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Brisnik V, Rottenkolber M, Vukas J, Schechner M, Lukaschek K, Jung-Sievers C, Gensichen J, Thiem U, Drey M, Krüger N, Mair A, Guthrie B, Fischer S, Dreischulte T. Potential deprescribing indications for antidepressants between 2012 and 2019: repeated cross-sectional analysis in two Scottish health boards. BMC Med 2024; 22:378. [PMID: 39256761 PMCID: PMC11389559 DOI: 10.1186/s12916-024-03584-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Accepted: 08/23/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND Antidepressants have a pivotal role in the treatment of many psychiatric disorders, but there are concerns about long-term use and adverse effects. The objectives of this study were (1) to examine time trends in antidepressant use, (2) to estimate the prevalence of long-term and potential high-risk antidepressant use, and (3) to examine patient characteristics associated with potential deprescribing indications (PDIs) (i.e., simultaneous long-term and potential high-risk antidepressant use). METHODS Repeated population-based cross-sectional study for all 609,299 people aged ≥ 18 years resident in the Tayside or Fife regions of Scotland. The prevalence of antidepressant use was examined on June 30th (index date) of each year from 2012 to 2019, while the prevalence of long-term and potential high-risk use as well as PDIs was assessed and compared on the same dates in 2012 and 2019. Binary logistic regression modeling was used to examine patient characteristics associated with PDIs. RESULTS Antidepressant use increased by 27% from 12.0 to 15.3% among adult residents between 2012 and 2019. While the proportion of antidepressants users dispensed ≥ 1 antidepressant for > 2 years increased from 54.3 to 61.9% between 2012 and 2019, the proportion of antidepressant users triggering ≥ 1 indicator of potential high-risk use decreased slightly from 37.9 to 34.7%. In 2019, potential high-risk use most commonly related to indicators targeting fall risk (16.0%), cardiovascular risks (14.1%), insomnia (10.6%), and risk of orthostatic hypotension (8.6%). More than 1 in 4 (25.8%) antidepressant users had PDIs. The main risk factors associated with PDIs included increasing age (65-79, adjusted OR 14.12; 95% CI, 13.15-15.17), increasing number of drugs taken concomitantly (≥ 15 drugs, adjusted OR 7.37; 95% CI, 6.71-8.10), use of tricyclic antidepressants (≥ 50 mg) (adjusted OR 5.49; 95% CI, 5.02-6.01), and concomitant use of ≥ 2 antidepressants (adjusted OR 5.52; 95% CI, 5.20-5.85). CONCLUSIONS Long-term and potential high-risk use of antidepressants is widespread, and potential deprescribing indications (PDIs) are increasing, suggesting the need for a critical review of their ongoing use by clinicians. If deemed necessary, future deprescribing interventions may use the criteria applied here for identification of patients with PDIs and for evaluating intervention effectiveness.
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Affiliation(s)
- Vita Brisnik
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany
- Graduate Program "POKAL - Predictors and Outcomes in Primary Care Depression Care" (DFG-GrK2621), Munich, Germany
| | - Marietta Rottenkolber
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Jochen Vukas
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany
- Graduate Program "POKAL - Predictors and Outcomes in Primary Care Depression Care" (DFG-GrK2621), Munich, Germany
| | - Miriam Schechner
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Karoline Lukaschek
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany
- Graduate Program "POKAL - Predictors and Outcomes in Primary Care Depression Care" (DFG-GrK2621), Munich, Germany
| | - Caroline Jung-Sievers
- Graduate Program "POKAL - Predictors and Outcomes in Primary Care Depression Care" (DFG-GrK2621), Munich, Germany
- Institute of Medical Data Processing, Biometrics and Epidemiology (IBE), Faculty of Medicine, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, LMU Munich, Munich, Germany
| | - Jochen Gensichen
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany
- Graduate Program "POKAL - Predictors and Outcomes in Primary Care Depression Care" (DFG-GrK2621), Munich, Germany
| | - Ulrich Thiem
- Department of Geriatrics, Albertinen-Haus, Hamburg, Germany
| | - Michael Drey
- Department of Medicine IV, Geriatrics, LMU University Hospital, LMU Munich, Munich, Germany
| | - Nils Krüger
- Department of Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
- Deutsches Zentrum Für Herz- Und Kreislaufforschung (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Alpana Mair
- Effective Prescribing and Therapeutics Division, Scottish Government, Edinburgh, Scotland, UK
| | - Bruce Guthrie
- Advanced Care Research Centre, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Sebastian Fischer
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany
- Psychiatric Services Lucerne, Lucerne, Switzerland
| | - Tobias Dreischulte
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany.
- Graduate Program "POKAL - Predictors and Outcomes in Primary Care Depression Care" (DFG-GrK2621), Munich, Germany.
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Van Leeuwen E, Maund E, Woods C, Bowers H, Christiaens T, Kendrick T. Health care professional barriers and facilitators to discontinuing antidepressant use: A systematic review and thematic synthesis. J Affect Disord 2024; 356:616-627. [PMID: 38640978 DOI: 10.1016/j.jad.2024.04.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 04/12/2024] [Accepted: 04/14/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION Long-term antidepressant (AD) use, much longer than recommended, is very common and can lead to potential harms. OBJECTIVE To investigate the existing literature on perspectives of health professionals (HPs) regarding long-term AD treatment, focusing on barriers and facilitators to discontinuation. METHODS A systematic review with thematic synthesis. Eight electronic databases were searched until August 2023 including MEDLINE, PubMed, Embase, PsycINFO, CINAHL, AMED, Health Management Information Consortium, and the Networked Digital Library of Theses and Dissertation. RESULTS Thirteen studies were included in the review. Of these, nine focused on general practitioner perspectives, one on psychiatrist perspectives, and three on a mix of HPs perspectives. Barriers and facilitators to discontinuing long-term ADs emerged within eight themes, ordered chronologically based on HP considerations during an AD review: perception of AD use, fears, HP role and responsibility, HPs' perception of AD discontinuation, HPs' confidence regarding their ability to manage discontinuation, perceived patient readiness to stop, support from patient's trusted people, and support from other HPs. LIMITATIONS Coding and development of subthemes and themes was performed by one researcher and further developed through discussion within the research team. CONCLUSION Deprescribing long-term ADs is a challenging concept for HPs. The review found evidence that the barriers far outweigh the facilitators with fear of relapse as a main barrier. HP education, reassurance and confidence-building is essential to increase the initiation of the discontinuation process. Further research into the perspectives of pharmacists and mental health workers is needed as well as exploring the role of trusted people.
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Affiliation(s)
- Ellen Van Leeuwen
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Belgium; Department of Public Health and Primary Care, Ghent University, Belgium.
| | - Emma Maund
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, University of Southampton, Southampton, United Kingdom
| | - Catherine Woods
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, University of Southampton, Southampton, United Kingdom
| | - Hannah Bowers
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, University of Southampton, Southampton, United Kingdom
| | - Thierry Christiaens
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Belgium
| | - Tony Kendrick
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, University of Southampton, Southampton, United Kingdom
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Capiau A, Mehuys E, Grymonprez M, Van Tongelen I, Christiaens T, Tommelein E, Philippe G, Lahousse L, De Backer T, Boussery K. Detection and management of clinically relevant drug-drug interactions with direct oral anticoagulants: an intervention study in community pharmacies. Thromb Res 2024; 238:223-231. [PMID: 38733695 DOI: 10.1016/j.thromres.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/16/2024] [Accepted: 05/06/2024] [Indexed: 05/13/2024]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) are increasingly used and can be involved in clinically relevant drug-drug interactions (DDIs) that increase the risk of major bleeding or thromboembolism. Skilled drug interaction management is essential to ensure safe and effective use of DOACs. In this study, we aimed to investigate the impact of the detection and management of DDIs with DOACs in a real-life community pharmacy setting on the pharmacotherapy of DOAC users. METHODS We conducted an intervention study in 201 community pharmacies in Belgium. On random days, patients purchasing DOACs or drugs known to interact with them were screened. When a DDI with the DOAC was detected, the pharmacist contacted the prescribing physician to discuss the management of the interaction. A previously developed practice-oriented DDI list accompanied by management plans for ambulatory care was used for both screening and management of the DDIs. RESULTS In total, 751 patients were included, among whom 875 DDIs were identified, primarily pharmacodynamic DDIs (95.7 %). Predominant interacting drug classes included selective serotonin or serotonin and norepinephrine reuptake inhibitors (32.9 %), antiplatelets (30.9 %), and non-steroidal anti-inflammatory drugs (28.9 %). In 43.0 % of DDIs, an intervention was decided upon. At three-month follow-up, proposed pharmacotherapy changes had been implemented in 79.1 % of these DDIs. CONCLUSIONS This study demonstrates that active screening and management of DDIs with DOACs in community pharmacies, in close collaboration with prescribing physicians, resulted in changes in pharmacotherapy in a substantial number of patients. This may contribute significantly to the safer utilisation of DOACs in high-risk populations.
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Affiliation(s)
- Andreas Capiau
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium.
| | - Els Mehuys
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Maxim Grymonprez
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Inge Van Tongelen
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Thierry Christiaens
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Eline Tommelein
- Department of Pharmaceutical and Pharmacological sciences, Experimental Pharmacology, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Jette, Belgium
| | - Geneviève Philippe
- Center for Interdisciplinary Research on Medicines, Department of Pharmacy, University of Liège, Avenue Hippocrate 15, 4000 Liège, Belgium
| | - Lies Lahousse
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium; Department of Epidemiology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 Rotterdam, the Netherlands
| | - Tine De Backer
- Department of Cardiology, Heart Centre, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Koen Boussery
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
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Coe A, Gunn J, Allnutt Z, Kaylor-Hughes C. Understanding Australian general practice patients' decisions to deprescribe antidepressants in the WiserAD trial: a realist informed approach. BMJ Open 2024; 14:e078179. [PMID: 38355180 PMCID: PMC10868251 DOI: 10.1136/bmjopen-2023-078179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 01/31/2024] [Indexed: 02/16/2024] Open
Abstract
OBJECTIVES To evaluate how an approach to antidepressant deprescribing works, for whom, and in what contexts by (1) examining the experiences and perceptions of the approach for antidepressant users, (2) identifying the mechanisms of the approach and (3) describing what contexts are associated with antidepressant tapering. DESIGN This mixed methods study was informed by the principles of realist evaluation and was conducted in the first 3 months of participation in the WiserAD randomised control trial. SETTING General practice, Victoria, Australia. PARTICIPANTS 13 antidepressant users from general practice participating in the WiserAD trial for antidepressant deprescribing. INTERVENTION A patient-facing, web-based structured support tool that consists of a personalised tapering schedule, an action plan for managing withdrawal symptoms, a daily mood, sleep and activity tracker and mental health nurse support. PRIMARY/SECONDARY OUTCOME MEASURES The outcomes of the study were revealed on data analysis as per a realist evaluation approach which tests and refines an initial programme theory. RESULTS The contexts of learnt coping skills, knowledge and perceptions of antidepressants and feeling well were evident. Outcomes were intention to commence, initiation of deprescribing and successful completion of deprescribing. Key mechanisms for antidepressant deprescribing were (1) initiation of the deprescribing discussion; (2) patient self-efficacy; (3) provision of structured guidance; (4) coaching; (5) mood, sleep and activity tracking and (6) feelings of safety during the tapering period. CONCLUSIONS The WiserAD approach to antidepressant deprescribing supported participants to commence and/or complete tapering. The refined programme theory presents the WiserAD pragmatic framework for the application of antidepressant deprescribing in clinical practice. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT05355025; ACTRN12622000567729; ISRCTN11562922; Pre-results.
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Affiliation(s)
- Amy Coe
- Department of General Practice and Primary Care, The University of Melbourne, Carlton, Victoria, Australia
| | - Jane Gunn
- Department of General Practice and Primary Care, The University of Melbourne, Carlton, Victoria, Australia
| | - Zoe Allnutt
- Department of General Practice and Primary Care, The University of Melbourne, Carlton, Victoria, Australia
| | - Catherine Kaylor-Hughes
- Department of General Practice and Primary Care, The University of Melbourne, Carlton, Victoria, Australia
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Amrein MA, Hengartner MP, Näpflin M, Farcher R, Huber CA. Prevalence, trends, and individual patterns of long-term antidepressant medication use in the adult Swiss general population. Eur J Clin Pharmacol 2023; 79:1505-1513. [PMID: 37668659 PMCID: PMC10618304 DOI: 10.1007/s00228-023-03559-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/24/2023] [Indexed: 09/06/2023]
Abstract
PURPOSE Antidepressant use has increased in many European countries, mostly driven by longer treatment duration. The aim of this study was to provide prevalence rates of long-term users of antidepressants for the Swiss population over the last decade and to investigate associated factors for longer use. METHODS We examined the prevalence rates of individuals with at least one prescription for antidepressants using longitudinal health claims data for 2013 to 2021. We defined short- (< one year), medium- (one-two years), and long-term users (> two years) for 2015 to 2019. We applied a binary logistic regression model to investigate the effects of population (gender, age, area of living, language, health insurance plan, and nursing home) and treatment characteristics (psychiatric or psychotherapeutic care) on long-term compared to short- and medium-term users in 2019. RESULTS In 2021, 9% of the Swiss population (n = 770,698) received at least one antidepressant prescription, which remained stable since 2013. In 2019, the proportion of long-term users was 57.4%, with steady increase since 2015. The proportion of medium- and short-term users has decreased. Older age, being a woman, living in an urban area, living in a nursing home, being enrolled in a standard care plan, and receiving psychiatric or psychotherapeutic care were factors positively associated with being a long-term user. CONCLUSION The proportion of long-term users in Switzerland is high and steadily increasing. Given the ongoing debate about the confounding effects of relapse and withdrawal, more research is needed to investigate longer use of antidepressants that could indicate overprescribing.
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Affiliation(s)
- Melanie A Amrein
- Department of Health Sciences, Helsana Group, Zurich, Switzerland.
| | - Michael P Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences, Zurich, Switzerland
| | - Markus Näpflin
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Renato Farcher
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Carola A Huber
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
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McGoldrick A, Byrne H, Cadogan C. An assessment of the reporting of tapering methods in antidepressant discontinuation trials using the TIDieR checklist. Int J Clin Pharm 2023; 45:1074-1087. [PMID: 37269440 PMCID: PMC10600051 DOI: 10.1007/s11096-023-01602-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/03/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND The importance of tapering is increasingly recognised when discontinuing antidepressant medication. However, no previous studies have examined the reporting of antidepressant tapering methods in published studies. AIM The aim of this study was to assess the completeness of reporting of antidepressant tapering methods in a published systematic review using the Template for Intervention Description and Replication (TIDieR) checklist. METHOD A secondary analysis was conducted of studies included in a Cochrane systematic review that examined the effectiveness of approaches for discontinuing long-term antidepressant use. The completeness of reporting of antidepressant tapering methods in included studies was independently assessed by two researchers using the 12 items from the TIDieR checklist. RESULTS Twenty-two studies were included in the analysis. None of the study reports described all checklists items. No study clearly reported what materials had been provided (item 3) or whether tailoring had occurred (item 9). With the exception of providing a name for the intervention or study procedures (item 1), only a minority of studies clearly reported on any of the remaining checklist items. CONCLUSION The findings highlight a lack of detailed reporting of antidepressant tapering methods in published trials to date. This needs to be addressed as poor reporting could hinder replication and adaptation of existing interventions, as well as the potential for successful translation of effective tapering interventions into clinical practice.
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Affiliation(s)
- Amy McGoldrick
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, D02PN40, Ireland
| | - Helen Byrne
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, D02PN40, Ireland
| | - Cathal Cadogan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, D02PN40, Ireland.
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Colman L, Delaruelle K, Bracke P, Ceuterick M. Trends in the use of benzodiazepine receptor agonists among working-age adults in Belgium from 2004 to 2018. Front Public Health 2023; 11:1191151. [PMID: 37397739 PMCID: PMC10311493 DOI: 10.3389/fpubh.2023.1191151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction The use of psychotropics, such as benzodiazepine receptor agonists (BzRAs), among working-age adults in Belgium has shown educational differences. However, it is unclear how work status plays a role in this relationship. Therefore, this research aims to investigate whether work status explains observed educational differences in BzRA use. In addition, considering medicalisation processes, where non-medical factors, such as work status, are increasingly associated with medical mental health care-seeking behavior, this research also aims to investigate whether work status explains observed educational differences in BzRA use, regardless of mental health status. Methods Data are obtained from the Belgian Health Interview Survey (BHIS). Four successive waves are covered: 2004, 2008, 2013, and 2018. The weighted data represent a sample of 18,547 Belgian respondents aged 18 to 65 years old. Poisson regression models are used to analyze the research aims. Time evolutions are plotted using marginal means postestimation. Results The average use of BzRAs shows a slight decline over the waves studied (2004 = 5.99, 2008 = 5.88, 2013 = 5.33, 2018 = 4.31). Educational and work status differences in BzRA use are observed, regardless of mental health status. Individuals with longer education report lower use compared to individuals with shorter education, and individuals who are unemployed, (pre-)retired, or sick or disabled report higher use compared to employed individuals. Furthermore, work status acts as a mediator, partially explaining educational differences in BzRA use, regardless of mental health status. Discussion Work-related uncertainty leads to increased prescribing and medication use, regardless of mental health. Medicalisation and pharmaceuticalisation processes detach social problems from their social roots and treat them as personal failures. The marginalization of the social roots of unemployment, sick leave and involuntary (pre-)retirement has led to a personalization of responsibility. Negative feelings arising from such work statuses may cause isolated, non-specific symptoms for which medical treatment is sought.
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Self-reported reasons for reducing or stopping antidepressant medications in primary care: thematic analysis of the diamond longitudinal study. Prim Health Care Res Dev 2023; 24:e16. [PMID: 36843079 PMCID: PMC9972355 DOI: 10.1017/s1463423623000038] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023] Open
Abstract
BACKGROUND Current treatment guidelines advise that the deprescribing of antidepressants should occur around 6 months post-remission of symptoms. However, this is not routinely occurring in clinical practice, with between 30% and 50% of antidepressant users potentially continuing treatment with no clinical benefit. To support patients to deprescribe antidepressant treatment when clinically appropriate, it is important to understand what is important to patients when making the decision to reduce or cease antidepressants in a naturalistic setting. AIM The current study aimed to describe the self-reported reasons primary care patients have for reducing or stopping their antidepressant medication. METHODS Three hundred and seven participants in the diamond longitudinal study reported taking an SSRI/SNRI over the life of the study. Of the 307, 179 reported stopping or tapering their antidepressant during computer-assisted telephone interviews and provided a reason for doing so. A collective case study approach was used to collate the reasons for stopping or tapering. FINDINGS Reflexive thematic analysis of patient-reported factors revealed five overarching themes; 1. Depression; 2. Medication; 3. Healthcare system; 4. Psychosocial, and; 5. Financial. These findings are used to inform suggestions for the development and implementation of antidepressant deprescribing discussions in clinical practice.
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Hølmkjær P, Vermehren C, Holm A, Rozing MP, Høj K, Overbeck G. Tailoring a complex intervention to reduce antidepressants in institutionalized older persons with dementia. BMC Health Serv Res 2022; 22:1582. [PMID: 36572903 PMCID: PMC9791154 DOI: 10.1186/s12913-022-08961-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 12/12/2022] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION First-line treatment for behavioral and psychiatric symptoms of dementia is non-pharmacological. Still, psychotropic medication is widely used, despite its limited effect and harmful side-effects. More than half of all nursing home residents with dementia receive antidepressants, even though deprescribing is safe and feasible. Interventions to promote deprescribing of antidepressants in nursing homes are few and complex. To optimize the deprescribing process through an intervention, transparency for the development of the intervention is needed. We aim to describe the steps in the development and tailoring of an intervention targeting GPs, nursing home staff, and relatives to enhance collaboration on reducing the use of antidepressants in institutionalized older persons with dementia in Denmark. METHOD A step-wise process guided by the core elements in the Medical Research Council constituted the tailoring process. Five steps were included; 1) a literature search, 2) interviews with stakeholders, 3) drafting the intervention prototype, 4) professionals' assessment of the intervention, and 5) refinement of the intervention. The steps were conducted from June 2020 to June 2022. RESULTS Based on the literature search, interviews with stakeholders, and professionals' assessment of the intervention, four main themes were identified; 1) focusing on antidepressants, 2) importance of professional qualifications, 3) collaboration and communication, and 4) patient and relative involvement. They guided intervention development and refinement of the final intervention, which included 1) a case-based training course and 2) a dialog tool including a symptom assessment scale to be used in a structured consultation at the nursing home. CONCLUSION This study presents a detailed account of the tailoring process for a complex intervention to optimize deprescribing of antidepressants for older persons with dementia at nursing homes. By presenting a thorough development process, we expect to achieve increased adherence to the intervention which is currently being tested in an ongoing cluster randomized controlled trial. The transparency of the process will also increase the future development of other similar complex interventions.
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Affiliation(s)
- Pernille Hølmkjær
- grid.5254.60000 0001 0674 042XDepartment of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte Vermehren
- grid.4973.90000 0004 0646 7373Department of Clinical Pharmacology, University Hospital Copenhagen, Capital Region, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XDepartment of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Anne Holm
- grid.5254.60000 0001 0674 042XDepartment of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Maarten Pieter Rozing
- grid.5254.60000 0001 0674 042XDepartment of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Høj
- grid.7048.b0000 0001 1956 2722Research Unit for General Practice, Aarhus, Denmark ,grid.154185.c0000 0004 0512 597XDepartment of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark ,grid.27530.330000 0004 0646 7349Unit of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark
| | - Gritt Overbeck
- grid.5254.60000 0001 0674 042XDepartment of Public Health, Section of General Practice and Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
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Van Leeuwen E, Anthierens S, van Driel ML, De Sutter AIM, van den Branden E, Christiaens T. General practitioners' perspectives on discontinuation of long-term antidepressants in nursing homes. Eur J Gen Pract 2022; 28:23-31. [PMID: 35350964 PMCID: PMC8973341 DOI: 10.1080/13814788.2022.2038131] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Long-term use of antidepressant drugs (AD), much longer than recommended by guidelines, in nursing homes (NH) is common. NH home residents may have a relatively higher risk of adverse events. Moreover, in an NH setting nursing staff and relatives are intensively involved in the decision-making process. In many countries, General Practitioners’ (GPs) provide care for residents in NHs. Little is known about GPs’ perspectives on discontinuation of long-term AD in NH residents. Objectives To explore GPs’ views of discontinuing long-term AD in NH residents. Methods An exploratory qualitative study, with semi-structured interviews, was conducted with a purposive sample of 20 Belgian GPs. Interviews, conducted over six months in 2019, were analysed by thematic analysis. Results Twenty interviews were conducted until data saturation. The first theme, ‘reluctance to rock the boat: not worth taking the risk’, describes that GPs perceive discontinuation as an unpredictable risk without clear benefits. GPs’ main concern was the risk of destabilising the fragile balance in an older patient. Second, ‘it takes at least three to tango’, captures the unspoken alliance between GPs, nursing staff and relatives and suggests that agreement of at least these three partners is required. The third, ‘Opening the door: triggers to discontinue’, points to severe health problems and dementia as strong facilitators for discontinuation. Conclusion Discontinuation of long-term AD in NHs is a complex process for GPs. More evidence and attention to the role nursing staff and relatives play are needed to better guide the discontinuation of AD in older NH patients.
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Affiliation(s)
- Ellen Van Leeuwen
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Gent, Belgium.,Unit General Practice Ghent University, Department of Public Health and Primary Care, Ghent University, Gent, Belgium
| | - Sibyl Anthierens
- Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Mieke L van Driel
- Unit General Practice Ghent University, Department of Public Health and Primary Care, Ghent University, Gent, Belgium.,Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - An I M De Sutter
- Unit General Practice Ghent University, Department of Public Health and Primary Care, Ghent University, Gent, Belgium
| | - Evelien van den Branden
- Unit General Practice Ghent University, Department of Public Health and Primary Care, Ghent University, Gent, Belgium
| | - Thierry Christiaens
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Gent, Belgium
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