Recommended duration of treatment and criteria for gradual withdrawal

The treatment of major depression is usually structured in three phases: acute, continuation, and maintenance. The acute phase aims to achieve symptomatic remission, i.e., a 50% or greater improvement in symptoms from baseline, and usually lasts between 6 and 12 weeks.

During this stage, initial drug treatment is established and clinical responses are assessed. Partial or no response may require dose adjustments, a change in antidepressant, or augmentation strategies.

The continuation phase lasts for at least 6 to 9 months after remission is achieved. Its purpose is to prevent relapse, which is the return of symptoms before complete recovery has occurred.

Finally, the maintenance phase seeks to prevent recurrence, i.e., a new depressive episode after recovery. This phase can last for years in patients with multiple relapses, severe depression, or a significant family history.

Factors that determine the duration of treatment

There is no single fixed duration for all patients. Factors such as the number of previous episodes, the severity of the disorder, the presence of comorbidities (psychiatric or medical), and individual clinical response influence how long treatment should be maintained. In mild to moderate depression with a good prognosis, treatment may be discontinued after 6-12 months of remission.

In contrast, patients with recurrent or refractory episodes may require lifelong treatment. Likewise, residual symptoms (such as anhedonia, cognitive slowing, insomnia, or persistent negative thoughts) indicate that remission is not complete and constitute a risk factor for relapse. Their presence requires prolonging treatment until they disappear or stable functional improvement is achieved.

Criteria for gradual withdrawal of treatment

Treatment withdrawal should always be gradual and planned, avoiding abrupt discontinuation, which can lead to discontinuation effects or relapse.

Clinical criteria indicating that withdrawal may be considered include:

• Sustained complete remission for at least 6 to 12 months.

• Absence of clinically significant depressive or anxiety symptoms.

• Functional recovery (return to work, stable social relationships, good performance).

• Good psychosocial support.

• Absence of risk factors such as recent suicidal ideation, stressful life events, or serious comorbidities.

Drug reduction protocol

Reduction should be gradual, usually over a period of several weeks to months, depending on the drug, its half-life, and the final dose. For SSRIs (such as sertraline or paroxetine), a 25% reduction every 2 to 3 weeks is recommended, with assessment of emerging symp