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Kendrick T, Stuart B, Bowers H, Haji Sadeghi M, Page H, Dowrick C, Moore M, Gabbay M, Leydon GM, Yao GL, Little P, Griffiths G, Lewis G, May C, Moncrieff J, Johnson CF, Macleod U, Gilbody S, Dewar-Haggart R, Williams S, O’Brien W, Tiwari R, Woods C, Patel T, Khan N, van Ginneken N, Din A, Reidy C, Lucier R, Palmer B, Becque T, van Leeuwen E, Zhu S, Geraghty AWA. Internet and Telephone Support for Discontinuing Long-Term Antidepressants: The REDUCE Cluster Randomized Trial. JAMA Netw Open 2024; 7:e2418383. [PMID: 38913372 PMCID: PMC11197448 DOI: 10.1001/jamanetworkopen.2024.18383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 04/18/2024] [Indexed: 06/25/2024] Open
Abstract
Importance There is significant concern regarding increasing long-term antidepressant treatment for depression beyond an evidence-based duration. Objective To determine whether adding internet and telephone support to a family practitioner review to consider discontinuing long-term antidepressant treatment is safe and more effective than a practitioner review alone. Design, Setting, and Participants In this cluster randomized clinical trial, 131 UK family practices were randomized between December 1, 2018, and March 31, 2022, with remote computerized allocation and 12 months of follow-up. Participants and researchers were aware of allocation, but analysis was blind. Participants were adults who were receiving antidepressants for more than 1 year for a first episode of depression or more than 2 years for recurrent depression who were currently well enough to consider discontinuation and wished to do so and who were at low risk of relapse. Of 6725 patients mailed invitations, 330 (4.9%) were eligible and consented. Interventions Internet and telephone self-management support, codesigned and coproduced with patients and practitioners. Main Outcomes and Measures The primary (safety) outcome was depression at 6 months (prespecified complete-case analysis), testing for noninferiority of the intervention to under 2 points on the 9-item Patient Health Questionnaire (PHQ-9). Secondary outcomes (testing for superiority) were antidepressant discontinuation, anxiety, quality of life, antidepressant withdrawal symptoms, mental well-being, enablement, satisfaction, use of health care services, and adverse events. Analyses for the main outcomes were performed on a complete-case basis, and multiple imputation sensitivity analysis was performed on an intention-to-treat basis. Results Of 330 participants recruited (325 eligible for inclusion; 178 in intervention practices and 147 in control practices; mean [SD] age at baseline, 54.0 [14.9] years; 223 women [68.6%]), 276 (83.6%) were followed up at 6 months, and 240 (72.7%) at 12 months. The intervention proved noninferior; mean (SD) PHQ-9 scores at 6 months were slightly lower in the intervention arm than in the control arm in the complete-case analysis (4.0 [4.3] vs 5.0 [4.7]; adjusted difference, -1.1; 95% CI, -2.1 to -0.1; P = .03) but not significantly different in an intention-to-treat multiple imputation sensitivity analysis (adjusted difference, -0.9 (95% CI, -1.9 to 0.1; P = .08). By 6 months, antidepressants had been discontinued by 66 of 145 intervention arm participants (45.5%) who provided discontinuation data and 54 of 129 control arm participants (41.9%) (adjusted odds ratio, 1.02; 95% CI, 0.52-1.99; P = .96). In the intervention arm, antidepressant withdrawal symptoms were less severe, and mental well-being was better compared with the control arm; differences were small but significant. There were no significant differences in the other outcomes; 28 of 179 intervention arm participants (15.6%) and 22 of 151 control arm participants (14.6%) experienced adverse events. Conclusions and Relevance In this cluster randomized clinical trial of adding internet and telephone support to a practitioner review for possible antidepressant discontinuation, depression was slightly better with support, but the rate of discontinuation of antidepressants did not significantly increase. Improvements in antidepressant withdrawal symptoms and mental well-being were also small. There were no significant harms. Family practitioner review for possible discontinuation of antidepressants appeared safe and effective for more than 40% of patients willing and well enough to discontinue. Trial Registration ISRCTN registry Identifiers: ISRCTN15036829 (internal pilot trial) and ISRCTN12417565 (main trial).
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Affiliation(s)
- Tony Kendrick
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Beth Stuart
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Faculty of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Hannah Bowers
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Mahboobeh Haji Sadeghi
- Institute for Clinical and Applied Health Research, Hull-York Medical School, University of Hull, Hull, United Kingdom
| | - Helen Page
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom
| | - Christopher Dowrick
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom
| | - Michael Moore
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Mark Gabbay
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom
| | - Geraldine M. Leydon
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Guiqing Lily Yao
- Leicester Clinical Trials Unit, University of Leicester, Leicester, United Kingdom
| | - Paul Little
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton and University Hospital Southampton National Health Service (NHS) Foundation Trust, Southampton, United Kingdom
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, United Kingdom
| | - Carl May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joanna Moncrieff
- Division of Psychiatry, University College London, London, United Kingdom
| | - Chris F. Johnson
- Primary Care Pharmacy Services, NHS Greater Glasgow & Clyde, Glasgow, United Kingdom
| | - Una Macleod
- Institute for Clinical and Applied Health Research, Hull-York Medical School, University of Hull, Hull, United Kingdom
| | - Simon Gilbody
- Mental Health & Addiction Research Group, Department of Health Sciences, University of York, York, United Kingdom
| | - Rachel Dewar-Haggart
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Samantha Williams
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Wendy O’Brien
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Riya Tiwari
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Catherine Woods
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Tasneem Patel
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom
| | - Naila Khan
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom
| | - Nadja van Ginneken
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom
| | - Amy Din
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Claire Reidy
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Rebecca Lucier
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Bryan Palmer
- Patient and Public Contributor, Southampton, United Kingdom
| | - Taeko Becque
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Ellen van Leeuwen
- Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Shihua Zhu
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
- Community and Health Research Unit, School of Health & Social Care, University of Lincoln, Lincoln, United Kingdom
| | - Adam W. A. Geraghty
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
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