Dear Editor, Lewis et al.[1] have recently reported the relapse rates of 478 remitted depressed patients from 150 general practices in the UK. Patients who had been treated with antidepressant medications (ie, citalopram, fluoxetine, sertraline, or mirtazapine) for at least 9 months were randomly assigned to treatment maintenance or discontinuation (tapering of antidepressants with the use of matching placebo). Over a follow-up period of 52 weeks, a depressive relapse occurred in 39% of patients assigned to treatment maintenance and in 56% of those who discontinued antidepressants, showing an increased risk of relapse among patients stopping antidepressant medications after prolonged use (HR= 2.06, p< 0.001). These findings seem to suggest that both treatment options are not successful in preventing depressive relapse in the long term. However, it cannot be determined how many of the relapses could be confounded with withdrawal and post-withdrawal symptoms [2]. While the issue of withdrawal symptoms and that of severity and duration of depressive relapses were both raised by subsequent letters of Liang et al.[3] and of Kuschpel [4], the role of psychological interventions in the maintenance treatment of depression was not addressed.

The results of Lewis et al.[1] might leave the impression that there are no other valuable treatment options for relapse prevention in major depression than the continuation of antidepressant medications. As stated in a recent Cochrane review, there is a lack of pharmacological trials that adequately address withdrawal confounding bias and differentiate relapse from withdrawal symptoms [5]. However, several meta-analyses have shown that the sequential integration of psychotherapy after response to acute-phase pharmacotherapy, either during continuation of antidepressant medications or after their discontinuation, is associated with reduced risk of relapse and recurrence in major depression, and thus appears to be an effective treatment approach [6–8]. Further, a recent network meta-analysis [9] concludes that clinical guidelines should consider the role of psychotherapy (alone or in combination with antidepressants) as an effective treatment option in depression, given its more enduring effects compared to pharmacotherapy alone. Patients presenting with major depression should be informed about available treatment options. This represents a crucial part of the shared decision-making process considering personal treatment preferences, side and withdrawal effects, or potential harms of prolonged antidepressant medications use according to a long-term perspective [10].