Should a patient with a first episode of depression, currently on citalopram (escitalopram) 30 mg daily with improved PHQ-9 (Patient Health Questionnaire-9) scores, continue or stop the medication?

Management of First Episode Depression After Successful Treatment

She should continue to take this dose for at least another 4–9 months, then reassess. This approach aligns with clinical guidelines for first episodes of depression and provides the best protection against relapse while balancing the risks of premature discontinuation 1.

Treatment Duration for First Episode Depression

The American Family Physician clinical guidelines clearly state that treatment should continue for four to 12 months after a first episode of major depressive disorder 1. This patient has shown significant improvement with citalopram, as evidenced by her PHQ-9 score decreasing from 18 to 7, but has only been on treatment for 5 weeks.

Risk of Premature Discontinuation

• Antidepressant medication does not prevent relapse if discontinued at the end of the acute phase 1
• Systematic reviews show that continued treatment with antidepressants after remission protects against recurrence and relapse 1
• After a first episode of depression, the probability of a recurrent episode is approximately 50% 1

Treatment Phases for Depression

The American College of Physicians defines three distinct phases of depression treatment 2:

1. Acute Phase (6-12 weeks): Initial treatment to achieve response
2. Continuation Phase (4-9 months): Prevents relapse of the current episode
3. Maintenance Phase (≥1 year): For patients with multiple episodes

This patient is still in the acute phase of treatment (5 weeks) and needs to complete both the acute and continuation phases before considering discontinuation.

Evidence Supporting Continued Treatment

Research specifically on citalopram shows that patients continuing treatment have significantly lower relapse rates compared to those who discontinue:

• A placebo-controlled study showed that patients continuing citalopram had a 13.8% relapse rate compared to 24.3% in those who discontinued 3
• Patients who receive explicit instructions about expected duration of therapy are less likely to discontinue treatment prematurely 4

Common Pitfalls to Avoid

1. Premature discontinuation: Stopping medication as soon as symptoms improve is a common mistake that significantly increases relapse risk
2. Inadequate follow-up: Patients with fewer than 3 follow-up visits are more likely to discontinue therapy prematurely 4
3. Poor communication: Discrepancies often exist between instructions physicians report giving and what patients remember being told 4

Recommendations for This Patient

• Continue citalopram 30 mg daily for at least 4-9 more months (completing both acute and continuation phases)
• Schedule regular follow-up appointments (at least every 3 months) to monitor response and side effects
• Clearly communicate the importance of continuing medication despite symptom improvement
• Reassess at the end of the continuation phase (approximately 6-10 months of total treatment)
• Consider discontinuation only after this period if remission is maintained and this is truly her first episode

This approach maximizes the chance of sustained remission while following evidence-based guidelines for first-episode depression treatment.