the answer is always, "Yes." Why? Because all psychiatric illnesses are probabilistic, not deterministic. Probabilistic means that although some things are a lot more common than others, nothing is certain and nothing is impossible.

I sometimes resort to physics as a metaphor to explain this idea. Isaac Newton used mathematics to paint the universe as an absolutely rigid machine in which causes always led to results in a predictable manner. In his view of the universe, if you knew what every particle in the universe was doing at this second, you'd be able to predict all future events flawlessly out to the end of time.

This way of thinking about things works very well for many practical things like firing cannon balls, sending rockets to the moon or building bridges, but it turns out that when you look really closely at matter, it only approximates the certainty that Newton described. This realization has become enshrined in a theory called quantum mechanics, which -- in essence -- says that no final certainties exist in the physical world, only various degrees of likelihood.

For example, although most of us think of atoms like little solar systems with the nucleus being like the sun and electrons swirling around it like planets, the physical reality is much weirder. In fact, an electron only tends to stay close to the atom of which it is a part. The further away you go from the atom the less likelihood there is for finding one of its electrons, but the chance isn't zero, and it is possible that you might find an atom's electron on the other side of the universe. It's not impossible, just so unlikely that it might as well be impossible.

The odds of things happening in psychiatric disorders is like that wandering electron. Some things are much more likely than others, but nothing is impossible.

So what about your situation? As you say, the more often one is depressed the more often -- on average -- that one will be depressed in the future. Statistically, if you've had four episodes of major depression, you've got close to a 100 percent chance of having more episodes. When one has had as many episodes as you have, your odds of relapsing in short order if you stop your medication are discouragingly high. Based on what we know now, if you want to avoid another episode you should stay on your medication indefinitely.

Having said this there are other things you can do to help ward off another depressive episode. Good studies show that psychotherapy can help prevent future episodes, as can a type of combined therapy and meditation called Mindfulness-Based Cognitive Therapy or MBCT, which has shown great promise in recent studies. We have many reasons to think that regular exercise, good sleep and a healthy diet are also helpful. And of course, given that stress causes depression, anything you can do to reduce stress and heartache in your life (easier said than done for all of us) will also be hugely helpful.

I have one final thought. When I hear someone say they've had four depressive episodes by age 26, I wonder if they might have a bipolar condition that has been missed. I find that often the simplest way to figure this out is to ask people whether they have two mood states or three. People with what unipolar depression will usually tell you they have two states: a depressed state and a state in which they are not depressed or at least a lot less depressed. Bipolar individuals will usually realize they have three states if they think about it: a state in which they feel fairly normal, a state in which they are clearly depressed and a third state that can sometimes seem like uncharacteristic agitation/irritability or sometimes manifest as unrealistic happiness/euphoria.

If you recognize three mood states in your life's story, I would strongly recommend you discuss this with your physician. Undiagnosed bipolar disorder is a major cause for people not doing well with their depression.