What proportion of initially prescribed antidepressants is still being prescribed chronically after 5 years in general practice? A longitudinal cohort analysis

Patterns of antidepressant prescribing and health-related outcomes among older adults in Northern Ireland: an administrative data study

OBJECTIVES

This study identifies patterns of antidepressant prescribing and subsequent hospital admissions from 2010 to 2018 amongst older adults in Northern Ireland (NI).

METHOD

Participants comprised all General Practitioner (GP)-registered adults aged fifty-five years and above on 01/01/2010 (n = 386,119). Administrative data linkage included demographic information; antidepressant prescribing data from the NI Enhanced Prescribing Database (EPD); and hospital patient admissions. Repeated measures latent class analysis (RMLCA) identified patterns of antidepressant prescribing (from 2010 to 2018).

RESULTS

RMLCA identified four latent classes: decreasing antidepressant prescribing (5.9%); increasing antidepressant prescribing (8.0%); no-antidepressant prescribing (68.7%); and long-term antidepressant prescribing (17.5%). Compared with those in no-antidepressant prescribing class, persons in the remaining classes were more likely to be female and younger, and less likely to live in either rural areas or less-deprived areas. Compared with no-antidepressant prescribing, those with increasing antidepressant prescribing were 60% and 52% more likely to be admitted to hospital in 2019 and 2020, respectively, and their admission rate per year was 11% and 8% higher in 2019 and 2020, respectively. Similarly, those with long-term prescriptions were 70% and 67% more likely to be admitted to hospital in 2019 and 2020, respectively, and their admission rate per year was 14% and 9% higher in 2019 and 2020, respectively.

CONCLUSION

Findings show that approximately 26% of the NI hospital admissions population were impacted by sustained or increasing antidepressant prescribing. Because of their increased likelihood of hospitalization, these individuals may benefit from psychosocial support and social prescribing alternatives to psychopharmacological treatment.

Antidepressant deprescribing: State of the art and recommendations-A literature overview

INTRODUCTION

In recent years, the consumption of antidepressants has arisen. However, deprescribing antidepressant therapy is very complicated. The aim of this study was to implement practical recommendations for the development of guidelines to be used for antidepressant deprescription in clinical practice.

MATERIALS AND METHODS

The literature search has been conducted on March 13, 2023, using Scopus and PubMed databases. The following search string has been used: "antidepressants AND (deprescribing OR deprescription)". All studies reporting a deprescribing intervention for antidepressant medication, regardless of the study design, have been included. Studies that did not report antidepressant drug deprescription interventions and non-English-language papers have been excluded.

RESULTS

From the literature search, a total of 230 articles have been extracted. Applying the exclusion criteria, 26 articles have been considered eligible. Most of the analyzed studies (16, 61%) have been carried out in the real world, 3 (11%) were RCTs, 5 (19%) were qualitative studies, in particular expert opinions, 1 (4%) was a literature review, and 1 (4%) was a post-trial observational follow-up of an RCT. In 8 out of 26 studies (31%), the analyzed antidepressants have been specified: 2 (8%) focused on anticholinergics, 2 (8%) on SSRIs, 3 (11%) on tricyclic antidepressants, and 1 (4%) on esketamine. Nineteen out of 26 studies (73%) did not stratify antidepressants by therapeutic class. The sample sizes analyzed in the studies ranged from a minimum of 4 patients to a maximum of 113,909, and 12 studies included geriatric age as an inclusion criterion. A patient's therapy review has been the main deprescribing intervention, and it has been identified in 14 (54%) articles. Interventions have been carried out by clinicians in 4 (15%) studies, general practitioners in 5 (19%) studies, nurses in 2 (8%) studies, pharmacists in 4 (15%) studies, multidisciplinary teams in 10 (38%) studies, and patients in 1 (4%) study.

CONCLUSIONS

From the literature review, it emerged that there is no clear evidence useful to support clinicians in antidepressant deprescribing interventions.

Associations of antidepressant medication consumption with changes in personality pathology and quality of life among community-dwelling adults

BACKGROUND

Although antidepressant medication (ADM) has produced small advantages over pill placebo in randomized controlled trials, consuming ADM has predicted prospectively increasing depressive symptom severity in samples of community-dwelling adults.

OBJECTIVE

We extended the community literature by testing ADM's relations to changes in personality and quality of life that may underpin depression.

METHOD

In this longitudinal, observational study, community-dwelling adults (N = 601) were assessed twice, 8 months apart on average. Assessments included depressive symptoms, personality, life satisfaction and quality, and prescription medication consumption.

RESULTS

Consuming ADM at time 1 predicted relative increases in depressive symptoms (dysphoria), maladaptive traits (negative affect, negative temperament, disinhibition, low conscientiousness), personality dysfunction (non-coping, self-pathology), and decreases in life satisfaction and quality from time 1 to 2, before and after adjustment for age, gender, race, income, education, physical health problems, and use of other psychotropics. In no analysis did ADM use predict better outcomes.

CONCLUSION

Among community-dwelling adults, ADM use is a risk factor for psychosocial deterioration in domains including depressive symptoms, personality pathology, and quality of life. Until mechanisms connecting ADM to poor outcomes in community samples are understood, additional caution in use of ADM and consideration of empirically supported non-pharmacologic treatments is prudent.

Antidepressants and Risk of Liver Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Previous results regarding the association between the antidepressants use and risk of liver cancer are controversial.

OBJECTIVE

This study aimed to assess whether antidepressants use increases liver cancer risk.

METHODS

We systematically searched several English and Chinese databases, including the Cochrane Library, MEDLINE, Embase, PsycINFO, Web of Science, CNKI, CQVIP database, Wanfang database, and SinoMed, and 3 clinical trial registration platforms through May 2022. Observational studies evaluating liver cancer risk in patients on antidepressants use were included, and the quality of studies was assessed using the Newcastle-Ottawa scale. A random-effects model was used to calculate the pooled effect estimates and 95% confidence intervals (CIs).

RESULTS

We included 11 studies with a total of 132 396 liver cancer cases. The meta-relative risk (RR) for liver cancer associated with antidepressants use was 0.72 (95% CI 0.59-0.86). In subgroup analyses, only selective serotonin reuptake inhibitors were negatively correlated with risk of liver cancer (RR 0.64, 95% CI 0.51-0.79); both dose subgroups ≤365cDDD (RR 0.77, 95% CI 0.69-0.85) and >365cDDD (RR 0.57, 95% CI 0.40-0.81) were associated with lower liver cancer risk; only in patients with chronic viral hepatitis, the use of antidepressants reduced liver cancer risk (RR 0.70, 95% CI 0.54-0.90).

CONCLUSIONS AND RELEVANCE

The result of the current meta-analysis shows antidepressants use is not associated with increased risk of liver cancer and appears to be correlated with decreased risk. However, the observed association needs to be verified by more powerful evidence from prospective, methodologically rigorous studies.

Prevalence, trends, and individual patterns of long-term antidepressant medication use in the adult Swiss general population

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.

Prepandemic psychotropic drug status in Portugal: a nationwide pharmacoepidemiological profile

The prescription of psychotropic drugs has been rising in Europe over the last decade. This study provides a comprehensive profile of prepandemic consumption patterns of antidepressant, antipsychotic, and anxiolytic drugs in Portugal considering full nationwide psychotropic drug prescription and dispensing records (2016-2019) against several criteria, including active ingredient, sociodemographics, medical specialty, and incurred costs. An increase of 29.6% and 34.7% in the consumption of antipsychotics and antidepressants between 2016 and 2019 is highlighted, accompanied by an increase of 37M Eur in total expenditure (> 20M Eur in public copay) for these classes of drugs. Disparities in sociodemographic and geographical incidence are identified. Amongst other pivotal results, 64% of psychotropic drug prescriptions are undertaken by general practitioners, while only 21% undertaken by neurological and psychiatric specialties. Nationwide patterns of psychotropic drug prescription further reveal notable trends and determinants, establishing a reference point for cross-regional studies and being currently assessed at a national level to establish psychosocial initiatives and guidelines for medical practice and training.

Endocrine disease history and the risk of postpartum depression

BACKGROUND

Previous research has suggested that some women are at increased risk of postpartum depression (PPD) because of an extra sensitivity to fluctuating hormones before and after parturition. This may particularly apply to women with endocrine disease, characterised by a less than optimal capability to self-regulate the hormonal feedback system.

AIMS

To investigate if women with endocrine disease history are at increased risk of developing PPD.

METHOD

Based on information from Danish national registers, this nationwide cohort study included 888 989 deliveries (1995-2018). Endocrine disease history was defined as thyroid disease, pre-pregnancy diabetes, polycystic ovary syndrome and/or previous gestational diabetes within 10 years before pregnancy start. PPD was defined as use of antidepressants and/or hospital contact for depression within 6 months after childbirth.

RESULTS

Among 888 989 deliveries, 4.1% had a history of endocrine disease and 0.5% had a PPD episode. Overall, women with an endocrine disease history had a 42% (risk ratio 1.42, 95% CI 1.24-1.62) higher risk of PPD when compared with women with no endocrine disease. However, we also found the reverse association, whereby women with a PPD history had a 50% (hazard ratio 1.5, 95% CI 1.4-1.6) higher risk of endocrine disease when compared with women with no PPD history.

CONCLUSIONS

Women with endocrine disease history had a 40% higher risk of PPD compared with women with no endocrine disease. More attention should be given to pregnant women with endocrine disease history to increase awareness of early signs of PPD. The bi-directionality of the association points to a common underlying factor.

Self-reported reasons for reducing or stopping antidepressant medications in primary care: thematic analysis of the diamond longitudinal study

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.

The burden of disease of fatal and non-fatal burn injuries for the full spectrum of care in the Netherlands

BACKGROUND

A comprehensive overview of the burden of disease of burns for the full spectrum of care is not available. Therefore, we estimated the burden of disease of burns for the full spectrum in the Netherlands in 2018, and explored whether the burden of disease changed over the past 5 years (2014-2018).

METHODS

Data were collected at four levels: general practice, emergency department, hospital, and mortality data. For each level, years lived with disability (YLD), years of life lost (YLL), and disability-adjusted life-years (DALY) were estimated using a tailored methodology.

RESULTS

Burns resulted in a total of 9278 DALYs in the Netherlands in 2018, comprising of 7385 YLDs (80%) and 1892 YLLs (20%). Burn patients who visited the general practice contributed most DALYs (64%), followed by deceased burn patients (20%), burn patients admitted to hospital (14%) and those treated at the emergency department (2%). The burden of disease was comparable in both sexes (4734 DALYs (51%) for females; 4544 DALYs (49%) for males), though the distribution of DALYs by level of care varied; females contributed more DALYs at the general practice level, and males at all other levels of care. Among children boys 0-4 years had the highest burden of disease (784 DALYs (9%)), and among adults, females 18-34 years old (1319 DALYs (14.2%)) had the highest burden of disease. Between 2014 and 2018 there was a marginal increase of 0.8% in the number of DALYs.

CONCLUSIONS

Burns cause a substantial burden of disease, with burns requiring care at the general practice level contributing most DALYs. Information on burden of burns by the full level of care as well as by subgroup is important for the development of tailored burn prevention strategies, and the updated figures are recommended to be used for priority setting and resource allocation.

Outcomes of hyperbolic tapering of antidepressants

Background

In patients attempting to discontinue their antidepressant medication, there have been no prospective studies on patterns of withdrawal as a function of the rate of antidepressant reduction during the tapering trajectory, and moderators thereof.

Objective

To investigate withdrawal as a function of gradual dose reduction.

Design

Prospective cohort study.

Methods

The sampling frame consisted of 3956 individuals in the Netherlands who received an antidepressant tapering strip between 19 May 2019 and 22 March 2022 in routine clinical practice. Of these, 608 patients, majorly with previous unsuccessful attempts to stop, provided daily ratings of withdrawal in the context of reducing their antidepressant medications (mostly venlafaxine or paroxetine), using hyperbolic tapering strips offering daily tiny reductions in dose.

Results

Withdrawal in daily-step hyperbolic tapering trajectories was limited, and inverse to the rate of taper. Female sex, younger age, presence of one or more risk factors and faster rate of reduction over shorter tapering trajectories were associated with more withdrawal and differential course over time. Thus, sex and age differences were less marked early in the course of the trajectory, whereas differences associated with risk factors and shorter trajectories tended to peak early in the trajectory. There was evidence that tapering in weekly larger steps (mean per-week dose reduction: 33.4% of previous dose), in comparison with daily tiny steps (mean per-day dose reduction: 4.5% of previous dose or 25.3% per week), was associated with more withdrawal in trajectories of 1, 2 or 3 months, particularly for paroxetine and the group of other (non-paroxetine, non-venlafaxine) antidepressants.

Conclusion

Antidepressant hyperbolic tapering is associated with limited, rate-dependent withdrawal that is inverse to the rate of taper. The demonstration of multiple demographic, risk and complex temporal moderators in time series of withdrawal data indicates that antidepressant tapering in clinical practice requires a personalised process of shared decision making over the entire course of the tapering period.

Prescribing behavior of antidepressants for depressive disorders: A systematic review

Objective

Guidelines for the prescription of antidepressants for Depressive Disorders (DD) have been in place for a long time. However, there is a lack of systematic information on the prescribing behavior of antidepressants in evidence-based clinical practice in psychopharmacotherapy of depressive disorders. This may suggest a lack of implementation of clinical guidelines by clinicians. Existing literature mainly focuses on specific issues or medications. To provide general information on the prescribing behavior of antidepressants for depressive disorders, a systematic review of available studies since 2013 was conducted.

Methods and materials

To ensure a structured and systematic approach for the literature search and subsequent review process, the PRISMA guidelines for systematic reviews were followed. Major medical and health and psychological databases were used for the literature search. These included Ebsco Host, OVID, PubMed, Science Direct, Scopus, and Web of Science. The online application "Covidence" was employed to manage the titles collected and the full articles retrieved from the initial literature search. Upon finalizing the list of selected studies, data extraction was then conducted using a build-in function of the Covidence platform with the required information pre-set on a template for data extraction. The extracted information was tabulated and summarized in a table.

Results

Forty-one studies were identified after an extensive search of the literature following the PRISMA guidelines. Of these, 37 quantitative studies providing useful information were systematically reviewed and information extracted. There was a high level of heterogeneity among these studies with different foci or characteristics. Most studies were conducted in or utilized data obtained from hospital and primary healthcare settings. SSRIs were the most commonly prescribed type of antidepressant in the past decade, particularly among younger patients. Among these studies, antidepressants were mainly prescribed by psychiatrists with some by other physicians and general practitioners. This might reflect differences in legislation regarding professional requirements for prescribers or clinical practices.

Conclusions

A few themes that would be considered important in terms of the effect of prescription behavior on depression, specifically children/adolescents, special target populations, and off-label prescription. The results highlighted the need for more studies on a community-based approach and the role of GPs in the treatment of DD.

Antidepressant prescribing patterns in Australia

BACKGROUND

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (MDcpg²⁰¹⁵ and MDcpg²⁰²⁰) provide evidence-based and consensus-based recommendations for managing mood disorders.

AIMS

We examined Australian real-world prescribing habits to determine whether management in clinical practice aligned with MDcpg²⁰¹⁵ recommendations.

METHOD

A retrospective analysis of a cohort of patients ≥16 years old who had been dispensed a Pharmaceutical Benefits Scheme (PBS)-listed antidepressant between July 2013 and June 2019 was conducted using Australian Commonwealth Department of Human Services PBS 10% sample data.

RESULTS

Between July 2013 and June 2019, 239 944 patients in Australia commenced antidepressant treatment. Of these, 22% (52 694 patients) received a second treatment (a new class of treatment after a period of discontinuation or additional antipsychotic therapy) and 6% (15 741 patients) received a third treatment. Patients were initially prescribed primarily selective serotonin reuptake inhibitors (SSRIs; 52% of prescriptions) or tricyclic antidepressants (TCAs; 25%), even though TCAs are not recommended for first-line treatment. Fewer than one-quarter of patients were prescribed serotonin-noradrenaline reuptake inhibitors (13%) or other agents (10%). General practitioners (GPs) were more likely to initiate TCAs than psychiatrists (22% v. 7%).Once initiated, the overall median time patients remained on treatment was 4.5 months; this was highest with SSRIs (5.8 months) and lowest with TCAs (0.9 months).

CONCLUSIONS

First-line prescribing broadly follows guidelines. GP and psychiatrist prescribing patterns differ, perhaps reflecting different patient groups and the need to tailor treatment to individuals. Future guidelines should aim to capture the different presentations and complexity of depression.

Indications related to antidepressant prescribing in the Nivel-PCD database and the SIDIAP database

BACKGROUND

Antidepressant drug consumption has increased, mainly in the elderly. This trend could be explained by the use for indications other than depression. We aimed to describe the indications related to antidepressant drug new users in two primary care settings.

METHODS

A longitudinal study of new antidepressant users aged ≥65 was conducted, with data from the Nivel-PCD (The Netherlands) and SIDIAP (Catalonia) databases (2010-2015). As a proxy for indication, diagnoses registered around the 3 months of antidepressant prescribing were collected. Indications were classified in seven categories and an additional one of non-selected indications. The percentage and incidence calculated over the total population registered was described.

RESULTS

A total of 16,537 and 199,168 new antidepressant users were identified in the Nivel-PCD and SIDIAP databases, respectively (women aged 65-69 were the most prevalent). Depression was the most frequent indication (24.0% and 31.3%), followed by anxiety (12.5% and 19.5%) and sleep disorders (10.2% and 26.4%). Tricyclic antidepressants were the most commonly prescribed in Nivel-PCD (48.7%), mainly associated with neuropathic pain, and selective serotonin reuptake inhibitor antidepressants in SIDIAP (63.1%), associated with depression. The non-selected indications category showed an upward trend in the Nivel-PCD database while in the SIDIAP database it decreased.

LIMITATIONS

It is not mandatory for physicians to register a diagnosis with each prescription.

CONCLUSIONS

Depression was the most common prescribing indication in The Netherlands and Spain, followed by anxiety and sleep disorders. The most commonly prescribed antidepressant differed between the countries and is likely explained by differences in local guidelines.

Exploration of GP perspectives on deprescribing antidepressants: a qualitative study

OBJECTIVE

Our aim was to explore general practitioners' (GPs) perceptions and experiences of discontinuing antidepressants.

STUDY DESIGN

A qualitative study using semistructured interviews was undertaken between July 2019 and March 2020. The interviews were transcribed and analysed using a thematic analysis framework.

SETTING

GPs affiliated with a university education and research network for general practice in Ireland.

PARTICIPANTS

A purposive sample of GPs (n=10).

RESULTS

Five themes emerged: shared decision-making; personalised therapy; medication-tapering toolkit; health service factors and concerns around tapering. GPs described being less likely to engage in deprescribing for patients with long-term and/or recurrent depression, older patients and those with comorbidities due to fear of relapse. Access to evidence-based psychological therapies, guidelines, information on rates of relapse, patient leaflets on discontinuing antidepressants and reminder prompts on GP-prescribing software were suggested to optimise appropriate antidepressant discontinuation. There was some suggestion that patients may use antidepressants for longer when talk therapy is not available or taken up.

CONCLUSIONS

GPs are largely confident in their role of managing mild-to-moderate depression and deprescribing antidepressants. This study provides an insight into factors that influence GPs' decisions to deprescribe antidepressants. More information on rates of relapse after discontinuation would be helpful to inform decision-making.

Use of sequence analysis for classifying individual antidepressant trajectories to monitor population mental health

BACKGROUND

Over the past decade, antidepressant prescriptions have increased in European countries and the United States, partly due to an increase in the number of new cases of mental illness. This paper demonstrates an innovative approach to the classification of population level change in mental health status, using administrative data for a large sample of the Scottish population. We aimed to identify groups of individuals with similar patterns of change in pattern of prescribing, validate these groups by comparison with other indicators of mental illness, and characterise the population most at risk of increasing mental ill health.

METHODS

National Health Service (NHS) prescription data were linked to the Scottish Longitudinal Study (SLS), a 5.3% sample of the Scottish population (N = 151,418). Antidepressant prescription status over the previous 6 months was recorded for every month for which data were available (January 2009-December 2014), and sequence dissimilarity was computed by optimal matching. Hierarchical clustering was used to create groups of participants who had similar patterns of change, with multi-level logistic regression used to understand group membership.

RESULTS

Five distinct prescription pattern groups were observed, indicating: no prescriptions (76%), occasional prescriptions (10%), continuation of prior use of prescriptions (8%), a new course of prescriptions started (4%) or ceased taking prescriptions (3%). Young, white, female participants, of low social grade, residing in socially deprived neighbourhoods, living alone, being separated/divorced or out of the labour force, were more likely to be in the group that started a new course of antidepressant prescriptions.

CONCLUSIONS

The use of sequence analysis for classifying individual antidepressant trajectories offers a novel approach for capturing population-level changes in mental health risk. By classifying individuals into groups based on their anti-depressant medication use we can better identify how over time, mental health is associated with individual risk factors and contextual factors at the local level and the macro political and economic scale.

How effective are antidepressants for depression over the long term? A critical review of relapse prevention trials and the issue of withdrawal confounding

The aim of this article is to discuss the validity of relapse prevention trials and the issue of withdrawal confounding in these trials. Recommendations for long-term antidepressant treatment are based almost exclusively on discontinuation trials. In these relapse prevention trials, participants with remitted depression are randomised either to have the antidepressant abruptly discontinued and replaced by inert placebo or to continue active treatment. The drug-placebo difference in relapse rates at the end of the maintenance phase is then interpreted as a prophylactic drug effect. These trials consistently produce remarkable benefits for maintenance treatment. However, the internal validity of this trial protocol is compromised, as research has shown that abruptly stopping antidepressants can cause severe withdrawal reactions that lead to (or manifest as) depression relapses. That is, there is substantial withdrawal confounding in discontinuation trials, which renders their findings uninterpretable. It is not clear to what degree the drug-placebo separation in relapse prevention (discontinuation) trials is due to withdrawal reactions, but various estimations suggest that it is presumably the majority. A review of findings based on other methodologies, including real-world long-term effectiveness trials like STAR*D and various naturalistic cohort studies, do not indicate that antidepressants have considerable prophylactic effects. As absence of evidence does not imply evidence of absence, no definitive conclusions can be drawn from the literature. To enable a thorough risk-benefit evaluation, real-world effectiveness trials should not only focus on relapse prevention, but also assess antidepressants' long-term effects on social functioning and quality of life. Thus far, reliable long-term data on these outcome domains are lacking.

Protracted withdrawal syndrome after stopping antidepressants: a descriptive quantitative analysis of consumer narratives from a large internet forum

BACKGROUND

Protracted withdrawal syndrome (PWS) after stopping antidepressants (frequently also referred to as post-acute withdrawal syndrome or PAWS) has been described in a few case reports. However, a detailed quantitative analysis of specific symptom manifestations in antidepressant PWS is still lacking.

METHODS

We extracted patient narratives from a large English-language internet forum SurvivingAntidepressants.org, a peer support site concerned about withdrawal from antidepressants. PWS was ascertained based on diagnostic criteria proposed by Chouinard and Chouinard, specifically ⩾6 months of continuous antidepressant use, with emergence of new and/or more intense symptoms after discontinuation that last beyond the initial 6 weeks of acute withdrawal. We assessed medication history, outcome of PWS, and the prevalence of specific symptoms.

RESULTS

In total, n = 69 individual reports of protracted withdrawal were selected for analysis. At time of the subjects' most recent reports, duration of PWS ranged from 5 to 166 months, mean = 37 months, median = 26 months. Length of time on the antidepressant causing protracted withdrawal ranged from 6 to 278 months, mean = 96 months, and median = 79 months. Throughout the withdrawal experience, affective symptoms, mostly anxiety, depression, emerging suicidality and agitation, were reported by 81%. Somatic symptoms, mostly headache, fatigue, dizziness, brain zaps, visual changes, muscle aches, tremor, diarrhea, and nausea were reported by 75%. Sleep problems (44%) and cognitive impairments (32%) were mentioned less frequently. These broad symptom domains were largely uncorrelated.

CONCLUSION

PWS or PAWS from antidepressants can be severe and long-lasting, and its manifestations clinically heterogeneous. Long-term antidepressant exposure may cause multiple body system impairments. Although both somatic and affective symptoms are frequent, they are mostly unrelated in terms of occurrence. Proper recognition and detection of PWS thus requires a comprehensive assessment of medication history, duration of the withdrawal syndrome, and its various somatic, affective, sleep, and cognitive symptoms.

Barriers to discontinuing antidepressants in patients with depressive and anxiety disorders: a review of the literature and clinical recommendations

Use of antidepressants has recently increased, mainly caused by the increase of long-term users. Although evidence-based indications for long-term use are lacking, it is assumed that long-term use is unnecessary or undesirable in some patients. Perceived barriers to discontinuing antidepressants contribute to unnecessary or undesirable long-term use. Identifying barriers prior to, during and following discontinuation may enable strategies to overcome them. This narrative review summarises relevant qualitative and quantitative articles on perceived barriers to discontinuing antidepressants and provides recommendations for clinical practice. We can conclude that implications for clinical practice are diverse and the most important barriers experienced by patients and physicians include the fear of relapse or recurrence, insufficient evaluation and monitoring, withdrawal symptoms, and actual relapse or recurrence.

Symptoms of anxiety and depression and risk of atrial fibrillation-The HUNT study

BACKGROUND

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. Anxiety and depression may activate the autonomic nervous system which is likely to play an important role in the etiology of AF. However, little is known about the association between symptoms of anxiety and depression and risk of AF.

OBJECTIVE

This study aimed to assess the association between symptoms of anxiety and depression and risk of AF.

METHODS

In a population-based study, 37,402 adult residents were followed for incident AF from 2006 to 2008 until 2015. Participants were classified according to data on anxiety and depression symptoms. Cox proportional regression models were used to adjust for common AF risk factors.

RESULTS

During a median follow-up of 8.1 years, 1433 (3.8%) participants developed AF. In comparisons with no anxiety symptoms, the multivariable-adjusted hazard ratios (HRs) were 1.1 (95% CI: 0.9-1.5) for mild to moderate anxiety symptoms and 1.0 (95% CI: 0.8-1.4) for severe anxiety symptoms. In comparisons with no depression symptoms, the multivariable-adjusted HRs were 1.5 (95% CI: 1.2-1.8) for mild to moderate depression symptoms and 0.9 (95% CI: 0.6-1.3) for severe depression symptoms. Recurrent anxiety/depression symptoms were not associated with increased AF risk.

CONCLUSIONS

In this large, population-based study, we found no evidence of an association between symptoms of anxiety or severe depression and AF risk, even for recurrent anxiety or depression symptoms. An unexpected association of symptoms of mild to moderate depression with increased AF risk requires confirmation in other studies. Our findings add to the sparse literature on symptoms of anxiety and depression and risk of AF.