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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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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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Gao M, Kirk M, Lash E, Knight H, Michalopoulou M, Guess N, Browning M, Weich S, Burnet P, Jebb SA, Stevens R, Aveyard P. Evaluating the efficacy and mechanisms of a ketogenic diet as adjunctive treatment for people with treatment-resistant depression: A protocol for a randomised controlled trial. J Psychiatr Res 2024; 174:230-236. [PMID: 38653031 DOI: 10.1016/j.jpsychires.2024.04.023] [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: 02/05/2024] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND One-third of people with depression do not respond to antidepressants, and, after two adequate courses of antidepressants, are classified as having treatment-resistant depression (TRD). Some case reports suggest that ketogenic diets (KDs) may improve some mental illnesses, and preclinical data indicate that KDs can influence brain reward signalling, anhedonia, cortisol, and gut microbiome which are associated with depression. To date, no trials have examined the clinical effect of a KD on TRD. METHODS This is a proof-of-concept randomised controlled trial to investigate the efficacy of a six-week programme of weekly dietitian counselling plus provision of KD meals, compared with an intervention involving similar dietetic contact time and promoting a healthy diet with increased vegetable consumption and reduction in saturated fat, plus food vouchers to purchase healthier items. At 12 weeks we will assess whether participants have continued to follow the assigned diet. The primary outcome is the difference between groups in the change in Patient Health Questionnaire-9 (PHQ-9) score from baseline to 6 weeks. PHQ-9 will be measured at weeks 2, 4, 6 and 12. The secondary outcomes are the differences between groups in the change in remission of depression, change in anxiety score, functioning ability, quality of life, cognitive performance, reward sensitivity, and anhedonia from baseline to 6 and 12 weeks. We will also assess whether changes in reward sensitivity, anhedonia, cortisol awakening response and gut microbiome may explain any changes in depression severity. DISCUSSION This study will test whether a ketogenic diet is an effective intervention to reduce the severity of depression, anxiety and improve quality of life and functioning ability for people with treatment-resistant depression.
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Affiliation(s)
- Min Gao
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; NIHR Oxford Health Biomedical Research Centre, Warneford Hospital, Oxford, UK.
| | - Megan Kirk
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; NIHR Oxford Health Biomedical Research Centre, Warneford Hospital, Oxford, UK
| | - Eva Lash
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; NIHR Oxford Health Biomedical Research Centre, Warneford Hospital, Oxford, UK
| | - Heather Knight
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Moscho Michalopoulou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicola Guess
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Michael Browning
- Department of Psychiatry, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
| | - Scott Weich
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Philip Burnet
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Susan A Jebb
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; NIHR Oxford Health Biomedical Research Centre, Warneford Hospital, Oxford, UK; NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; NIHR Oxford Health Biomedical Research Centre, Warneford Hospital, Oxford, UK; NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
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Brisnik V, Vukas J, Jung-Sievers C, Lukaschek K, Alexander GC, Thiem U, Thürmann P, Schüle C, Fischer S, Baum E, Drey M, Harder S, Niebling W, Janka U, Krause O, Gensichen J, Dreischulte T. Deprescribing of antidepressants: development of indicators of high-risk and overprescribing using the RAND/UCLA Appropriateness Method. BMC Med 2024; 22:193. [PMID: 38735930 PMCID: PMC11089726 DOI: 10.1186/s12916-024-03397-w] [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: 10/12/2023] [Accepted: 04/18/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Antidepressants are first-line medications for many psychiatric disorders. However, their widespread long-term use in some indications (e.g., mild depression and insomnia) is concerning. Particularly in older adults with comorbidities and polypharmacy, who are more susceptible to adverse drug reactions, the risks and benefits of treatment should be regularly reviewed. The aim of this consensus process was to identify explicit criteria of potentially inappropriate antidepressant use (indicators) in order to support primary care clinicians in identifying situations, where deprescribing of antidepressants should be considered. METHODS We used the RAND/UCLA Appropriateness Method to identify the indicators of high-risk and overprescribing of antidepressants. We combined a structured literature review with a 3-round expert panel, with results discussed in moderated meetings in between rounds. Each of the 282 candidate indicators was scored on a 9-point Likert scale representing the necessity of a critical review of antidepressant continuation (1-3 = not necessary; 4-6 = uncertain; 7-9 = clearly necessary). Experts rated the indicators for the necessity of review, since decisions to deprescribe require considerations of patient risk/benefit balance and preferences. Indicators with a median necessity rating of ≥ 7 without disagreement after 3 rating rounds were accepted. RESULTS The expert panel comprised 2 general practitioners, 2 clinical pharmacologists, 1 gerontopsychiatrist, 2 psychiatrists, and 3 internists/geriatricians (total N = 10). After 3 assessment rounds, there was consensus for 37 indicators of high-risk and 25 indicators of overprescribing, where critical reviews were felt to be necessary. High-risk prescribing indicators included settings posing risks of drug-drug, drug-disease, and drug-age interactions or the occurrence of adverse drug reactions. Indicators with the highest ratings included those suggesting the possibility of cardiovascular risks (QTc prolongation), delirium, gastrointestinal bleeding, and liver injury in specific patient subgroups with additional risk factors. Overprescribing indicators target patients with long treatment durations for depression, anxiety, and insomnia as well as high doses for pain and insomnia. CONCLUSIONS Explicit indicators of antidepressant high-risk and overprescribing may be used directly by patients and health care providers, and integrated within clinical decision support tools, in order to improve the overall risk/benefit balance of this commonly prescribed class of prescription drugs.
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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 - GrK 2621), 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 - GrK 2621), Munich, Germany
| | - Caroline Jung-Sievers
- Graduate Program "POKAL - Predictors and Outcomes in Primary Care Depression Care", (DFG - GrK 2621), Munich, Germany
- Institute of Medical Data Processing, Biometrics and Epidemiology (IBE), Faculty of Medicine, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, 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 - GrK 2621), Munich, Germany
| | - G Caleb Alexander
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ulrich Thiem
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Geriatrics, Albertinen-Haus, Hamburg, Germany
| | - Petra Thürmann
- Chair of Clinical Pharmacology, Faculty of Health, Department of Medicine, University Witten/Herdecke, Witten, Germany
- Philipp Klee-Institute of Clinical Pharmacology, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - Cornelius Schüle
- Department of Psychiatry and Psychotherapy, LMU University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Fischer
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany
- Psychiatric Services Lucerne, Lucerne, Switzerland
| | - Erika Baum
- Institute of General Practice and Family Medicine, Philipps University Marburg, Marburg, Germany
| | - Michael Drey
- Department of Medicine IV, Geriatrics, LMU University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Harder
- Institute for Clinical Pharmacology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | - Wilhelm Niebling
- Department of Medicine, Division of General Practice, Medical Center, University of Freiburg, Freiburg, Germany
| | - Ulrike Janka
- Department of Psychiatry and Psychotherapy, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Olaf Krause
- Institute of General Practice and Palliative Medicine, Medical School Hannover, Hannover, 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 - GrK 2621), Munich, Germany
| | - 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 - GrK 2621), Munich, Germany.
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Duffy L, Lewis G, Marston L, Kendrick T, Kessler D, Moore M, Wiles N, Lewis G. Clinical factors associated with relapse in depression in a sample of UK primary care patients who have been on long-term antidepressant treatment. Psychol Med 2024; 54:951-961. [PMID: 37753652 DOI: 10.1017/s0033291723002659] [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] [Indexed: 09/28/2023]
Abstract
BACKGROUND This paper investigates whether age of onset of depression, duration of the last episode, number of episodes, and residual symptoms of depression and anxiety are associated with depression relapse in primary care patients who have been on long-term maintenance antidepressant treatment and no longer meet ICD10 criteria for depression. METHODS An observational cohort using data from ANTLER (N = 478), a double-blind placebo-controlled trial. The primary outcome was time to relapse using the retrospective CIS-R. Participants were followed for 12 months. RESULTS Primary outcome was available for 468 participants. Time to relapse in those with more than five previous episodes of depression was shorter, hazard ratio (HR) 1.84 (95% confidence interval [CI] 1.23-2.75) compared to people with two episodes; HR 1.57 (95% CI 1.01-2.43) after adjustment. The residual symptoms of depression at baseline were also associated with increased relapse: HR 1.05 (95% CI 1.01-1.09) and HR 1.06 (95% CI 1.01-1.12) in the adjusted model. There was evidence of reduced rate of relapse in older age of onset group: HR 0.86 (95% CI 0.78-0.95); HR attenuated after adjustment HR 0.91 (95% CI 0.81-1.02). There was no evidence of an association between duration of the current episode and residual anxiety symptoms with relapse. CONCLUSIONS The number of previous episodes and residual symptoms of depression were associated with increased likelihood of relapse. These factors could inform joint decision making when patients are considering tapering off maintenance antidepressant treatment or considering other treatments to prevent relapse.
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Affiliation(s)
- Larisa Duffy
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London W1 T 7NF, UK
| | - Gemma Lewis
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London W1 T 7NF, UK
| | - Louise Marston
- Research Dept. of Primary Care and Population Health, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
- Priment Clinical Trials Unit, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Tony Kendrick
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - David Kessler
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Moore
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - Nicola Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London W1 T 7NF, UK
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Kamp CB, Petersen JJ, Faltermeier P, Juul S, Siddiqui F, Barbateskovic M, Kristensen AT, Moncrieff J, Horowitz MA, Hengartner MP, Kirsch I, Gluud C, Jakobsen JC. Beneficial and harmful effects of tricyclic antidepressants for adults with major depressive disorder: a systematic review with meta-analysis and trial sequential analysis. BMJ MENTAL HEALTH 2024; 27:e300730. [PMID: 39093721 PMCID: PMC10806869 DOI: 10.1136/bmjment-2023-300730] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 12/11/2023] [Indexed: 08/04/2024]
Abstract
QUESTION Tricyclic antidepressants are used to treat depression worldwide, but the adverse effects have not been systematically assessed. Our objective was to assess the beneficial and harmful effects of all tricyclic antidepressants for adults with major depressive disorder. STUDY SELECTION AND ANALYSIS We conducted a systematic review with meta-analysis and trial sequential analysis. We searched CENTRAL, MEDLINE, Embase, LILACS and other sources from inception to January 2023 for randomised clinical trials comparing tricyclic antidepressants versus placebo or 'active placebo' for adults with major depressive disorder. The primary outcomes were depressive symptoms measured on the 17-item Hamilton Depression Rating Scale (HDRS-17), serious adverse events and quality of life. The minimal important difference was defined as three points on the HDRS-17. FINDINGS We included 103 trials randomising 10 590 participants. All results were at high risk of bias, and the certainty of the evidence was very low or low. All trials only assessed outcomes at the end of the treatment period at a maximum of 12 weeks after randomisation. Meta-analysis and trial sequential analysis showed evidence of a beneficial effect of tricyclic antidepressants compared with placebo (mean difference -3.77 HDRS-17 points; 95% CI -5.91 to -1.63; 17 trials). Meta-analysis showed evidence of a harmful effect of tricyclic antidepressants compared with placebo on serious adverse events (OR 2.78; 95% CI 2.18 to 3.55; 35 trials), but the required information size was not reached. Only 2 out of 103 trials reported on quality of life and t-tests showed no evidence of a difference. CONCLUSIONS The long-term effects of tricyclic antidepressants and the effects on quality of life are unknown. Short-term results suggest that tricyclic antidepressants may reduce depressive symptoms while also increasing the risks of serious adverse events, but these results were based on low and very low certainty evidence. PROSPERO REGISTRATION NUMBER CRD42021226161.
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Affiliation(s)
- Caroline Barkholt Kamp
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Johanne Juul Petersen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Pascal Faltermeier
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- MSH Medical School Hamburg, University of Applied Sciences and Medical University, Hamburg, Germany
| | - Sophie Juul
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Psychotherapeutic Center Stolpegård, Gentofte, Denmark
| | - Faiza Siddiqui
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | | | - Joanna Moncrieff
- Division of Psychiatry, University College London (honorary for MAH), London, UK
- Department of Research and Development, North East London NHS Foundation Trust, London, UK
| | - Mark Abie Horowitz
- Division of Psychiatry, University College London (honorary for MAH), London, UK
- Department of Research and Development, North East London NHS Foundation Trust, London, UK
| | | | - Irving Kirsch
- Program in Placebo Studies, Harvard Medical School, Boston, Massachusetts, USA
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Huijbers MJ, Wentink C, Lucassen PL, Kramers C, Akkermans R, Spijker J, Speckens AE. Supporting antidepressant discontinuation using mindfulness plus monitoring versus monitoring alone: A cluster randomized trial in general practice. PLoS One 2023; 18:e0290965. [PMID: 37669281 PMCID: PMC10479886 DOI: 10.1371/journal.pone.0290965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 08/17/2023] [Indexed: 09/07/2023] Open
Abstract
Discontinuing antidepressant medication (ADM) can be challenging for patients and clinicians. In the current study we investigated if Mindfulness-Based Cognitive Therapy (MBCT) added to supported protocolized discontinuation (SPD) is more effective than SPD alone to help patients discontinue ADM. This study describes a prospective, cluster-randomized controlled trial (completed). From 151 invited primary care practices in the Netherlands, 36 (24%) were willing to participate and randomly allocated to SPD+MBCT (k = 20) or SPD (k = 16). Adults using ADM > 9 months were invited by GPs to discuss tapering, followed by either MBCT+SPD, or SPD alone. Exclusion criteria included current psychiatric treatment; substance use disorder; non-psychiatric indication for ADM; attended MBCT within past 5 years; cognitive barriers. From the approximately 3000 invited patients, 276 responded, 119 participated in the interventions and 92 completed all assessments. All patients were offered a decision aid and a personalized tapering schedule (with GP). MBCT consisted of eight group sessions of 2.5 hours and one full day of practice. SPD was optional and consisted of consultations with a mental health assistant. Patients were assessed at baseline and 6, 9 and 12 months follow-up, non-blinded. In line with our protocol, primary outcome was full discontinuation of ADM within 6 months. Secondary outcomes were depression, anxiety, withdrawal symptoms, rumination, well-being, mindfulness skills, and self-compassion. Patients allocated to SPD + MBCT (n = 73) were not significantly more successful in discontinuing (44%) than those allocated to SPD (n = 46; 33%), OR 1.60, 95% CI 0.73 to 3.49, p = .24, number needed to treat = 9. Only 20/73 allocated to MBCT (27%) completed MBCT. No serious adverse events were reported. In conclusion, we were unable to demonstrate a significant benefit of adding MBCT to SPD to support discontinuation in general practice. Actual participation in patient-tailored interventions was low, both for practices and for patients. (Trial registration: ClinicalTrials.gov PRS ID: NCT03361514 registered December 2017).
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Affiliation(s)
- Marloes J. Huijbers
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carolien Wentink
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter L.B.J. Lucassen
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cornelis Kramers
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Reinier Akkermans
- Department of Primary and Community Care, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Spijker
- Expertise Centre for Depression, Pro Persona Nijmegen, Nijmegen, The Netherlands
| | - Anne E.M. Speckens
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
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John R, Stevie L, Mark H, Joanna M. The need for antidepressant withdrawal support services: Recommendations from 708 patients. Psychiatry Res 2023; 326:115303. [PMID: 37364505 DOI: 10.1016/j.psychres.2023.115303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/09/2023] [Accepted: 06/10/2023] [Indexed: 06/28/2023]
Abstract
Approximately half of the tens of millions of people currently taking antidepressants will experience withdrawal symptoms when they try to reduce or come off them. Nearly half of these describe their symptoms as severe in surveys. Many prescribing doctors seem ill-informed and unprepared to provide effective discontinuation advice and support, often misdiagnosing withdrawal as a relapse of depression or anxiety. 708 members of online support groups for people on antidepressants, from 31 countries, completed a sentence in an online survey: 'A public health service to help people come off antidepressants should include ................'. Two independent researchers categorised their responses into themes, and then reached consensus via discussion. Seven themes emerged: 'Prescriber Role', 'Information', 'Other Supports/Services', 'Strong Negative Feelings re Doctors/Services etc.', Informed Consent When Prescribed', 'Drug Companies' and: 'Public Health Campaign'. The most frequently mentioned requirements of the Prescriber Role were that prescribers be properly informed, provide small doses/liquid/tapering strips, develop a withdrawal plan and believe patients about their withdrawal experiences. The most frequently recommended other services were psychotherapy/counselling, support groups, patient led/informed services, nutrition advice, 24-hour crisis support and 'holistic/lifestyle' approaches. Many respondents were angry about how uninformed their doctors were and how they had been treated.
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Affiliation(s)
- Read John
- School of Psychology, University of East London, London, UK.
| | - Lewis Stevie
- Unaffiliated Researcher, Lived Experience of Prescribed Drug Dependence, Cardiff, UK
| | - Horowitz Mark
- Mental Health Sciences Unit, University College London, London, UK
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9
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Read J, Moncrieff J, Horowitz MA. Designing withdrawal support services for antidepressant users: Patients' views on existing services and what they really need. J Psychiatr Res 2023; 161:298-306. [PMID: 36989904 DOI: 10.1016/j.jpsychires.2023.03.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/20/2023] [Accepted: 03/07/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Public Health England has recommended that services be put in place to support people who choose to withdraw from antidepressants because of a current gap. This study aims to explore the views of members of online withdrawal peer-support groups about existing healthcare and what additional support is needed. METHODS The administrators of 15 online support groups for people stopping antidepressants were asked to advertise an online survey to their members. The survey, which was online from May 2021 to April 2022, was completed by 1276 people from 49 countries. RESULTS 71% of respondents found their doctors' advice unhelpful (57% 'very unhelpful') regarding stopping an antidepressant; the main reasons being 'Recommended a reduction rate that was too quick for me', 'Not familiar enough with withdrawal symptoms to advise me' and 'Suggested stopping antidepressants would not cause withdrawal symptoms'. One in three did not seek advice from their prescriber when deciding whether to withdraw, with the main reasons being 'I felt they would not be supportive' (58%) and 'I felt that they didn't have the expertise to help me' (51%). The most common prescriber responses to those who did seek advice was 'Suggested a quick withdrawal schedule' (56%) and 'Not supportive and offered no guidance' (27%). The most common discontinuation periods recommended by doctors were one month (23%) and two weeks (19%). A range of potential professional services were rated 'very useful', most frequently: 'Access to smaller doses (e.g. tapering strips, liquid, smaller dose tablets) to ensure gradual reduction' (88%) and 'A health professional providing a personalised, flexible reduction plan' (79%). LIMITATIONS This was a convenience sample, which may have been biased towards people who took longer to withdraw, and experienced more withdrawal symptoms, than antidepressant users in general. Black and ethnic minority people, and people without access to the internet, were underrepresented. CONCLUSIONS Most participants reported their prescribers were unable to help them safely stop antidepressants, compelling them to turn to online peer-support groups instead. Our findings indicate, in keeping with previous studies, that clinicians require upskilling in safe tapering of antidepressants, and that patients need specialised services to help them stop safely.
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Affiliation(s)
- John Read
- School of Psychology, University of East London, London, UK
| | - Joanna Moncrieff
- Department of Psychiatry, University College London, London, UK(1); Goodmayes Hospital, North East London NHS Foundation Trust, London, UK.
| | - Mark Abie Horowitz
- Department of Psychiatry, University College London, London, UK(1); Goodmayes Hospital, North East London NHS Foundation Trust, London, UK
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10
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Palmer EG, Sornalingam S, Page L, Cooper M. Withdrawing from SSRI antidepressants: advice for primary care. Br J Gen Pract 2023; 73:138-140. [PMID: 36823051 PMCID: PMC9976819 DOI: 10.3399/bjgp23x732273] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 12/14/2022] [Indexed: 02/25/2023] Open
Affiliation(s)
- Emilia G Palmer
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton
| | - Sangeetha Sornalingam
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton
| | - Lisa Page
- Brighton & Sussex Medical School & Sussex Partnership NHS Foundation Trust, Brighton
| | - Maxwell Cooper
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton
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11
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Horowitz MA, Framer A, Hengartner MP, Sørensen A, Taylor D. Estimating Risk of Antidepressant Withdrawal from a Review of Published Data. CNS Drugs 2023; 37:143-157. [PMID: 36513909 PMCID: PMC9911477 DOI: 10.1007/s40263-022-00960-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 12/15/2022]
Abstract
Adaptation of the brain to the presence of a drug predicts withdrawal on cessation. The outcome of adaptation is often referred to as 'physical dependence' in pharmacology, as distinct from addiction, although these terms have unfortunately become conflated in some diagnostic guides. Physical dependence to antidepressants may occur in some patients, consistent with the fact that some patients experience withdrawal effects from these medications. It is thought that longer duration of use, higher dose and specific antidepressants affect the risk of antidepressant withdrawal effects as they might cause greater adaptation of the brain. We searched PubMed for relevant systematic reviews and other relevant analyses to summarise existing data on determinants of antidepressant withdrawal incidence, severity and duration. Overall, data were limited. From survey data, increased duration of use was associated with an increased incidence and severity of withdrawal effects, consistent with some evidence from data provided by drug manufacturers. Duration of use may be related to duration of withdrawal effects but data are heterogenous and sparse. Serotonin and noradrenaline reuptake inhibitors and paroxetine are associated with higher risks than other antidepressants, though data for some antidepressants are lacking. Higher doses of antidepressant has some weak association with an increased risk of withdrawal, with some ceiling effects, perhaps reflecting receptor occupancy relationships. Past experience of withdrawal effects is known to predict future risk. Based on these data, we outline a preliminary rubric for determining the risk of withdrawal symptoms for a particular patient, which may have relevance for determining tapering rates. Given the limited scope of the current research, future research should aim to clarify prediction of antidepressant withdrawal risk, especially by examining the risk of withdrawal in long-term users of medication, as well as the severity and duration of effects, to improve the preliminary tool for predictive purposes. Further research into the precise adaptations in long-term antidepressant use may improve the ability to predict withdrawal effects for a particular patient.
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Affiliation(s)
- Mark Abie Horowitz
- North East London NHS Foundation Trust, Goodmayes Hospital, Ilford, UK. .,Division of Psychiatry, University College London (Honorary), Maple House, 149 Tottenham Court Rd, Fitzrovia, London, W1T 7BN, UK.
| | - Adele Framer
- SurvivingAntidepressants.org, San Francisco, CA USA
| | - Michael P. Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences, Zurich, Switzerland
| | - Anders Sørensen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - David Taylor
- South London and Maudsley NHS Foundation Trust, London, UK ,Institute of Pharmaceutical Science, King’s College London, London, UK
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12
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Bansal N, Hudda M, Payne RA, Smith DJ, Kessler D, Wiles N. Antidepressant use and risk of adverse outcomes: population-based cohort study. BJPsych Open 2022; 8:e164. [PMID: 36097725 PMCID: PMC9534882 DOI: 10.1192/bjo.2022.563] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Antidepressants are one of the most widely prescribed drugs in the global north. However, little is known about the health consequences of long-term treatment. AIMS This study aimed to investigate the association between antidepressant use and adverse events. METHOD The study cohort consisted of UK Biobank participants whose data was linked to primary care records (N = 222 121). We assessed the association between antidepressant use by drug class (selective serotonin reuptake inhibitors (SSRIs) and 'other') and four morbidity (diabetes, hypertension, coronary heart disease (CHD), cerebrovascular disease (CV)) and two mortality (cardiovascular disease (CVD) and all-cause) outcomes, using Cox's proportional hazards model at 5- and 10-year follow-up. RESULTS SSRI treatment was associated with decreased risk of diabetes at 5 years (hazard ratio 0.64, 95% CI 0.49-0.83) and 10 years (hazard ratio 0.68, 95% CI 0.53-0.87), and hypertension at 10 years (hazard ratio 0.77, 95% CI 0.66-0.89). At 10-year follow-up, SSRI treatment was associated with increased risks of CV (hazard ratio 1.34, 95% CI 1.02-1.77), CVD mortality (hazard ratio 1.87, 95% CI 1.38-2.53) and all-cause mortality (hazard ratio 1.73, 95% CI 1.48-2.03), and 'other' class treatment was associated with increased risk of CHD (hazard ratio 1.99, 95% CI 1.31-3.01), CVD (hazard ratio 1.86, 95% CI 1.10-3.15) and all-cause mortality (hazard ratio 2.20, 95% CI 1.71-2.84). CONCLUSIONS Our findings indicate an association between long-term antidepressant usage and elevated risks of CHD, CVD mortality and all-cause mortality. Further research is needed to assess whether the observed associations are causal, and elucidate the underlying mechanisms.
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Affiliation(s)
- Narinder Bansal
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Mohammed Hudda
- Population Health Research Institute, St George's, University of London, UK
| | - Rupert A Payne
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Daniel J Smith
- Centre for Clinical Brain Sciences, University of Edinburgh, Royal Edinburgh Hospital, UK
| | - David Kessler
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Nicola Wiles
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, UK
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13
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Horowitz MA, Taylor D. Distinguishing relapse from antidepressant withdrawal: clinical practice and antidepressant discontinuation studies. BJPSYCH ADVANCES 2022. [DOI: 10.1192/bja.2021.62] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SUMMARY
We now recognise that withdrawal symptoms from antidepressants are common, and can be severe and long-lasting in some people. Many withdrawal symptoms overlap with symptoms of anxiety or depression, making it difficult to distinguish withdrawal from relapse. We describe how their onset soon after dose reduction, the association of psychological with physical symptoms, their prompt response to reinstatement, and their typical ‘wave’ pattern of onset, peak and resolution can help distinguish withdrawal symptoms from relapse. We also examine evidence that suggests that antidepressant withdrawal symptoms are misdiagnosed as relapse in discontinuation studies aimed at demonstrating the ability of antidepressants to prevent future relapse (relapse prevention properties). In these discontinuation studies people have their antidepressants stopped abruptly, or rapidly, making withdrawal symptoms very likely, and little effort is made to measure withdrawal symptoms or distinguish them from relapse. We conclude that there is currently no robust evidence for the relapse prevention properties of antidepressants, and current guidance might need to be re-evaluated.
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14
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Jannini TB, Lorenzo GD, Bianciardi E, Niolu C, Toscano M, Ciocca G, Jannini EA, Siracusano A. Off-label Uses of Selective Serotonin Reuptake Inhibitors (SSRIs). Curr Neuropharmacol 2022; 20:693-712. [PMID: 33998993 PMCID: PMC9878961 DOI: 10.2174/1570159x19666210517150418] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/22/2021] [Accepted: 05/05/2021] [Indexed: 11/22/2022] Open
Abstract
Psychiatric drugs have primacy for off-label prescribing. Among those, selective serotonin reuptake inhibitors (SSRIs) are highly versatile and, therefore, widely prescribed. Moreover, they are commonly considered as having a better safety profile compared to other antidepressants. Thus, when it comes to off-label prescribing, SSRIs rank among the top positions. In this review, we present the state of the art of off-label applications of selective serotonin reuptake inhibitors, ranging from migraine prophylaxis to SARS-CoV-2 antiviral properties. Research on SSRIs provided significant evidence in the treatment of premature ejaculation, both with the on-label dapoxetine 30 mg and the off-label paroxetine 20 mg. However, other than a serotoninergic syndrome, serious conditions like increased bleeding rates, hyponatremia, hepatoxicity, and post-SSRIs sexual dysfunctions, are consistently more prominent when using such compounds. These insidious side effects might be frequently underestimated during common clinical practice, especially by nonpsychiatrists. Thus, some points must be addressed when using SSRIs. Among these, a psychiatric evaluation before every administration that falls outside the regulatory agencies-approved guidelines has to be considered mandatory. For these reasons, we aim with the present article to identify the risks of inappropriate uses and to advocate the need to actively boost research encouraging future clinical trials on this topic.
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Affiliation(s)
- Tommaso B. Jannini
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giorgio D. Lorenzo
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy;,IRCCS-Fondazione Santa Lucia, Rome, Italy
| | | | - Cinzia Niolu
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Massimiliano Toscano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy;,Department of Neurology, Fatebenefratelli Hospital, Isola Tiberina, Rome, Italy
| | - Giacomo Ciocca
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome, Italy
| | | | - Alberto Siracusano
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy;,Address correspondence to this author at the Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy; E-mail:
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15
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Van Leeuwen E, Anthierens S, van Driel ML, De Sutter A, De Beir R, Christiaens T. Should I, can I, dare I? Patients' view on stopping long-term antidepressant use, a qualitative study. Acta Clin Belg 2022; 77:962-969. [PMID: 35007191 DOI: 10.1080/17843286.2021.2024384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND AIM The rise in long-term antidepressant use is concerning. Long-term antidepressant (AD) use, much longer than recommended by guidelines, can result in risk of adverse events and generate unnecessary costs. In order to mitigate these risks, patients views about their antidepressants and how to discontinue need to be taken into account. We aimed to explore patients' experiences and views of discontinuing long-term AD, barriers and facilitators of discontinuation and required support. METHODS Semi-structured face to face interviews were conducted with 14 patients with long-term AD use in primary care. Interviews were analysed thematically. RESULTS Participants describe various perceptions about discontinuation. There is fear of returning to their depression, even in those who were ambivalent about the effectiveness and safety of AD continuation. Participants describe low confidence in their own coping resources, fear of stress, and previous negative experiences with stopping. This enhances their perception of AD dependence. Participants indicate the importance of the support of their GP and their social network to help them withdraw. CONCLUSION Discontinuation of long-term antidepressants is a complex issue for patients. More awareness of the lack of evidence and the potential risks of long-term AD continuation is required. By raising the issue and offering support during discontinuation GPs can help their patients stop AD. A greater focus on non-pharmacological approaches of depression in primary care is needed to reduce unnecessary AD use.
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Affiliation(s)
- Ellen Van Leeuwen
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
- Unit General Practice Ghent University, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Sibyl Anthierens
- Department of Family Medicine & Population Health (FAMPOP), 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, Ghent, Belgium
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - An De Sutter
- Unit General Practice Ghent University, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Rani De Beir
- Huisartsenpraktijk Eureka, General Practice “Van Poucke”, Belgium
- Ghent University: Universiteit Gent, Belgium
| | - Thierry Christiaens
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
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16
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Johnson CF, Maxwell M, Williams B, Dougall N, MacGillivray S. Dose-response effects of selective serotonin reuptake inhibitor monotherapy for the treatment of depression: systematic review of reviews and meta-narrative synthesis. BMJ MEDICINE 2022; 1:e000017. [PMID: 36936596 PMCID: PMC9978765 DOI: 10.1136/bmjmed-2021-000017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/05/2022] [Indexed: 12/04/2022]
Abstract
Objective To assess and clarify the relations between selective serotonin reuptake inhibitor (SSRI) dose efficacy, acceptability (early treatment discontinuation (dropouts)), and tolerability (reported adverse drug effects), and critically evaluate methods previously used to examine SSRI dose-response effects for the treatment of depression in adults. Design Systematic review of reviews and meta-narrative synthesis. Data sources Embase, Medline, PsycINFO, Scopus, and the Cochrane Collaboration library, from 1975 to December 2021. Reference lists of national depression treatment guidelines were systemically searched by hand. Eligibility criteria for selecting studies Reviews assessing SSRI monotherapy dose-response effects for the treatment of depression in adults (age ≥18 years) reporting efficacy, acceptability, or tolerability. Reviews meeting inclusion criteria had a high degree of heterogeneity, due to methodological diversity; therefore, a meta-narrative synthesis approach was applied. Standard daily doses were defined as 20 mg citalopram, fluoxetine, paroxetine; 50 mg sertraline; and 10 mg escitalopram. Risk of bias was assessed using the Risk of Bias in Systematic Reviews tool, in line with Cochrane recommendations. Results The search identified 9138 records; 387 full text reports were assessed for eligibility, 42 of which matched the inclusion criteria. The majority, 83% (n=35), of reviews included data for studies with a duration of ≤12 weeks (ie, the acute phase of depression treatment). Of 39 reviews assessing efficacy, the majority (n=26) indicated that individual SSRIs and SSRI class demonstrated flat dose-response effects; standard doses were optimal for efficacy. Acceptability or tolerability were assessed in 28 reviews. Higher than standard daily doses were associated with higher dropout rates and a greater incidence of adverse drug effects (eg, nausea, sexual dysfunction, fatigue, anxiety). Despite a range of methods being reported, there was an overall consensus regarding SSRI dose related efficacy, dropouts, and adverse drug effects. Conclusion Standard daily doses of SSRIs for the treatment of depression in adults provide a favourable balance between efficacy, acceptability, and tolerability. Patients are encouraged to talk to their prescriber or community pharmacist if they experience adverse effects or have any concerns about their drug treatments.
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Affiliation(s)
- Chris F Johnson
- Pharmacy Services, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Margaret Maxwell
- Midwifery and AHP Research Unit, University of Stirling, Stirling, UK
| | - Brian Williams
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Nadine Dougall
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
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17
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Ellen VL, Anthierens S, van Driel ML, Sutter AD, van den Branden E, Christiaens T. 'Never change a winning team': GPs' perspectives on discontinuation of long-term antidepressants. Scand J Prim Health Care 2021; 39:533-542. [PMID: 34895003 PMCID: PMC8725864 DOI: 10.1080/02813432.2021.2006487] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 09/01/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Long-term antidepressant use, much longer than recommended by guidelines, can harm patients and generate unnecessary costs. Most antidepressants are prescribed by general practitioners (GPs) but it remains unclear why they do not discontinue long-term use. AIM To explore GPs' views and experiences of discontinuing long-term antidepressants, barriers and facilitators of discontinuation and required support. DESIGN AND SETTING Qualitative study in Belgian GPs. METHOD 20 semi-structured face-to-face interviews with GPs. Interviews were analysed thematically. RESULTS The first theme, 'Success stories' describes three strong motivators to discontinue antidepressants: patient health issues, patient requests and a new positive life event. Second, not all GPs consider long-term antidepressant use a 'problem' as they perceive antidepressants as effective and safe. GPs' main concern is the risk of relapse. Third, GPs foresee that discontinuation of antidepressants is not an easy and straightforward process. GPs weigh up whether they have the necessary skills and whether it is worth the effort to start this process. CONCLUSION Discontinuation of long-term antidepressants is a difficult and uncertain process for GPs, especially in the absence of a facilitating life-event or patient demand. The absence of a compelling need for discontinuation and fear of relapse of symptoms in a stable patient are important barriers for GPs when considering discontinuation. In order to increase GPs' motivation to discontinue long-term antidepressants, more emphasis on the futility of the actual effect and on potential harms related to long-term use is needed.KEY POINTSCurrent awareness:Long-term antidepressant use, much longer than recommended by guidelines, can harm patients and generate unnecessary costs.Main statements: • Discontinuation of long-term antidepressants is a difficult and uncertain process for GPs. • More emphasis on the futility of the actual effect of antidepressants and on potential harms related to long-term use is needed.
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Affiliation(s)
- Van Leeuwen Ellen
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Sibyl Anthierens
- Family Medicine and Population, Health University of Antwerp, Antwerp, Belgium
| | - Mieke L. van Driel
- Faculty of Medicine, Primary Care Clinical Unit, University of Queensland, Brisbane, Australia
| | - An De Sutter
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | | | - Thierry Christiaens
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
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18
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Duffy L, Clarke CS, Lewis G, Marston L, Freemantle N, Gilbody S, Hunter R, Kendrick T, Kessler D, King M, Lanham P, Mangin D, Moore M, Nazareth I, Wiles N, Bacon F, Bird M, Brabyn S, Burns A, Donkor Y, Hunt A, Pervin J, Lewis G. Antidepressant medication to prevent depression relapse in primary care: the ANTLER RCT. Health Technol Assess 2021; 25:1-62. [PMID: 34842135 DOI: 10.3310/hta25690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There has been a steady increase in the number of primary care patients receiving long-term maintenance antidepressant treatment, despite limited evidence of a benefit of this treatment beyond 8 months. OBJECTIVE The ANTidepressants to prevent reLapse in dEpRession (ANTLER) trial investigated the clinical effectiveness and cost-effectiveness of antidepressant medication in preventing relapse in UK primary care. DESIGN This was a Phase IV, double-blind, pragmatic, multisite, individually randomised parallel-group controlled trial, with follow-up at 6, 12, 26, 39 and 52 weeks. Participants were randomised using minimisation on centre, type of antidepressant and baseline depressive symptom score above or below the median using Clinical Interview Schedule - Revised (two categories). Statisticians were blind to allocation for the outcome analyses. SETTING General practices in London, Bristol, Southampton and York. PARTICIPANTS Individuals aged 18-74 years who had experienced at least two episodes of depression and had been taking antidepressants for ≥ 9 months but felt well enough to consider stopping their medication. Those who met an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis of depression or with other psychiatric conditions were excluded. INTERVENTION At baseline, participants were taking citalopram 20 mg, sertraline 100 mg, fluoxetine 20 mg or mirtazapine 30 mg. They were randomised to either remain on their current medication or discontinue medication after a tapering period. MAIN OUTCOME MEASURES The primary outcome was the time, in weeks, to the beginning of the first depressive episode after randomisation. This was measured by a retrospective Clinical Interview Schedule - Revised that assessed the onset of a depressive episode in the previous 12 weeks, and was conducted at 12, 26, 39 and 52 weeks. The depression-related resource use was collected over 12 months from medical records and patient-completed questionnaires. Quality-adjusted life-years were calculated using the EuroQol-5 Dimensions, five-level version. RESULTS Between 9 March 2017 and 1 March 2019, we randomised 238 participants to antidepressant continuation (the maintenance group) and 240 participants to antidepressant discontinuation (the discontinuation group). The time to relapse of depression was shorter in the discontinuation group, with a hazard ratio of 2.06 (95% confidence interval 1.56 to 2.70; p < 0.0001). By 52 weeks, relapse was experienced by 39% of those who continued antidepressants and 56% of those who discontinued antidepressants. The secondary analysis revealed that people who discontinued experienced more withdrawal symptoms than those who remained on medication, with the largest difference at 12 weeks. In the discontinuation group, 37% (95% confidence interval 28% to 45%) of participants remained on their randomised medication until the end of the trial. In total, 39% (95% confidence interval 32% to 45%) of participants in the discontinuation group returned to their original antidepressant compared with 20% (95% confidence interval 15% to 25%) of participants in maintenance group. The health economic evaluation demonstrated that participants randomised to discontinuation had worse utility scores at 3 months (-0.037, 95% confidence interval -0.059 to -0.015) and fewer quality-adjusted life-years over 12 months (-0.019, 95% confidence interval -0.035 to -0.003) than those randomised to continuation. The discontinuation pathway, besides giving worse outcomes, also cost more [extra £2.71 per patient over 12 months (95% confidence interval -£36.10 to £37.07)] than the continuation pathway, although the cost difference was not significant. CONCLUSIONS Patients who discontinue long-term maintenance antidepressants in primary care are at increased risk of relapse and withdrawal symptoms. However, a substantial proportion of patients can discontinue antidepressants without relapse. Our findings will give patients and clinicians an estimate of the likely benefits and harms of stopping long-term maintenance antidepressants and improve shared decision-making. The participants may not have been representative of all people on long-term maintenance treatment and we could study only a restricted range of antidepressants and doses. Identifying patients who will not relapse if they discontinued antidepressants would be clinically important. TRIAL REGISTRATION Current Controlled Trials ISRCTN15969819 and EudraCT 2015-004210-26. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 69. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Larisa Duffy
- Division of Psychiatry, University College London, London, UK
| | - Caroline S Clarke
- Research Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Gemma Lewis
- Division of Psychiatry, University College London, London, UK
| | - Louise Marston
- Research Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Nick Freemantle
- PRIMENT Clinical Trials Unit, University College London, London, UK.,Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Simon Gilbody
- Department of Health and Social Care Sciences, University of York, York, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Tony Kendrick
- Primary Care Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - David Kessler
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael King
- Research Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Paul Lanham
- Division of Psychiatry, University College London, London, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada.,Department of General Practice, University of Otago, Christchurch, New Zealand
| | - Michael Moore
- Primary Care Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Irwin Nazareth
- Research Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Nicola Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Faye Bacon
- Division of Psychiatry, University College London, London, UK
| | - Molly Bird
- Division of Psychiatry, University College London, London, UK
| | - Sally Brabyn
- Department of Health and Social Care Sciences, University of York, York, UK
| | - Alison Burns
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Yvonne Donkor
- Division of Psychiatry, University College London, London, UK
| | - Anna Hunt
- Primary Care Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Jodi Pervin
- Department of Health and Social Care Sciences, University of York, York, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, UK
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19
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Coe A, Kaylor-Hughes C, Fletcher S, Murray E, Gunn J. Deprescribing intervention activities mapped to guiding principles for use in general practice: a scoping review. BMJ Open 2021; 11:e052547. [PMID: 34489296 PMCID: PMC8422486 DOI: 10.1136/bmjopen-2021-052547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To identify and characterise activities for deprescribing used in general practice and to map the identified activities to pioneering principles of deprescribing. SETTING Primary care. DATA SOURCES Medline, EMBASE (Ovid), CINAHL, Australian New Zealand Clinical Trials Registry (ANZCTR), Clinicaltrials.gov, ISRCTN registry, OpenGrey, Annals of Family Medicine, BMC Family Practice, Family Practice and British Journal of General Practice (BJGP) from inception to the end of June 2021. STUDY SELECTION Included studies were original research (randomised controlled trial, quasi-experimental, cohort study, qualitative and case studies), protocol papers and protocol registrations. DATA EXTRACTION Screening and data extraction was completed by one reviewer; 10% of the studies were independently reviewed by a second reviewer. Coding of full-text articles in NVivo was conducted and mapped to five deprescribing principles. RESULTS Fifty studies were included. The most frequently used activities were identification of appropriate patients for deprescribing (76%), patient education (50%), general practitioners (GP) education (48%), and development and use of a tapering schedule (38%). Six activities did not align with the five deprescribing principles. As such, two principles (engage practice staff in education and appropriate identification of patients, and provide feedback to staff about deprescribing occurrences within the practice) were added. CONCLUSION Activities and guiding principles for deprescribing should be paired together to provide an accessible and comprehensive guide to deprescribing by GPs. The addition of two principles suggests that practice staff and practice management teams may play an instrumental role in sustaining deprescribing processes within clinical practice. Future research is required to determine the most of effective activities to use within each principle and by whom.
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Affiliation(s)
- Amy Coe
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Susan Fletcher
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Murray
- Primary Care and Population Health, University College London, London, UK
| | - Jane Gunn
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
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20
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Bowers H, Kendrick T, van Ginneken N, Glowacka M, Williams S, Leydon GM, May C, Dowrick C, Moncrieff J, Johnson CF, Moore M, Laine R, Geraghty AWA. A Digital Intervention for Primary Care Practitioners to Support Antidepressant Discontinuation (Advisor for Health Professionals): Development Study. J Med Internet Res 2021; 23:e25537. [PMID: 34269688 PMCID: PMC8325079 DOI: 10.2196/25537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/22/2021] [Accepted: 04/27/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The number of people receiving antidepressants has increased in the past 3 decades, mainly because of people staying on them longer. However, in many cases long-term treatment is not evidence based and risks increasing side effects. Additionally, prompting general practitioners (GPs) to review medication does not improve the rate of appropriate discontinuation. Therefore, GPs and other health professionals may need help to support patients discontinuing antidepressants in primary care. OBJECTIVE This study aims to develop a digital intervention to support practitioners in helping patients discontinue inappropriate long-term antidepressants (as part of a wider intervention package including a patient digital intervention and patient telephone support). METHODS A prototype digital intervention called Advisor for Health Professionals (ADvisor HP) was planned and developed using theory, evidence, and a person-based approach. The following elements informed development: a literature review and qualitative synthesis, an in-depth qualitative study, the development of guiding principles for design elements, and theoretical behavioral analyses. The intervention was then optimized through think-aloud qualitative interviews with health professionals while they were using the prototype intervention. RESULTS Think-aloud qualitative interviews with 19 health professionals suggested that the digital intervention contained useful information and was readily accessible to practitioners. The development work highlighted a need for further guidance on drug tapering schedules for practitioners and clarity about who is responsible for broaching the subject of discontinuation. Practitioners highlighted the need to have information in easily and quickly accessible formats because of time constraints in day-to-day practice. Some GPs felt that some information was already known to them but understood why this was included. Practitioners differed in their ideas about how they would use ADvisor HP in practice, with some preferring to read the resource in its entirety and others wanting to dip in and out as needed. Changes were made to the wording and structure of the intervention in response to the feedback provided. CONCLUSIONS ADvisor HP is a digital intervention that has been developed using theory, evidence, and a person-based approach. The optimization work suggests that practitioners may find this tool to be useful in supporting the reduction of long-term antidepressant use. Further quantitative and qualitative evaluation through a randomized controlled trial is needed to examine the feasibility, effectiveness, and cost-effectiveness of the intervention.
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Affiliation(s)
- Hannah Bowers
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Tony Kendrick
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Nadja van Ginneken
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom
| | - Marta Glowacka
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, United Kingdom
| | - Samantha Williams
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Geraldine M Leydon
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Carl May
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Christopher Dowrick
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom
| | - Joanna Moncrieff
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, United Kingdom
| | - Chris F Johnson
- Pharmacy & Prescribing Support Unit, Pharmacy Services, NHS Greater Glasgow & Clyde, Glasgow, United Kingdom
| | - Michael Moore
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Rebecca Laine
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Adam W A Geraghty
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
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21
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Van Leeuwen E, van Driel ML, Horowitz MA, Kendrick T, Donald M, De Sutter AI, Robertson L, Christiaens T. Approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults. Cochrane Database Syst Rev 2021; 4:CD013495. [PMID: 33886130 PMCID: PMC8092632 DOI: 10.1002/14651858.cd013495.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Depression and anxiety are the most frequent indication for which antidepressants are prescribed. Long-term antidepressant use is driving much of the internationally observed rise in antidepressant consumption. Surveys of antidepressant users suggest that 30% to 50% of long-term antidepressant prescriptions had no evidence-based indication. Unnecessary use of antidepressants puts people at risk of adverse events. However, high-certainty evidence is lacking regarding the effectiveness and safety of approaches to discontinuing long-term antidepressants. OBJECTIVES To assess the effectiveness and safety of approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults. SEARCH METHODS We searched all databases for randomised controlled trials (RCTs) until January 2020. SELECTION CRITERIA We included RCTs comparing approaches to discontinuation with continuation of antidepressants (or usual care) for people with depression or anxiety who are prescribed antidepressants for at least six months. Interventions included discontinuation alone (abrupt or taper), discontinuation with psychological therapy support, and discontinuation with minimal intervention. Primary outcomes were successful discontinuation rate, relapse (as defined by authors of the original study), withdrawal symptoms, and adverse events. Secondary outcomes were depressive symptoms, anxiety symptoms, quality of life, social and occupational functioning, and severity of illness. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. MAIN RESULTS We included 33 studies involving 4995 participants. Nearly all studies were conducted in a specialist mental healthcare service and included participants with recurrent depression (i.e. two or more episodes of depression prior to discontinuation). All included trials were at high risk of bias. The main limitation of the review is bias due to confounding withdrawal symptoms with symptoms of relapse of depression. Withdrawal symptoms (such as low mood, dizziness) may have an effect on almost every outcome including adverse events, quality of life, social functioning, and severity of illness. Abrupt discontinuation Thirteen studies reported abrupt discontinuation of antidepressant. Very low-certainty evidence suggests that abrupt discontinuation without psychological support may increase risk of relapse (hazard ratio (HR) 2.09, 95% confidence interval (CI) 1.59 to 2.74; 1373 participants, 10 studies) and there is insufficient evidence of its effect on adverse events (odds ratio (OR) 1.11, 95% CI 0.62 to 1.99; 1012 participants, 7 studies; I² = 37%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of abrupt discontinuation on withdrawal symptoms (1 study) is very uncertain. None of these studies included successful discontinuation rate as a primary endpoint. Discontinuation by "taper" Eighteen studies examined discontinuation by "tapering" (one week or longer). Most tapering regimens lasted four weeks or less. Very low-certainty evidence suggests that "tapered" discontinuation may lead to higher risk of relapse (HR 2.97, 95% CI 2.24 to 3.93; 1546 participants, 13 studies) with no or little difference in adverse events (OR 1.06, 95% CI 0.82 to 1.38; 1479 participants, 7 studies; I² = 0%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of discontinuation on withdrawal symptoms (1 study) is very uncertain. Discontinuation with psychological support Four studies reported discontinuation with psychological support. Very low-certainty evidence suggests that initiation of preventive cognitive therapy (PCT), or MBCT, combined with "tapering" may result in successful discontinuation rates of 40% to 75% in the discontinuation group (690 participants, 3 studies). Data from control groups in these studies were requested but are not yet available. Low-certainty evidence suggests that discontinuation combined with psychological intervention may result in no or little effect on relapse (HR 0.89, 95% CI 0.66 to 1.19; 690 participants, 3 studies) compared to continuation of antidepressants. Withdrawal symptoms were not measured. Pooling data on adverse events was not possible due to insufficient information (3 studies). Discontinuation with minimal intervention Low-certainty evidence from one study suggests that a letter to the general practitioner (GP) to review antidepressant treatment may result in no or little effect on successful discontinuation rate compared to usual care (6% versus 8%; 146 participants, 1 study) or on relapse (relapse rate 26% vs 13%; 146 participants, 1 study). No data on withdrawal symptoms nor adverse events were provided. None of the studies used low-intensity psychological interventions such as online support or a changed pharmaceutical formulation that allows tapering with low doses over several months. Insufficient data were available for the majority of people taking antidepressants in the community (i.e. those with only one or no prior episode of depression), for people aged 65 years and older, and for people taking antidepressants for anxiety. AUTHORS' CONCLUSIONS Currently, relatively few studies have focused on approaches to discontinuation of long-term antidepressants. We cannot make any firm conclusions about effects and safety of the approaches studied to date. The true effect and safety are likely to be substantially different from the data presented due to assessment of relapse of depression that is confounded by withdrawal symptoms. All other outcomes are confounded with withdrawal symptoms. Most tapering regimens were limited to four weeks or less. In the studies with rapid tapering schemes the risk of withdrawal symptoms may be similar to studies using abrupt discontinuation which may influence the effectiveness of the interventions. Nearly all data come from people with recurrent depression. There is an urgent need for trials that adequately address withdrawal confounding bias, and carefully distinguish relapse from withdrawal symptoms. Future studies should report key outcomes such as successful discontinuation rate and should include populations with one or no prior depression episodes in primary care, older people, and people taking antidepressants for anxiety and use tapering schemes longer than 4 weeks.
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Affiliation(s)
- Ellen Van Leeuwen
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Mieke L van Driel
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Mark A Horowitz
- Division of Psychiatry, University College London, London, UK
| | - Tony Kendrick
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - Maria Donald
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - An Im De Sutter
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Lindsay Robertson
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Thierry Christiaens
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
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22
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Guy A, Brown M, Lewis S, Horowitz M. The 'patient voice': patients who experience antidepressant withdrawal symptoms are often dismissed, or misdiagnosed with relapse, or a new medical condition. Ther Adv Psychopharmacol 2020; 10:2045125320967183. [PMID: 33224468 PMCID: PMC7659022 DOI: 10.1177/2045125320967183] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 09/24/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Stopping antidepressants commonly causes withdrawal symptoms, which can be severe and long-lasting. National Institute for Health and Care Excellence (NICE) guidance has been recently updated to reflect this; however, for many years withdrawal (discontinuation) symptoms were characterised as 'usually mild and self-limiting over a week'. Consequently, withdrawal symptoms might have been misdiagnosed as relapse of an underlying condition, or new onset of another medical illness, but this has never been studied. METHOD This paper outlines the themes emerging from 158 respondents to an open invitation to describe the experience of prescribed psychotropic medication withdrawal for petitions sent to British parliaments. The accounts include polypharmacy (mostly antidepressants and benzodiazepines) but we focus on antidepressants because of the relative lack of awareness about their withdrawal effects compared with benzodiazepines. Mixed method analysis was used, including a 'lean thinking' approach to evaluate common failure points. RESULTS The themes identified include: a lack of information given to patients about the risk of antidepressant withdrawal; doctors failing to recognise the symptoms of withdrawal; doctors being poorly informed about the best method of tapering prescribed medications; patients being diagnosed with relapse of the underlying condition or medical illnesses other than withdrawal; patients seeking advice outside of mainstream healthcare, including from online forums; and significant effects on functioning for those experiencing withdrawal. DISCUSSION Several points for improvement emerge: the need for updating of guidelines to help prescribers recognise antidepressant withdrawal symptoms and to improve informed consent processes; greater availability of non-pharmacological options for managing distress; greater availability of best practice for tapering medications such as antidepressants; and the vital importance of patient feedback. Although the patients captured in this analysis might represent medication withdrawal experiences that are more severe than average, they highlight the current inadequacy of health care systems to recognise and manage prescribed drug withdrawal, and patient feedback in general.
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Affiliation(s)
- Anne Guy
- Psychotherapist, Secretariat Co-ordinator for the All-Party Parliamentary Group for Prescribed Drug Dependence, Basingstoke, Hampshire, UK
| | - Marion Brown
- Retired Psychotherapist and Co-Founder of a Patient Support Group ‘Recovery and Renewal’, Helensburgh, UK
| | - Stevie Lewis
- Lived Experience of Prescribed Drug Dependence, Cardiff, UK
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23
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Kendrick T. Strategies to reduce use of antidepressants. Br J Clin Pharmacol 2020; 87:23-33. [PMID: 32656861 DOI: 10.1111/bcp.14475] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/22/2020] [Accepted: 06/29/2020] [Indexed: 01/02/2023] Open
Abstract
Antidepressant prescribing has increased year on year since the introduction of the selective serotonin reuptake inhibitors (SSRIs) in the 1980s. More than 10% of adults in England are now taking antidepressants for depression/anxiety, with a median length of treatment of more than 2 years, but antidepressants can cause side effects and withdrawal symptoms which increase with longer use. Surveys of antidepressant users suggest 30-50% have no evidence-based indication to continue, but coming off antidepressants is often difficult due to fears of relapse, withdrawal symptoms and a lack of psychological treatments to replace maintenance treatment and prevent relapse. GPs should not prescribe antidepressants routinely for mild depressive/anxiety symptoms. Patients starting antidepressants should be advised that they are to be taken for a limited period only, and that there is a risk of withdrawal problems on stopping them. Prescribers should actively review long-term antidepressant use and suggest coming off them slowly to patients who are well. The relationship between SSRI dose and serotonin transporter receptor occupancy suggests that hyperbolic tapering regimes may be helpful for patients with troubling withdrawal symptoms who cannot stop treatment within 4-8 weeks, and tapering strips can allow carefully titrated slower dose reduction over some months. Internet and telephone support to patients wanting to reduce their antidepressants is being trialled in the REDUCE programme. More research is needed to establish the incidence of withdrawal symptoms in representative samples of patients coming off antidepressants, and large randomised controlled trials are needed to test different tapering strategies.
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Affiliation(s)
- Tony Kendrick
- Primary Care, Population Sciences & Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
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24
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Kendrick T, Geraghty AWA, Bowers H, Stuart B, Leydon G, May C, Yao G, O’Brien W, Glowacka M, Holley S, Williams S, Zhu S, Dewar-Haggart R, Palmer B, Bell M, Collinson S, Fry I, Lewis G, Griffiths G, Gilbody S, Moncrieff J, Moore M, Macleod U, Little P, Dowrick C. REDUCE (Reviewing long-term antidepressant use by careful monitoring in everyday practice) internet and telephone support to people coming off long-term antidepressants: protocol for a randomised controlled trial. Trials 2020; 21:419. [PMID: 32448374 PMCID: PMC7245840 DOI: 10.1186/s13063-020-04338-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 04/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Around one in ten adults take antidepressants for depression in England, and their long-term use is increasing. Some need them to prevent relapse, but 30-50% could possibly stop them without relapsing and avoid adverse effects and complications of long-term use. However, stopping is not always easy due to withdrawal symptoms and a fear of relapse of depression. When general practitioners review patients on long-term antidepressants and recommend to those who are suitable to stop the medication, only 6-8% are able to stop. The Reviewing long-term antidepressant use by careful monitoring in everyday practice (REDUCE) research programme aims to identify safe and cost-effective ways of helping patients taking long-term antidepressants taper off treatment when appropriate. METHODS Design: REDUCE is a two-arm, 1:1 parallel group randomised controlled trial, with randomisation clustered by participating family practices. SETTING England and north Wales. POPULATION patients taking antidepressants for longer than 1 year for a first episode of depression or longer than 2 years for repeated episodes of depression who are no longer depressed and want to try to taper off their antidepressant use. INTERVENTION provision of 'ADvisor' internet programmes to general practitioners or nurse practitioners and to patients designed to support antidepressant withdrawal, plus three patient telephone calls from a psychological wellbeing practitioner. The control arm receives usual care. Blinding of patients, practitioners and researchers is not possible in an open pragmatic trial, but statistical and health economic data analysts will remain blind to allocation. OUTCOME MEASURES the primary outcome is self-reported nine-item Patient Health Questionnaire at 6 months for depressive symptoms. SECONDARY OUTCOMES depressive symptoms at other follow-up time points, anxiety, discontinuation of antidepressants, social functioning, wellbeing, enablement, quality of life, satisfaction, and use of health services for costs. SAMPLE SIZE 402 patients (201 intervention and 201 controls) from 134 general practices recruited over 15-18 months, and followed-up at 3, 6, 9 and 12 months. A qualitative process evaluation will be conducted through interviews with 15-20 patients and 15-20 practitioners in each arm to explore why the interventions were effective or not, depending on the results. DISCUSSION Helping patients reduce and stop antidepressants is often challenging for practitioners and time-consuming for very busy primary care practices. If REDUCE provides evidence showing that access to internet and telephone support enables more patients to stop treatment without increasing depression we will try to implement the intervention throughout the National Health Service, publishing practical guidance for professionals and advice for patients to follow, publicised through patient support groups. TRIAL REGISTRATION ISRCTN:12417565. Registered on 7 October 2019.
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Affiliation(s)
- Tony Kendrick
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Adam W. A. Geraghty
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Hannah Bowers
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Beth Stuart
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Geraldine Leydon
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Carl May
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Guiqing Yao
- Department of Health Sciences, University of Leicester, George Davies Centre, Leicester, UK
| | - Wendy O’Brien
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Marta Glowacka
- Department for Rehabilitation and Sport Sciences, Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK
| | - Simone Holley
- School of Psychology, Building 44 Highfield Campus, University of Southampton, Southampton, UK
| | - Samantha Williams
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Shihua Zhu
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Rachel Dewar-Haggart
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Bryan Palmer
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Margaret Bell
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Sue Collinson
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Imogen Fry
- School of Psychology, Building 44 Highfield Campus, University of Southampton, Southampton, UK
| | - Glyn Lewis
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton and University Hospitals Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, UK
| | - Simon Gilbody
- Department of Health Sciences, Seebohm Rowntree Building, University of York, York, UK
| | - Joanna Moncrieff
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Michael Moore
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Una Macleod
- Hull York Medical School, Allam Medical Building, University of Hull, Hull, UK
| | - Paul Little
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Christopher Dowrick
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
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Hengartner MP. How effective are antidepressants for depression over the long term? A critical review of relapse prevention trials and the issue of withdrawal confounding. Ther Adv Psychopharmacol 2020; 10:2045125320921694. [PMID: 32435449 PMCID: PMC7225779 DOI: 10.1177/2045125320921694] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/27/2020] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Michael P. Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences (ZHAW), PO Box 707, Zurich, CH-8037, Switzerland
- Medical Faculty, University of Zurich, Zurich, Switzerland
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Bowers HM, Kendrick T, Glowacka M, Williams S, Leydon G, May C, Dowrick C, Moncrieff J, Laine R, Nestoriuc Y, Andersson G, Geraghty AWA. Supporting antidepressant discontinuation: the development and optimisation of a digital intervention for patients in UK primary care using a theory, evidence and person-based approach. BMJ Open 2020; 10:e032312. [PMID: 32152159 PMCID: PMC7064123 DOI: 10.1136/bmjopen-2019-032312] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES We aimed to develop a digital intervention to support antidepressant discontinuation in UK primary care that is scalable, accessible, safe and feasible. In this paper, we describe the development using a theory, evidence and person-based approach. DESIGN Intervention development using a theory, evidence and person-based approach. SETTING Primary Care in the South of England. PARTICIPANTS Fifteen participants with a range of antidepressant experience took part in 'think aloud' interviews for intervention optimisation. INTERVENTION Our digital intervention prototype (called 'ADvisor') was developed on the basis of a planning phase consisting of qualitative and quantitative reviews, an in-depth qualitative study, the development of guiding principles and a theory-based behavioural analysis. Our optimisation phase consisted of 'think aloud' interviews where the intervention was iteratively refined. RESULTS The qualitative systematic review and in-depth qualitative study highlighted the centrality of fear of depression relapse as a key barrier to discontinuation. The quantitative systematic review showed that psychologically informed approaches such as cognitive-behavioural therapy were associated with greater rates of discontinuation than simple advice to reduce. Following a behavioural diagnosis based on the behaviour change wheel, social cognitive theory provided a theoretical basis for the intervention. The intervention was optimised on the basis of think aloud interviews, where participants suggested they like the flexibility of the system and found it reassuring. Changes were made to the tone of the material and the structure was adjusted based on this qualitative feedback. CONCLUSIONS 'ADvisor' is a theory, evidence and person-based digital intervention designed to support antidepressant discontinuation. The intervention was perceived as helpful and reassuring in optimisation interviews. Trials are now needed to determine the feasibility, clinical and cost-effectiveness of this approach.
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Affiliation(s)
- Hannah M Bowers
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Tony Kendrick
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Marta Glowacka
- Faculty of Health and Social Sciences, Bournemouth University, Poole, UK
| | - Samantha Williams
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Geraldine Leydon
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Carl May
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Chris Dowrick
- Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
| | - Joanna Moncrieff
- Mental Health Sciences, University College London and North East London mental health trust, London, UK
| | - Rebecca Laine
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Yvonne Nestoriuc
- Department of Psychology, Helmet Schmidt University, Hamburg, Germany
| | - Gerhard Andersson
- Department of Behavioural Sciences and Learning, Linkoping University, Linköping, Sweden
- Department of Clinical Neuroscience and Psychiatry, Karolinska Institutet, Stockholm, Sweden
| | - Adam W A Geraghty
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
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Read J. How common and severe are six withdrawal effects from, and addiction to, antidepressants? The experiences of a large international sample of patients. Addict Behav 2020; 102:106157. [PMID: 31841871 DOI: 10.1016/j.addbeh.2019.106157] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/01/2019] [Accepted: 10/05/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The incidence and severity of withdrawal effects when coming off antidepressants (ADs) have recently received considerable attention. National guidelines on the topic have proven to be inaccurate. This paper reports the largest direct-to-patient international survey on these issues. METHODS Data generated by an online survey from 867 people from 31 countries, who had taken ADs continuously for at least one month, and had tried to come off (successfully or not) was analysed. RESULTS The majority (59%) had taken ADs for more than three years. Of those who were still taking them, 29% had been doing so for at least 20 years. 61% reported some degree of withdrawal effects, and 44% of these described the effects as 'severe'. The most common of six listed withdrawal effects were anxiety/panic (66%) and irritability (62%). The most common spontaneously reported 'other' withdrawal effect was suicidality (2%). 40% reported that they felt addicted, with 39% of these describing their addiction as 'severe'. Over half (55%) reported some degree of difficulty coming off, with 27% ticking 'very difficult', and 11% 'very easy'. Duration of treatment was related to withdrawal, addiction and difficulty coming off. Younger people experienced more frequent withdrawal effects. Only six people (0.7%) recalled being told anything about withdrawal, dependence or addiction by the initial prescriber. CONCLUSIONS These findings confirm previous studies, using a range of methodologies, finding high incidences of withdrawal effects, frequently at severe levels. National guidelines, and those of professional organisations, urgently need to be updated to reflect this evidence.
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Van Leeuwen E, van Driel ML, De Sutter AIM, Anderson K, Robertson L, Christiaens T. Discontinuation of long-term antidepressant use for depressive and anxiety disorders in adults. Hippokratia 2020. [DOI: 10.1002/14651858.cd013495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Ellen Van Leeuwen
- Ghent University; Clinical Pharmacology Unit of the Department of Pharmacology; Ghent Belgium 9000
- Ghent University; Department of Family Medicine and Primary Health Care; Ghent Belgium
| | - Mieke L van Driel
- The University of Queensland; Primary Care Clinical Unit, Faculty of Medicine; Brisbane Queensland Australia 4029
| | - An IM De Sutter
- Ghent University; Department of Family Medicine and Primary Health Care; Ghent Belgium
| | - Kristen Anderson
- The University of Queensland; School of Pharmacy; Brisbane Australia
| | - Lindsay Robertson
- University of York; Cochrane Common Mental Disorders; Heslington York UK YO10 5DD
| | - Thierry Christiaens
- Ghent University; Clinical Pharmacology Unit of the Department of Pharmacology; Ghent Belgium 9000
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Hengartner MP, Schulthess L, Sorensen A, Framer A. Protracted withdrawal syndrome after stopping antidepressants: a descriptive quantitative analysis of consumer narratives from a large internet forum. Ther Adv Psychopharmacol 2020; 10:2045125320980573. [PMID: 33489088 PMCID: PMC7768871 DOI: 10.1177/2045125320980573] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/23/2020] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Michael P Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences (ZHAW), PO Box 707, Zurich, 8037, Switzerland
| | - Lukas Schulthess
- Department of Applied Psychology, Zurich University of Applied Sciences, Switzerland
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Scholten W, Batelaan N, Van Balkom A. Barriers to discontinuing antidepressants in patients with depressive and anxiety disorders: a review of the literature and clinical recommendations. Ther Adv Psychopharmacol 2020; 10:2045125320933404. [PMID: 32577215 PMCID: PMC7290254 DOI: 10.1177/2045125320933404] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 05/09/2020] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
| | - Neeltje Batelaan
- Amsterdam UMC, Vrije Universiteit, Psychiatry, Amsterdam Public Health Research Institute, The Netherlands
| | - Anton Van Balkom
- Amsterdam UMC, Vrije Universiteit, Psychiatry, Amsterdam Public Health Research Institute, The Netherlands
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31
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How do we determine whether antidepressants are useful or not? Lancet Psychiatry 2019; 6:888. [PMID: 31631865 DOI: 10.1016/s2215-0366(19)30344-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 08/07/2019] [Indexed: 12/20/2022]
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Management of treatment-resistant depression in primary care: a mixed-methods study. Br J Gen Pract 2019; 68:e673-e681. [PMID: 30249609 PMCID: PMC6145970 DOI: 10.3399/bjgp18x699053] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/23/2018] [Indexed: 11/09/2022] Open
Abstract
Background Non-response to antidepressant medication is common in primary care. Little is known about how GPs manage patients with depression that does not respond to medication. Aim To describe usual care for primary care patients with treatment-resistant depression (TRD). Design and setting Mixed-methods study using data from a UK primary care multicentre randomised controlled trial. Method In total, 235 patients with TRD randomised to continue with usual GP care were followed up at 3-month intervals for a year. Self-report data were collected on antidepressant medication, number of GP visits, and other treatments received. In addition, 14 semi-structured face-to-face interviews were conducted with a purposive sample after the 6-month follow-up and analysed thematically. Results Most patients continued on the same dose of a single antidepressant between baseline and 3 months (n = 147/186 at 3 months, 79% (95% confidence interval [CI] = 73 to 85%)). Figures were similar for later follow-ups (for example, 9–12 months: 72% (95% CI = 63 to 79%). Medication changes (increasing dose; switching to a different antidepressant; adding a second antidepressant) were uncommon. Participants described usual care mainly as taking antidepressants, with consultations focused on other (physical) health concerns. Few accessed other treatments or were referred to secondary care. Conclusion Usual care in patients with TRD mainly entailed taking antidepressants, and medication changes were uncommon. The high prevalence of physical and psychological comorbidity means that, when these patients consult, their depression may not be discussed. Strategies are needed to ensure the active management of this large group of patients whose depression does not respond to antidepressant medication.
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Releasing GP capacity with pharmacy prescribing support and New Ways of Working: a prospective observational cohort study. Br J Gen Pract 2019; 68:e735-e742. [PMID: 30249610 DOI: 10.3399/bjgp18x699137] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 06/15/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND General practice in the UK is experiencing a workforce crisis. However, it is unknown what impact prescribing support teams may have on freeing up GP capacity and time for clinical activities. AIM To release GP time by providing additional prescribing resources to support general practices between April 2016 and March 2017. DESIGN AND SETTING Prospective observational cohort study in 16 urban general practices that comprise Inverclyde Health and Social Care Partnership in Scotland. METHOD GPs recorded the time they spent dealing with special requests, immediate discharges, outpatient requests, and other prescribing issues for 2 weeks prior to the study and for two equivalent periods during the study. Specialist clinical pharmacists performed these key prescribing activities to release GP time and Read coded their activities. GP and practice staff were surveyed to assess their expectations at baseline and their experiences during the final data-collection period. Prescribing support staff were also surveyed during the study period. RESULTS GP time spent on key prescribing activities significantly reduced by 51% (79 hours, P<0.001) per week, equating to 4.9 hours (95% confidence interval = 3.4 to 6.4) per week per practice. The additional clinical pharmacist resource was well received and appreciated by GPs and practices. As well as freeing up GP capacity, practices and practitioners also identified improvements in patient safety, positive effects on staff morale, and reductions in stress. Prescribing support staff also indicated that the initiative had a positive impact on job satisfaction and was considered sustainable, although practice expectations and time constraints created new challenges. CONCLUSION Specialist clinical pharmacists are safe and effective in supporting GPs and practices with key prescribing activities in order to directly free GP capacity. However, further work is required to assess the impact of such service developments on prescribing cost-efficiency and clinical pharmacist medication review work.
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A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based? Addict Behav 2019; 97:111-121. [PMID: 30292574 DOI: 10.1016/j.addbeh.2018.08.027] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 08/24/2018] [Accepted: 08/26/2018] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The U.K.'s current National Institute for Health and Care Excellence and the American Psychiatric Association's depression guidelines state that withdrawal reactions from antidepressants are 'self-limiting' (i.e. typically resolving between 1 and 2weeks). This systematic review assesses that claim. METHODS A systematic literature review was undertaken to ascertain the incidence, severity and duration of antidepressant withdrawal reactions. We identified 24 relevant studies, with diverse methodologies and sample sizes. RESULTS Withdrawal incidence rates from 14 studies ranged from 27% to 86% with a weighted average of 56%. Four large studies of severity produced a weighted average of 46% of those experiencing antidepressant withdrawal effects endorsing the most extreme severity rating on offer. Seven of the ten very diverse studies providing data on duration contradict the U.K. and U.S.A. withdrawal guidelines in that they found that a significant proportion of people who experience withdrawal do so for more than two weeks, and that it is not uncommon for people to experience withdrawal for several months. The findings of the only four studies calculating mean duration were, for quite heterogeneous populations, 5days, 10days, 43days and 79weeks. CONCLUSIONS We recommend that U.K. and U.S.A. guidelines on antidepressant withdrawal be urgently updated as they are clearly at variance with the evidence on the incidence, severity and duration of antidepressant withdrawal, and are probably leading to the widespread misdiagnosing of withdrawal, the consequent lengthening of antidepressant use, much unnecessary antidepressant prescribing and higher rates of antidepressant prescriptions overall. We also recommend that prescribers fully inform patients about the possibility of withdrawal effects.
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Wentink C, Huijbers MJ, Lucassen P, Kramers C, Akkermans R, Adang E, Spijker J, Speckens AEM. Discontinuation of antidepressant medication in primary care supported by monitoring plus mindfulness-based cognitive therapy versus monitoring alone: design and protocol of a cluster randomized controlled trial. BMC FAMILY PRACTICE 2019; 20:105. [PMID: 31349796 PMCID: PMC6660713 DOI: 10.1186/s12875-019-0989-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 07/04/2019] [Indexed: 11/17/2022]
Abstract
Background Antidepressant use continues to rise, mainly explained by an increase in the proportion of patients receiving long term treatment. Although treatment guidelines recommend discontinuation after sustained remission, discontinuing antidepressants appears to be challenging for both patients and general practitioners (GPs). Mindfulness-Based Cognitive Therapy (MBCT) is an effective intervention that reduces the risk of relapse in recurrent depression and might facilitate discontinuation by teaching patients to cope with withdrawal symptoms and fear of relapse. The current study aims to investigate the effectiveness of the combination of Supported Protocolized Discontinuation (SPD) and MBCT in comparison with SPD alone in successful discontinuation of long-term use of antidepressants in primary care. Methods This study involves a cluster-randomized controlled trial conducted in primary care patients with long-term use antidepressants with baseline and 6, 9 and 12 months follow-up assessments. Patients choosing to discontinue their medication will be offered a combination of SPD and MBCT or SPD alone. Our primary outcome will be full discontinuation of antidepressant medication (= 0 mg) within 6 months after baseline assessment. Secondary outcome measures will be the severity of withdrawal symptoms, symptoms of depression and anxiety, psychological well-being, quality of life and medical and societal costs. Discussion In theory, stopping antidepressant medication seems straightforward. In practice however, patients and their GPs appear reluctant to initiate and accomplish this process. Both patients and professionals are in need of appropriate tools and information to better support the process of discontinuing antidepressant medication. Trial registration ClinicalTrials.gov PRS ID: NCT03361514 retrospectively registered October 2017.
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Affiliation(s)
- Carolien Wentink
- Department of Psychiatry, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Marloes J Huijbers
- Department of Psychiatry, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, the Netherlands
| | - Peter Lucassen
- Department of Primary and Community Care, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, the Netherlands
| | - Cornelis Kramers
- Department of Pharmacology and Toxicology and Department of Internal Medicine, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, the Netherlands
| | - Reinier Akkermans
- Department of Primary and Community Care, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, the Netherlands
| | - Eddy Adang
- Department for Health Evidence, Radboud University Medical Center Nijmegen, Postbus 9101, 6500 HB, Nijmegen, The Netherlands
| | - Jan Spijker
- Pro Persona Nijmegen, GGZ, Reinier Postlaan 6, 6525 GC, Nijmegen, The Netherlands
| | - Anne E M Speckens
- Department of Psychiatry, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, the Netherlands
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Bowers HM, Williams SJ, Geraghty AWA, Maund E, O'brien W, Leydon G, May CR, Kendrick T. Helping people discontinue long-term antidepressants: views of health professionals in UK primary care. BMJ Open 2019; 9:e027837. [PMID: 31278099 PMCID: PMC6615882 DOI: 10.1136/bmjopen-2018-027837] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 04/19/2019] [Accepted: 05/29/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE The aims of this paper were to identify, characterise and explain clinician factors that shape decision-making around antidepressant discontinuation in UK primary care. DESIGN Four focus groups and three interviews were conducted and analysed using thematic analysis. PARTICIPANTS Twenty-one general practitioners (GPs), four GP assistants, seven nurses and six community mental health team workers and psychotherapists took part in focus groups and interviews. SETTING Participants were recruited from seven primary care regions and two National Health Service Trusts providing community mental health services in the South of England. RESULTS Participants highlighted a number of barriers and enablers to discussing discontinuation with patients. They held a range of views around responsibility, with some suggesting it was the responsibility of the health professional (HP) to broach the subject, and others suggesting responsibility rested with the patients. HPs were concerned about destabilising the current situation, discussed how continuity and knowing the patient facilitated discontinuation talks, and discussed how confidence in their professional skills and knowledge affected whether they elected to raise discontinuation in consultations. CONCLUSIONS Findings indicate a need to consider support for HPs in the management of antidepressant medication and discussions of discontinuation in particular. They may also benefit from support around their fears of patient relapse and awareness of when and how to initiate discussions about discontinuation with their patients.
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Affiliation(s)
- Hannah M Bowers
- Primary Care and Population Sciences, University of Southampton Faculty of Medicine, Southampton, UK
| | - Samantha J Williams
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Adam W A Geraghty
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Emma Maund
- Primary Care and Population Sciences, University of Southampton Faculty of Medicine, Southampton, UK
| | - Wendy O'brien
- Primary Care and Population Sciences, University of Southampton Faculty of Medicine, Southampton, UK
| | | | - Carl R May
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Tony Kendrick
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
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Horowitz MA, Taylor D. Tapering of SSRI treatment to mitigate withdrawal symptoms. Lancet Psychiatry 2019; 6:538-546. [PMID: 30850328 DOI: 10.1016/s2215-0366(19)30032-x] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/20/2018] [Accepted: 12/21/2018] [Indexed: 12/23/2022]
Abstract
All classes of drug that are prescribed to treat depression are associated with withdrawal syndromes. SSRI withdrawal syndrome occurs often and can be severe, and might compel patients to recommence their medication. Although the withdrawal syndrome can be differentiated from recurrence of the underlying disorder, it might also be mistaken for recurrence, leading to long-term unnecessary medication. Guidelines recommend short tapers, of between 2 weeks and 4 weeks, down to therapeutic minimum doses, or half-minimum doses, before complete cessation. Studies have shown that these tapers show minimal benefits over abrupt discontinuation, and are often not tolerated by patients. Tapers over a period of months and down to doses much lower than minimum therapeutic doses have shown greater success in reducing withdrawal symptoms. Other types of medication associated with withdrawal, such as benzodiazepenes, are tapered to reduce their biological effect at receptors by fixed amounts to minimise withdrawal symptoms. These dose reductions are done with exponential tapering programmes that reach very small doses. This method could have relevance for tapering of SSRIs. We examined the PET imaging data of serotonin transporter occupancy by SSRIs and found that hyperbolically reducing doses of SSRIs reduces their effect on serotonin transporter inhibition in a linear manner. We therefore suggest that SSRIs should be tapered hyperbolically and slowly to doses much lower than those of therapeutic minimums, in line with tapering regimens for other medications associated with withdrawal symptoms. Withdrawal symptoms will then be minimised.
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Affiliation(s)
- Mark Abie Horowitz
- Prince of Wales Hospital, Sydney, NSW, Australia; Health and Environment Action Lab, London, UK.
| | - David Taylor
- Institute of Pharmaceutical Science, King's College London, London, UK
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Godman B, Kurdi A, McCabe H, Johnson CF, Barbui C, MacBride-Stewart S, Hurding S, Leporowski A, Bennie M, Morton A. Ongoing initiatives within the Scottish National Health Service to affect the prescribing of selective serotonin reuptake inhibitors and their influence. J Comp Eff Res 2019; 8:535-547. [DOI: 10.2217/cer-2018-0132] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Aim: Increasing use of selective serotonin-reuptake inhibitors (SSRIs) in Scotland, coupled with safety concerns with some SSRIs, and the increasing availability of generic SSRIs, have resulted in multiple initiatives to improve the quality and efficiency of their prescribing in Scotland. Our aim is to assess their influence to provide future direction. Materials & methods: The prescription costs analysis database was used to document utilization and expenditure on SSRIs between 2001 and 2017 alongside documenting the initiatives. Results: Multiple interventions over the years increased international nonproprietary name prescribing up to 99.9% lowering overall costs. This, coupled with initiatives to limit escitalopram prescribing due to concerns with its value, resulted in a 73.7% reduction in SSRI expenditure between 2001 and 2017 despite a 2.34-fold increase in utilization. Safety warnings resulted in a significant reduction in the prescribing of paroxetine, citalopram and escitalopram alongside a significant increase in sertraline Conclusion: Multiple initiatives have increased the quality and efficiency of SSRI prescribing in Scotland providing direction to others.
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Affiliation(s)
- Brian Godman
- Strathclyde Institute of Pharmacy & Biomedicial Sciences, University of Strathclyde, Glasgow, UK
- Division of Clinical Pharmacology, Karolinska, Karolinska Institutet, Stockholm, Sweden
- Department of Public Health Pharmacy & Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, South Africa
| | - Amanj Kurdi
- Strathclyde Institute of Pharmacy & Biomedicial Sciences, University of Strathclyde, Glasgow, UK
- Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil, Iraq
| | - Holly McCabe
- Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, UK
| | - Chris F Johnson
- Prescribing Support Unit, National Health Service Greater Glasgow & Clyde (NHS GGC), Glasgow, UK
| | - Corrado Barbui
- WHO Collaborating Centre for Research & Training in Mental Health & Service Evaluation, Department of Neuroscience, Biomedicine & Movement Sciences, Section of Psychiatry, University of Verona, Italy
| | - Sean MacBride-Stewart
- Prescribing Support Unit, National Health Service Greater Glasgow & Clyde (NHS GGC), Glasgow, UK
| | - Simon Hurding
- Therapeutics Branch, Scottish Government, Edinburgh, UK
| | - Axel Leporowski
- Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, UK
| | - Marion Bennie
- Strathclyde Institute of Pharmacy & Biomedicial Sciences, University of Strathclyde, Glasgow, UK
| | - Alec Morton
- Department of Management Science, Strathclyde Business School, University of Strathclyde, Glasgow, UK
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Hafferty JD, Wigmore EM, Howard DM, Adams MJ, Clarke TK, Campbell AI, MacIntyre DJ, Nicodemus KK, Lawrie SM, Porteous DJ, McIntosh AM. Pharmaco-epidemiology of antidepressant exposure in a UK cohort record-linkage study. J Psychopharmacol 2019; 33:482-493. [PMID: 30808242 DOI: 10.1177/0269881119827888] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Antidepressants are the most commonly prescribed psychiatric medication but concern has been raised about significant increases in their usage in high income countries. We aimed to quantify antidepressant prevalence, incidence, adherence and predictors of use in the adult population. METHODS The study record-linked administrative prescribing and morbidity data to the Generation Scotland cohort ( N = 11,052), between 2009 and 2016. Prevalence and incidence of any antidepressant use was determined. Antidepressant adherence was measured using Proportion of Days Covered and Medication Possession Ratio. Time-to-event analysis for incident antidepressant use within 5 years of Generation Scotland: Scottish Family Health Study (GS:SFHS) recruitment was performed to reveal patient-level predictors of use. RESULTS Almost one-third (28.0%, 95%CI 26.9-29.1) of the adults in our sample were prescribed at least one antidepressant in the 5-year period 2012-2016. There was a 36.2% increase in annual prevalence between 2010 and 2016. Incidence was 2.4(2.1-2.7)% per year. The majority of antidepressant episodes (57.6%) were greater than 9 months duration and adherence was generally high (69.0% with Proportion of Days Covered >80%). Predictors of new antidepressant use included history of affective disorder, being female, physical comorbidities, higher neuroticism scores, and lower cognitive function scores. CONCLUSIONS Antidepressant prevalence is greater than previously reported but incidence remains relatively stable. We found the majority of antidepressant episodes to be of relatively long duration with good estimated adherence. Our study supports the hypothesis that increased long-term use among existing (and returning) users, along with wider ranges of indications for antidepressants, has significantly increased the prevalence of these medications.
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Affiliation(s)
- Jonathan D Hafferty
- 1 Division of Psychiatry, Royal Edinburgh Hospital, University of Edinburgh, Edinburgh, UK
| | - Eleanor M Wigmore
- 1 Division of Psychiatry, Royal Edinburgh Hospital, University of Edinburgh, Edinburgh, UK
| | - David M Howard
- 1 Division of Psychiatry, Royal Edinburgh Hospital, University of Edinburgh, Edinburgh, UK
| | - Mark J Adams
- 1 Division of Psychiatry, Royal Edinburgh Hospital, University of Edinburgh, Edinburgh, UK
| | - Toni-Kim Clarke
- 1 Division of Psychiatry, Royal Edinburgh Hospital, University of Edinburgh, Edinburgh, UK
| | - Archie I Campbell
- 2 Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - Donald J MacIntyre
- 1 Division of Psychiatry, Royal Edinburgh Hospital, University of Edinburgh, Edinburgh, UK
| | - Kristin K Nicodemus
- 2 Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, UK.,3 Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Stephen M Lawrie
- 1 Division of Psychiatry, Royal Edinburgh Hospital, University of Edinburgh, Edinburgh, UK
| | - David J Porteous
- 2 Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, UK.,3 Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Andrew M McIntosh
- 1 Division of Psychiatry, Royal Edinburgh Hospital, University of Edinburgh, Edinburgh, UK.,3 Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
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Maund E, Stuart B, Moore M, Dowrick C, Geraghty AWA, Dawson S, Kendrick T. Managing Antidepressant Discontinuation: A Systematic Review. Ann Fam Med 2019; 17:52-60. [PMID: 30670397 PMCID: PMC6342590 DOI: 10.1370/afm.2336] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 10/08/2018] [Accepted: 11/01/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We aimed to determine the effectiveness of interventions to manage antidepressant discontinuation, and the outcomes for patients. METHODS We conducted a systematic review with narrative synthesis and meta-analysis of studies published to March 2017. Studies were eligible for inclusion if they were randomized controlled trials, quasi-experimental studies, or observational studies assessing interventions to facilitate discontinuation of antidepressants for depression in adults. Our primary outcomes were antidepressant discontinuation and discontinuation symptoms. Secondary outcomes were relapse/recurrence; quality of life; antidepressant reduction; and sexual, social, and occupational function. RESULTS Of 15 included studies, 12 studies (8 randomized controlled trials, 2 single-arm trials, 2 retrospective cohort studies) were included in the synthesis. None were rated as having high risk for selection or detection bias. Two studies prompting primary care clinician discontinuation with antidepressant tapering guidance found 6% and 7% of patients discontinued, vs 8% for usual care. Six studies of psychological or psychiatric treatment plus tapering reported cessation rates of 40% to 95%. Two studies reported a higher risk of discontinuation symptoms with abrupt termination. At 2 years, risk of relapse/recurrence was lower with cognitive behavioral therapy plus taper vs clinical management plus taper (15% to 25% vs 35% to 80%: risk ratio = 0.34; 95% CI, 0.18-0.67; 2 studies). Relapse/recurrence rates were similar for mindfulness-based cognitive therapy with tapering and maintenance antidepressants (44% to 48% vs 47% to 60%; 2 studies). CONCLUSIONS Cognitive behavioral therapy or mindfulness-based cognitive therapy can help patients discontinue antidepressants without increasing the risk of relapse/recurrence, but are resource intensive. More scalable interventions incorporating psychological support are needed.
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Affiliation(s)
- Emma Maund
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Beth Stuart
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Michael Moore
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Christopher Dowrick
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, United Kingdom
| | - Adam W A Geraghty
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Sarah Dawson
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Tony Kendrick
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
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Read J, Gee A, Diggle J, Butler H. Staying on, and coming off, antidepressants: The experiences of 752 UK adults. Addict Behav 2019; 88:82-85. [PMID: 30172165 DOI: 10.1016/j.addbeh.2018.08.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 08/18/2018] [Accepted: 08/18/2018] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Prescription rates for antidepressants (ADs) are high and continue to increase, despite evidence of significant adverse effects, including withdrawal symptoms, and marginal benefit relative to placebo only for short-term treatment of major depression. Such high rates seem to be explicable more in terms of long term usage and repeat prescribing rather than by increases in depression or new patients. METHOD This paper reports the responses of a convenience sample of 752 people who had taken antidepressants, but no other psychiatric drugs, 'within the last two years' and completed the Medications for Mental Health Survey online in the UK. RESULTS Most participants had either come off antidepressants (34%) or had tried and failed (36%). Of those still taking them 76% had been doing so for at least a year and 36% for five years or more. 26% expected to take them forever. About half (48%) did not have their drugs reviewed at least every three months. Most (65%) had never had a discussion with the prescriber about coming off. Nearly half (45%) of those who had stopped the drugs had done so without consulting their doctor. However, of those who came off after consulting their doctor, the majority (65%) experienced the doctor to be supportive. CONCLUSIONS The findings are consistent with the idea that high rates are largely explicable by chronic usage, which in turn is partially explained by withdrawal symptoms. Prescribers should strive to establish collaborative relationships in which patients are fully informed about withdrawal effects and their views, about starting and finishing medication, should be explored and valued.
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Sheehan R, Strydom A, Brown E, Marston L, Hassiotis A. Association of Focused Medication Review With Optimization of Psychotropic Drug Prescribing: A Systematic Review and Meta-analysis. JAMA Netw Open 2018; 1:e183750. [PMID: 30646263 PMCID: PMC6324597 DOI: 10.1001/jamanetworkopen.2018.3750] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Medication review has been proposed to achieve improved use of psychotropic drugs, but benefits have not been confirmed. OBJECTIVE To synthesize evidence for focused psychotropic medication review in medication optimization. DATA SOURCES Medline, PsycINFO, EMBASE, and CINAHL Plus were searched from inception to February 2018 using the index terms "drug utilization review" and "psychotropic drugs" and synonyms. Additional articles were retrieved using citation tracking and reference checking. STUDY SELECTION Full-length, peer-reviewed articles that reported focused psychotropic medication review were included. Inclusion was determined against prespecified criteria and assessed independently. DATA EXTRACTION AND SYNTHESIS Study quality was assessed using National Institutes for Health appraisal tools and informed a structured synthesis of results. Meta-analysis using a random effects model was conducted. MAIN OUTCOMES AND MEASURES Change in the number or dosage of psychotropic medications, change in clinical parameters, change in patient-reported outcomes, and economic data were collected. RESULTS A total of 26 studies met the inclusion criteria. Four studies were randomized clinical trials (n = 712 participants), while the remainder were before-after studies (n = 7844 participants). Most studies were conducted in elderly individuals, people with dementia, and adults with intellectual disability. Focused psychotropic medication review is a complex intervention; the professional(s) involved, target drug, degree of integration with usual care, and participant involvement varied greatly among the studies. Meta-analysis included 3 studies (n = 652 participants). Psychotropic medication review was associated with a reduction in prescribing of psychotropic drugs compared with control (pooled odds ratio, 0.24; 95% CI, 0.14-0.39) in elderly participants with cognitive impairment living in nursing homes. Before-after studies consistently reported a change in psychotropic drug prescribing after medication review, regardless of the population. Studies that reported the effects of psychotropic medication review on clinical outcomes failed to demonstrate benefit. Economic implications of focused psychotropic medication review were not adequately assessed. The quality of evidence is poor and studies are at risk of bias. CONCLUSIONS AND RELEVANCE Focused psychotropic medication review was associated with a reduction in prescribing of psychotropic drugs, but has not been shown to improve clinical outcomes or to provide economic benefit. More robust evidence is needed before programs of focused psychotropic medication review can be recommended as part of routine care for any patient group.
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Affiliation(s)
- Rory Sheehan
- Division of Psychiatry, University College London, London, United Kingdom
| | - André Strydom
- Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Emma Brown
- Division of Psychiatry, University College London, London, United Kingdom
| | - Louise Marston
- Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Angela Hassiotis
- Division of Psychiatry, University College London, London, United Kingdom
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Huijbregts KM, Hoogendoorn A, Slottje P, van Balkom AJLM, Batelaan NM. Long-Term and Short-Term Antidepressant Use in General Practice: Data from a Large Cohort in the Netherlands. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 86:362-369. [PMID: 29131110 DOI: 10.1159/000480456] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 08/14/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Antidepressant use is highly prevalent. Research has mainly focused on efficacy during short periods of use for depression and anxiety. There is a relative paucity of data regarding the frequency of long-term use. METHODS To determine the prevalence and possible increase of long-term use of antidepressants over recent years, we analyzed routine general practice care data in a large cohort of patients (n = 156,620) in and around Amsterdam, The Netherlands. Additionally, predictors of long-term use were studied. RESULTS Prevalence of long-term use of antidepressants is substantial, and such use appears to be increasing: 30.3% of use was long-term over the period 1995-2005 compared to 43.7% for the period 2005-2015. Higher age, a registered diagnosis of anxiety or depression, and the use of SSRIs or SNRIs were associated with long-term use in multivariate analysis. In addition, specific antidepressants were differentially associated with long-term use. CONCLUSIONS Long-term antidepressant use is substantial and appears to be on the rise. Awareness of this phenomenon should be increased, such use should be prevented when possible, and reasons for long-term use need to be examined.
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Affiliation(s)
- Klaas M Huijbregts
- Department of Psychiatry and Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Magnée T, de Beurs DP, Schellevis FG, Verhaak PF. Antidepressant prescriptions and mental health nurses: an observational study in Dutch general practice from 2011 to 2015. Scand J Prim Health Care 2018; 36:47-55. [PMID: 29338537 PMCID: PMC5901440 DOI: 10.1080/02813432.2018.1426145] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PURPOSE The purpose of this study was to investigate developments in antidepressant prescriptions by Dutch general practitioners, alongside the national introduction of mental health nurses. Antidepressant prescriptions are very common in general practice, but are often not in line with recommendations. The recent introduction of mental health nurses may have decreased antidepressant prescriptions, as general practitioners (GPs) have greater potential to offer psychological treatment as a first choice option instead of medication. MATERIAL AND METHODS Anonymised data from the medical records of general practices participating in the NIVEL Primary Care Database in 2011-2015 were analysed in an observational study. We used multilevel logistic regression analyses to determine whether total antidepressant prescriptions and antidepressants prescribed within one week of diagnosing anxiety or depression decreased in the period 2011-2015. We analysed whether changes in antidepressant prescriptions were associated with the employment or consultation of mental health nurses. RESULTS Antidepressants were prescribed in 30.3% of all anxiety or depression episodes; about half were prescribed within the first week. Antidepressants prescriptions for anxiety or depression increased slightly in the period 2011-2015. The employment of mental health nurses was not associated with a decreased number of prescriptions of antidepressants. Patients who had at least one mental health nurse consultation had fewer immediate prescriptions of antidepressants, but not fewer antidepressants in general. CONCLUSIONS Antidepressant prescriptions are still common in general practice. So far, the introduction of mental health nurses has not decreased antidepressant prescriptions, but it may have a postponing effect.
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Affiliation(s)
- Tessa Magnée
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
- CONTACT T. Magnée Netherlands Institute for Health Services Research (NIVEL), P.O. Box 1568, 3500 BN Utrecht, The Netherlands
| | - Derek P. de Beurs
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Francois G. Schellevis
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
- Department of General Practice & Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Centre, Amsterdam, The Netherlands
| | - Peter F. Verhaak
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
- Department of General Practice, Groningen University, Groningen, The Netherlands
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Brett J, Karanges EA, Daniels B, Buckley NA, Schneider C, Nassir A, Zoega H, McLachlan AJ, Pearson SA. Psychotropic medication use in Australia, 2007 to 2015: Changes in annual incidence, prevalence and treatment exposure. Aust N Z J Psychiatry 2017; 51:990-999. [PMID: 28758432 DOI: 10.1177/0004867417721018] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine changes in annual patterns of psychotropic medication use in Australia from 2007 to 2015. METHODS We used a 10% sample of individual-level nationwide dispensing claims for concessional beneficiaries dispensed psychotropic medications (stratified by class, subclass) to investigate annual trends and changes in the incidence and prevalence of use, median annual duration of exposure, proportion of people with single psychotropic dispensing and median defined daily doses per person dispensed each medicine per year. RESULTS Over the study period, there was a 26.1% decrease in the incidence and a 2.6% increase in the prevalence of all psychotropic medicine use. We observed a decrease in the annual incidence and prevalence of antidepressants (11.6% and 16.8%, respectively) but increases in the median annual duration of exposure (7.4%). Amitriptyline had the highest proportion of single dispensings of all antidepressants throughout the study period (26.5% in 2015) and defined daily doses per person dispensed each medicine per year increased by 20% for antidepressants overall. Benzodiazepine use decreased across all measures over the study period apart from long-term use (exposure for >240 days of the year), which in 2015 was 23.6% of those dispensed a benzodiazepine. We observed a relative increase in the incidence and prevalence of antipsychotic use (14.2% and 26.8%, respectively), and haloperidol had the highest proportion of single dispensings of any antipsychotic throughout the study period (47.5% in 2015). We observed a relative increase in the incidence and prevalence of attention-deficit hyperactivity disorder medication use of 114.0% and 101.8%, respectively, over the study period. CONCLUSION Increasing doses and treatment durations of antidepressants warrants further investigation due to concerns about overuse. Single dispensings of amitriptyline and haloperidol may indicate off-label use and long-term use of benzodiazepines remains problematic. Despite increases in attention-deficit hyperactivity disorder medication use, prevalence of use is still much lower than the estimated prevalence of attention-deficit hyperactivity disorder in the adult population.
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Affiliation(s)
- Jonathan Brett
- 1 Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Emily A Karanges
- 1 Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Benjamin Daniels
- 1 Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Carl Schneider
- 3 Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Atheer Nassir
- 3 Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Helga Zoega
- 1 Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
- 4 Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Andrew J McLachlan
- 3 Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
- 5 Centre for Education and Research on Ageing, Concord Hospital, Sydney, NSW, Australia
| | - Sallie-Anne Pearson
- 1 Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
- 3 Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
- 6 Menzies Centre for Health Policy, The University of Sydney, Sydney, NSW, Australia
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Batelaan NM, Bosman RC, Muntingh A, Scholten WD, Huijbregts KM, van Balkom AJLM. Risk of relapse after antidepressant discontinuation in anxiety disorders, obsessive-compulsive disorder, and post-traumatic stress disorder: systematic review and meta-analysis of relapse prevention trials. BMJ 2017; 358:j3927. [PMID: 28903922 PMCID: PMC5596392 DOI: 10.1136/bmj.j3927] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objectives To examine the risk of relapse and time to relapse after discontinuation of antidepressants in patients with anxiety disorder who responded to antidepressants, and to explore whether relapse risk is related to type of anxiety disorder, type of antidepressant, mode of discontinuation, duration of treatment and follow-up, comorbidity, and allowance of psychotherapy.Design Systematic review and meta-analyses of relapse prevention trials.Data sources PubMed, Cochrane, Embase, and clinical trial registers (from inception to July 2016).Study selection Eligible studies included patients with anxiety disorder who responded to antidepressants, randomised patients double blind to either continuing antidepressants or switching to placebo, and compared relapse rates or time to relapse.Data extraction Two independent raters selected studies and extracted data. Random effect models were used to estimate odds ratios for relapse, hazard ratios for time to relapse, and relapse prevalence per group. The effect of various categorical and continuous variables was explored with subgroup analyses and meta-regression analyses respectively. Bias was assessed using the Cochrane tool.Results The meta-analysis included 28 studies (n=5233) examining relapse with a maximum follow-up of one year. Across studies, risk of bias was considered low. Discontinuation increased the odds of relapse compared with continuing antidepressants (summary odds ratio 3.11, 95% confidence interval 2.48 to 3.89). Subgroup analyses and meta-regression analyses showed no statistical significance. Time to relapse (n=3002) was shorter when antidepressants were discontinued (summary hazard ratio 3.63, 2.58 to 5.10; n=11 studies). Summary relapse prevalences were 36.4% (30.8% to 42.1%; n=28 studies) for the placebo group and 16.4% (12.6% to 20.1%; n=28 studies) for the antidepressant group, but prevalence varied considerably across studies, most likely owing to differences in the length of follow-up. Dropout was higher in the placebo group (summary odds ratio 1.31, 1.06 to 1.63; n=27 studies).Conclusions Up to one year of follow-up, discontinuation of antidepressant treatment results in higher relapse rates among responders compared with treatment continuation. The lack of evidence after a one year period should not be interpreted as explicit advice to discontinue antidepressants after one year. Given the chronicity of anxiety disorders, treatment should be directed by long term considerations, including relapse prevalence, side effects, and patients' preferences.
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Affiliation(s)
- Neeltje M Batelaan
- Department of Psychiatry and Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center Amsterdam, Amsterdam, Netherlands
- GGZ inGeest, Academic Outpatient Department for Anxiety Disorders, Amsterdam, Netherlands
| | - Renske C Bosman
- Department of Psychiatry and Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center Amsterdam, Amsterdam, Netherlands
| | - Anna Muntingh
- Department of Psychiatry and Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center Amsterdam, Amsterdam, Netherlands
- GGZ inGeest, Academic Outpatient Department for Anxiety Disorders, Amsterdam, Netherlands
| | - Willemijn D Scholten
- Department of Psychiatry and Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center Amsterdam, Amsterdam, Netherlands
- GGZ inGeest, Academic Outpatient Department for Anxiety Disorders, Amsterdam, Netherlands
| | - Klaas M Huijbregts
- Department of Psychiatry and Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center Amsterdam, Amsterdam, Netherlands
- GGZ inGeest, Academic Outpatient Department for Anxiety Disorders, Amsterdam, Netherlands
| | - Anton J L M van Balkom
- Department of Psychiatry and Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, VU University Medical Center Amsterdam, Amsterdam, Netherlands
- GGZ inGeest, Academic Outpatient Department for Anxiety Disorders, Amsterdam, Netherlands
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Johnson CF, Williams B, MacGillivray SA, Dougall NJ, Maxwell M. 'Doing the right thing': factors influencing GP prescribing of antidepressants and prescribed doses. BMC FAMILY PRACTICE 2017; 18:72. [PMID: 28623894 PMCID: PMC5473964 DOI: 10.1186/s12875-017-0643-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/05/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Antidepressant prescribing continues to increase, with 5-16% of adults receiving antidepressants annually. Total prescribing growth is due in part to increased long-term use, greater selective serotonin re-uptake inhibitor (SSRI) use and the use of higher SSRI doses. Evidence does not support routine use of higher SSRI doses for depression treatment, and factors influencing the use of such doses are not well known. The aim of this study was to explore factors influencing GPs' use of antidepressants and their doses to treat depression. METHODS Semi-structured interviews with a purposive sample of 28 practising GPs; sampled by antidepressant prescribing volume, practice size and deprivation level. A topic guide drawing on past literature was used with enough flexibility to allow additional themes to emerge. Interviews were audio-recorded and transcribed verbatim. Framework analysis was employed. Constant comparison and disconfirmation were carried out across transcripts, with data collection being interspersed with analysis by three researchers. The thematic framework was then systematically applied to the data and conceptualised into an overarching explanatory model. RESULTS Depression treatment involved ethical and professional imperatives of 'doing the right thing' for individuals by striving to achieve the 'right care fit'. This involved medicalised and non-medicalised patient-centred approaches. Factors influencing antidepressant prescribing and doses varied over time from first presentation, to antidepressant initiation and longer-term treatment. When faced with distressed patients showing symptoms of moderate to severe depression GPs were confident prescribing SSRIs which they considered as safe and effective medicines, and ethically and professionally appropriate. Many GPs were unaware that higher doses lacked greater efficacy and onset of action occurred within 1-2 weeks, preferring to wait 8-12 weeks before increasing or switching. Ongoing pressures to maintain prescribing (e.g. fear of depression recurrence), few perceived continuation problems (e.g. lack of safety concerns) and lack of proactive medication review (e.g. patients only present in crisis), all combine to further drive antidepressant prescribing growth over time. CONCLUSIONS GPs strive to 'do the right thing' to help people. Antidepressants are only a single facet of depression treatment. However, increased awareness of drug limitations and regular proactive reviews may help optimise care.
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Affiliation(s)
- Chris F. Johnson
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, 2nd Floor, Main Building, West Glasgow Ambulatory Care Hospital, Dalnair Street, Yorkhill, Glasgow, G3 8SJ UK
| | - Brian Williams
- School of Health and Social Care, Edinburgh Napier University, Sighthill Court, Edinburgh, EH11 4BN UK
| | - Stephen A. MacGillivray
- School of Nursing and Health Sciences, University of Dundee, Airlie Place, Dundee, DD1 4HN UK
| | - Nadine J. Dougall
- School of Health and Social Care, Edinburgh Napier University, Sighthill Court, Edinburgh, EH11 4BN UK
| | - Margaret Maxwell
- Nursing Midwifery and Allied Health Professionals Research Unit, University of Stirling, Unit 13 Scion House, Stirling University Innovation Park, Stirling, FK9 4NF UK
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Kjosavik SR, Gillam MH, Roughead EE. Average duration of treatment with antidepressants among concession card holders in Australia. Aust N Z J Psychiatry 2016; 50:1180-1185. [PMID: 26671459 DOI: 10.1177/0004867415621392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To analyse the average treatment duration with antidepressants that are reimbursed for concession card holders under the Pharmaceutical Benefits Scheme in Australia. METHOD This pharmacoepidemiological study was based on a representative 10% sample of patients receiving Pharmaceutical Benefits Scheme prescriptions. Antidepressants redeemed by concession card holders in the period from 2010 to 2013 were analysed. A 5-year baseline period was used to exclude prevalent users from incident users. Estimation of treatment duration was based on the epidemiological equation: prevalence/incidence = average duration. The mean value for prevalence and incidence over the studied period was used in the equation. RESULTS The number of prevalent and incident users increased from 90,475 to 103,305 and from 25,006 to 26,289, respectively. The epidemiological average treatment duration in the period was about 4 years. When considered by age-bands, average treatment duration was 2 years in patients under 24 years, 3 years in patients 35 to 44 years and up to 5 years in the 55 to 64 year age group. Of new users of antidepressants reimbursed under the Pharmaceutical Benefits Scheme, 86% received their first prescription from general practitioners, 4.3% from psychiatrists and 9.7% from other physicians. CONCLUSION While recommendations have underlined the importance of giving antidepressants for a sufficient period of time, the results from this study show that it is as important to remind general practitioners to review patients on antidepressant treatment regularly, and try to cease drug treatment when timely.
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Affiliation(s)
- Svein Reidar Kjosavik
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute, University of South Australia, Adelaide, SA, Australia
- Centre for Age-Related Diseases, Stavanger University Hospital, Stavanger, Norway
- Research Unit for General Practice in Bergen, Uni Research Health, Bergen, Norway
| | - Marianne Hansen Gillam
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute, University of South Australia, Adelaide, SA, Australia
| | - Elisabeth E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute, University of South Australia, Adelaide, SA, Australia
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Long-term antidepressant use: a qualitative study on perspectives of patients and GPs in primary care. Br J Gen Pract 2016; 66:e708-19. [PMID: 27528709 DOI: 10.3399/bjgp16x686641] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/20/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Antidepressant use is often prolonged in patients with anxiety and/or depressive disorder(s) compared with recommendations in treatment guidelines to discontinue after sustained remission. AIM To unravel the motivations of patients and GPs causing long-term antidepressant use and to gain insight into possibilities to prevent unnecessary long-term use. DESIGN AND SETTING Qualitative study using semi-structured, in-depth interviews with patients and GPs in the Netherlands. METHOD Patients with anxiety and/or depressive disorder(s) (n = 38) and GPs (n = 26) were interviewed. Innovatively, the interplay between patients and their GPs was also investigated by means of patient-GP dyads (n = 20). RESULTS The motives and barriers of patients and GPs to continue or discontinue antidepressants were related to the availability of supportive guidance during discontinuation, the personal circumstances of the patient, and considerations of the patient or GP. Importantly, dyads indicated a large variation in policies of general practices around long-term use and continuation or discontinuation of antidepressants. Dyads further indicated that patients and GPs seemed unaware of each other's (mismatching) expectations regarding responsibility to initiate discussing continuation or discontinuation. CONCLUSION Although motives and barriers to antidepressant continuation or discontinuation were related to the same themes for patients and GPs, dyads indicated discrepancies between them. Discussion between patients and GPs about antidepressant use and continuation or discontinuation may help clarify mutual expectations and opinions. Agreements between a patient and their GP can be included in a patient-tailored treatment plan.
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Kendrick T, Stuart B, Newell C, Geraghty AWA, Moore M. Did NICE guidelines and the Quality Outcomes Framework change GP antidepressant prescribing in England? Observational study with time trend analyses 2003-2013. J Affect Disord 2015; 186:171-7. [PMID: 26241666 DOI: 10.1016/j.jad.2015.06.052] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 06/22/2015] [Accepted: 06/29/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Both the 2004 NICE depression guidelines and 2006 general practice Quality Outcomes Framework (QOF) encouraged improved targeting of antidepressant treatment for depression. METHODS Possible effects of the NICE guideline from January 2005, and QOF from April 2006, on rates of GP antidepressant prescribing were examined using time trend analyses of anonymised data from 142 English practices contributing to the Clinical Practice Research Datalink (CPRD), 2003-2013. RESULTS Sustained reductions were found in the proportion of first-ever depression episodes treated within 12 months, of 4.2% (95% C.I. 1.0-7.3%) following introduction of the NICE guideline, and 4.4% (2.3-6.5%) following introduction of the QOF. Treatment rates for first-ever episodes fell from 72.5% (70.8-74.1%) in Quarter 2 (Q2) 2003 to 61.0% (59.3-62.7%) in Q1 2012, but treatment rates for recurrent episodes increased from 74.3% (72.8-75.8%) to 77.8% (76.5-79.1%), so overall rates remained around 70%. Mean prescriptions per patient per year doubled from 2.06 (2.05-2.07) to 3.98 (3.97-3.99). LIMITATIONS Participating practices were larger than average and not representative across regions. Inferences of cause and effect from time trend analyses are subject to the possibility of unidentified confounders. No data were available on depression severity or appropriateness of prescribing. CONCLUSIONS Rates of GP antidepressant treatment for patients with incident depression fell following introduction of NICE depression guidelines and the QOF, but treatment rates for recurrent depression increased. Prescription numbers increased due to longer treatment courses. To impact on antidepressant prescribing rates, guidelines and performance indicators must address recurrent and long-term prescribing, rather than initial treatment decisions.
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Affiliation(s)
- Tony Kendrick
- Primary Care and Population Sciences, University of Southampton, UK.
| | - Beth Stuart
- Primary Care and Population Sciences, University of Southampton, UK
| | - Colin Newell
- Primary Care and Population Sciences, University of Southampton, UK
| | | | - Michael Moore
- Primary Care and Population Sciences, University of Southampton, UK
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