medRxiv : the preprint server for health sciences · 2026
Antidepressant Maintenance Versus Active Monitoring After Depression Remission: A Decision Analysis Stratified by Relapse Risk and Patient Preferences.
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Meyerson William U, Cai Tianxi, Smoller Jordan W
Аннотация
IMPORTANCE: Patients who achieve remission from major depressive disorder (MDD) often face a preference-sensitive decision between continued antidepressant maintenance and discontinuation with active monitoring. Quantifying the tradeoff between depression burden and long-term medication exposure may support more individualized shared decision-making.
OBJECTIVE: To quantify tradeoffs between continuous antidepressant maintenance and active monitoring after MDD remission, and to identify preference thresholds favoring each strategy across relapse-risk strata.
DESIGN: Individual-level decision-analytic health-state transition model calibrated to randomized maintenance-discontinuation trials and a longitudinal first depressive episode cohort, with a 5-year time horizon.
SETTING: Outpatient clinical decision after completion of an 8-month continuation phase following remission from MDD.
PARTICIPANTS: Adults in remission from MDD, represented across 4 clinically anchored relapse-risk strata ranging from very low risk after a first mild episode to high risk after highly recurrent depression.
EXPOSURES: Continuous antidepressant maintenance vs discontinuation with active monitoring and antidepressant restart after detected relapse.
MAIN OUTCOMES AND MEASURES: Severity-weighted depression-months, antidepressant medication-years, medication-years per depression-month averted, and net benefit across preference thresholds defined as the maximum additional medication-years a patient would be willing to accept to avert 1 depression-month.
RESULTS: Continuous maintenance reduced depression burden but required substantially more medication exposure, with efficiency strongly dependent on relapse risk. Medication-years per depression-month averted ranged from 11.8 (95% uncertainty interval [UI], 7.8-19.6) in the very low-risk group to 1.5 (95% UI, 0.8-3.0) in the high-risk group. At a preference threshold of 3 medication-years per depression-month averted, maintenance was preferred for moderate- and high-risk patients; at a threshold of 2, only for high-risk patients; and at a threshold of 1, for no risk group.
CONCLUSIONS AND RELEVANCE: In this decision-analytic model, the value of continuous antidepressant maintenance depended strongly on baseline relapse risk and patient preferences regarding long-term medication exposure. These findings provide a quantitative framework for shared decision-making about antidepressant maintenance after remission from MDD.
OBJECTIVE: To quantify tradeoffs between continuous antidepressant maintenance and active monitoring after MDD remission, and to identify preference thresholds favoring each strategy across relapse-risk strata.
DESIGN: Individual-level decision-analytic health-state transition model calibrated to randomized maintenance-discontinuation trials and a longitudinal first depressive episode cohort, with a 5-year time horizon.
SETTING: Outpatient clinical decision after completion of an 8-month continuation phase following remission from MDD.
PARTICIPANTS: Adults in remission from MDD, represented across 4 clinically anchored relapse-risk strata ranging from very low risk after a first mild episode to high risk after highly recurrent depression.
EXPOSURES: Continuous antidepressant maintenance vs discontinuation with active monitoring and antidepressant restart after detected relapse.
MAIN OUTCOMES AND MEASURES: Severity-weighted depression-months, antidepressant medication-years, medication-years per depression-month averted, and net benefit across preference thresholds defined as the maximum additional medication-years a patient would be willing to accept to avert 1 depression-month.
RESULTS: Continuous maintenance reduced depression burden but required substantially more medication exposure, with efficiency strongly dependent on relapse risk. Medication-years per depression-month averted ranged from 11.8 (95% uncertainty interval [UI], 7.8-19.6) in the very low-risk group to 1.5 (95% UI, 0.8-3.0) in the high-risk group. At a preference threshold of 3 medication-years per depression-month averted, maintenance was preferred for moderate- and high-risk patients; at a threshold of 2, only for high-risk patients; and at a threshold of 1, for no risk group.
CONCLUSIONS AND RELEVANCE: In this decision-analytic model, the value of continuous antidepressant maintenance depended strongly on baseline relapse risk and patient preferences regarding long-term medication exposure. These findings provide a quantitative framework for shared decision-making about antidepressant maintenance after remission from MDD.