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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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Coe A, Gunn J, Allnutt Z, Kaylor-Hughes C. Understanding Australian general practice patients' decisions to deprescribe antidepressants in the WiserAD trial: a realist informed approach. BMJ Open 2024; 14:e078179. [PMID: 38355180 PMCID: PMC10868251 DOI: 10.1136/bmjopen-2023-078179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 01/31/2024] [Indexed: 02/16/2024] Open
Abstract
OBJECTIVES To evaluate how an approach to antidepressant deprescribing works, for whom, and in what contexts by (1) examining the experiences and perceptions of the approach for antidepressant users, (2) identifying the mechanisms of the approach and (3) describing what contexts are associated with antidepressant tapering. DESIGN This mixed methods study was informed by the principles of realist evaluation and was conducted in the first 3 months of participation in the WiserAD randomised control trial. SETTING General practice, Victoria, Australia. PARTICIPANTS 13 antidepressant users from general practice participating in the WiserAD trial for antidepressant deprescribing. INTERVENTION A patient-facing, web-based structured support tool that consists of a personalised tapering schedule, an action plan for managing withdrawal symptoms, a daily mood, sleep and activity tracker and mental health nurse support. PRIMARY/SECONDARY OUTCOME MEASURES The outcomes of the study were revealed on data analysis as per a realist evaluation approach which tests and refines an initial programme theory. RESULTS The contexts of learnt coping skills, knowledge and perceptions of antidepressants and feeling well were evident. Outcomes were intention to commence, initiation of deprescribing and successful completion of deprescribing. Key mechanisms for antidepressant deprescribing were (1) initiation of the deprescribing discussion; (2) patient self-efficacy; (3) provision of structured guidance; (4) coaching; (5) mood, sleep and activity tracking and (6) feelings of safety during the tapering period. CONCLUSIONS The WiserAD approach to antidepressant deprescribing supported participants to commence and/or complete tapering. The refined programme theory presents the WiserAD pragmatic framework for the application of antidepressant deprescribing in clinical practice. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT05355025; ACTRN12622000567729; ISRCTN11562922; Pre-results.
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Affiliation(s)
- Amy Coe
- Department of General Practice and Primary Care, The University of Melbourne, Carlton, Victoria, Australia
| | - Jane Gunn
- Department of General Practice and Primary Care, The University of Melbourne, Carlton, Victoria, Australia
| | - Zoe Allnutt
- Department of General Practice and Primary Care, The University of Melbourne, Carlton, Victoria, Australia
| | - Catherine Kaylor-Hughes
- Department of General Practice and Primary Care, The University of Melbourne, Carlton, Victoria, Australia
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Gøtzsche PC, Demasi M. Interventions to help patients withdraw from depression drugs: A systematic review. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2024; 35:103-116. [PMID: 37718853 DOI: 10.3233/jrs-230011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
BACKGROUND Depression drugs can be difficult to come off due to withdrawal symptoms. Gradual tapering with tapering support is needed to help patients withdraw safely. OBJECTIVE To review the withdrawal success rates, using any intervention, and the effects on relapse/recurrence rates, symptom severity, quality of life, and withdrawal symptoms. METHODS Systematic review based on PubMed and Embase searches (last search 4 October 2022) of randomised trials with one or more treatment arms aimed at helping patients withdraw from a depression drug, regardless of indication for treatment. We calculated the mean and median success rates and the risk difference of depressive relapse when discontinuing or continuing depression drugs. RESULTS We included 13 studies (2085 participants). Three compared two withdrawal interventions and ten compared drug discontinuation vs. continuation. The success rates varied hugely between the trials (9% to 80%), with a weighted mean of 47% (95% confidence interval 38% to 57%) and a median of 50% (interquartile range 29% to 65%). A meta-regression showed that the length of taper was highly predictive for the risk of relapse (P = 0.00001). All the studies we reviewed confounded withdrawal symptoms with relapse; did not use hyperbolic tapering; withdrew the depression drug too fast; and stopped it entirely when receptor occupancy was still high. CONCLUSION The true proportion of patients on depression drugs who can stop safely without relapse is likely considerably higher than the 50% we found.
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Müller A, Konigorski S, Meißner C, Fadai T, Warren CV, Falkenberg I, Kircher T, Nestoriuc Y. Study protocol: combined N-of-1 trials to assess open-label placebo treatment for antidepressant discontinuation symptoms [FAB-study]. BMC Psychiatry 2023; 23:749. [PMID: 37833651 PMCID: PMC10576328 DOI: 10.1186/s12888-023-05184-y] [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: 08/17/2023] [Accepted: 09/12/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Antidepressant discontinuation is associated with a broad range of adverse effects. Debilitating discontinuation symptoms can impede the discontinuation process and contribute to unnecessary long-term use of antidepressants. Antidepressant trials reveal large placebo effects, indicating a potential use of open-label placebo (OLP) treatment to facilitate the discontinuation process. We aim to determine the effect of OLP treatment in reducing antidepressant discontinuation symptoms using a series of N-of-1 trials. METHODS A series of randomized, single-blinded N-of-1 trials will be conducted in 20 patients with fully remitted DSM-V major depressive disorder, experiencing moderate to severe discontinuation symptoms following antidepressant discontinuation. Each N-of-1 trial consists of two cycles, each comprising two-week alternating periods of OLP treatment and of no treatment in a random order, for a total of eight weeks. Our primary outcome will be self-reported discontinuation symptoms rated twice daily via the smartphone application 'StudyU'. Secondary outcomes include expectations about discontinuation symptoms and (depressed) mood. Statistical analyses will be based on a Bayesian multi-level random effects model, reporting posterior estimates of the overall and individual treatment effects. DISCUSSION Results of this trial will provide insight into the clinical application of OLP in treating antidepressant discontinuation symptoms, potentially offering a new cost-effective therapeutic tool. This trial will also determine the feasibility and applicability of a series of N-of-1 trials in a clinical discontinuation trial. TRIAL REGISTRATION ClinicalTrials.gov: NCT05051995, first registered September 20, 2021.
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Affiliation(s)
- Amke Müller
- Clinical Psychology, Helmut-Schmidt-University/University of the Federal Armed Forces Hamburg, Holstenhofweg 85, 22043, Hamburg, Germany.
- Institute of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Stefan Konigorski
- Digital Health - Machine Learning Group, Hasso-Plattner-Institute for Digital Engineering, Potsdam, Germany
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Department of Statistics, Harvard University, 150 Western Ave, Boston, MA, 02134, USA
| | - Carina Meißner
- Clinical Psychology, Helmut-Schmidt-University/University of the Federal Armed Forces Hamburg, Holstenhofweg 85, 22043, Hamburg, Germany
- Institute of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Tahmine Fadai
- Institute of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Claire V Warren
- Clinical Psychology, Helmut-Schmidt-University/University of the Federal Armed Forces Hamburg, Holstenhofweg 85, 22043, Hamburg, Germany
- Institute of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Irina Falkenberg
- Department of Psychiatry and Psychotherapy, University of Marburg, Marburg, Germany
| | - Tilo Kircher
- Department of Psychiatry and Psychotherapy, University of Marburg, Marburg, Germany
| | - Yvonne Nestoriuc
- Clinical Psychology, Helmut-Schmidt-University/University of the Federal Armed Forces Hamburg, Holstenhofweg 85, 22043, Hamburg, Germany
- Institute of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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McGoldrick A, Byrne H, Cadogan C. An assessment of the reporting of tapering methods in antidepressant discontinuation trials using the TIDieR checklist. Int J Clin Pharm 2023; 45:1074-1087. [PMID: 37269440 PMCID: PMC10600051 DOI: 10.1007/s11096-023-01602-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/03/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND The importance of tapering is increasingly recognised when discontinuing antidepressant medication. However, no previous studies have examined the reporting of antidepressant tapering methods in published studies. AIM The aim of this study was to assess the completeness of reporting of antidepressant tapering methods in a published systematic review using the Template for Intervention Description and Replication (TIDieR) checklist. METHOD A secondary analysis was conducted of studies included in a Cochrane systematic review that examined the effectiveness of approaches for discontinuing long-term antidepressant use. The completeness of reporting of antidepressant tapering methods in included studies was independently assessed by two researchers using the 12 items from the TIDieR checklist. RESULTS Twenty-two studies were included in the analysis. None of the study reports described all checklists items. No study clearly reported what materials had been provided (item 3) or whether tailoring had occurred (item 9). With the exception of providing a name for the intervention or study procedures (item 1), only a minority of studies clearly reported on any of the remaining checklist items. CONCLUSION The findings highlight a lack of detailed reporting of antidepressant tapering methods in published trials to date. This needs to be addressed as poor reporting could hinder replication and adaptation of existing interventions, as well as the potential for successful translation of effective tapering interventions into clinical practice.
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Affiliation(s)
- Amy McGoldrick
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, D02PN40, Ireland
| | - Helen Byrne
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, D02PN40, Ireland
| | - Cathal Cadogan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, D02PN40, Ireland.
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Wallis KA, Donald M, Horowitz M, Moncrieff J, Ware RS, Byrnes J, Thrift K, Cleetus M, Panahi I, Zwar N, Morgan M, Freeman C, Scott I. RELEASE (REdressing Long-tErm Antidepressant uSE): protocol for a 3-arm pragmatic cluster randomised controlled trial effectiveness-implementation hybrid type-1 in general practice. Trials 2023; 24:615. [PMID: 37770893 PMCID: PMC10537226 DOI: 10.1186/s13063-023-07646-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/12/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Many people experience withdrawal symptoms when they attempt to stop antidepressants. Withdrawal symptoms are readily misconstrued for relapse or ongoing need for medication, contributing to long-term use (> 12 months). Long-term antidepressant use is increasing internationally yet is not recommended for most people. Long-term use is associated with adverse effects including weight gain, sexual dysfunction, lethargy, emotional numbing and increased risk of falls and fractures. This study aims to determine the effectiveness of two multi-strategy interventions (RELEASE and RELEASE+) in supporting the safe cessation of long-term antidepressants, estimate cost-effectiveness, and evaluate implementation strategies. METHODS DESIGN: 3-arm pragmatic cluster randomised controlled trial effectiveness-implementation hybrid type-1. SETTING primary care general practices in southeast Queensland, Australia. POPULATION adults 18 years or older taking antidepressants for longer than 1 year. Practices will be randomised on a 1.5:1:1 ratio of Usual care:RELEASE:RELEASE+. INTERVENTION RELEASE for patients includes evidence-based information and resources and an invitation to medication review; RELEASE for GPs includes education, training and printable resources via practice management software. RELEASE+ includes additional internet support for patients and prescribing support including audit and feedback for GPs. OUTCOME MEASURES the primary outcome is antidepressant use at 12 months self-reported by patients. Cessation is defined as 0 mg antidepressant maintained for at least 2 weeks. SECONDARY OUTCOMES at 6 and 12 months are health-related quality of life, antidepressant side effects, well-being, withdrawal symptoms, emotional numbing, beliefs about antidepressants, depressive symptoms, and anxiety symptoms; and at 12 months 75% reduction in antidepressant dose; aggregated practice level antidepressant prescribing, and health service utilisation for costs. SAMPLE SIZE 653 patients from 28 practices. A concurrent evaluation of implementation will be through mixed methods including interviews with up to 40 patients and primary care general practitioners, brief e-surveys, and study administrative data to assess implementation outcomes (adoption and fidelity). DISCUSSION The RELEASE study will develop new knowledge applicable internationally on the effectiveness, cost-effectiveness, and implementation of two multi-strategy interventions in supporting the safe cessation of long-term antidepressants to improve primary health care and outcomes for patients. TRIAL REGISTRATION ANZCTR, ACTRN12622001379707p. Registered on 27 October 2022.
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Affiliation(s)
- Katharine A Wallis
- General Practice Clinical Unit, Medical School, The University of Queensland, Herston, Brisbane, QLD, 4072, Australia.
| | - Maria Donald
- General Practice Clinical Unit, Medical School, The University of Queensland, Herston, Brisbane, QLD, 4072, Australia
| | - Mark Horowitz
- NHS Foundation Trust, Research and Development Department, London, Northeast London, UK
| | | | - Robert S Ware
- Griffith University, Nathan, Brisbane, QLD, Australia
| | - Joshua Byrnes
- Griffith University, Nathan, Brisbane, QLD, Australia
| | - Karen Thrift
- General Practice Clinical Unit, Medical School, The University of Queensland, Herston, Brisbane, QLD, 4072, Australia
| | - MaryAnne Cleetus
- General Practice Clinical Unit, Medical School, The University of Queensland, Herston, Brisbane, QLD, 4072, Australia
| | - Idin Panahi
- General Practice Clinical Unit, Medical School, The University of Queensland, Herston, Brisbane, QLD, 4072, Australia
| | - Nicholas Zwar
- Faculty of Health Sciences and Medicine, Bond University, Robina, Gold Coast, QLD, Australia
| | - Mark Morgan
- Faculty of Health Sciences and Medicine, Bond University, Robina, Gold Coast, QLD, Australia
| | - Chris Freeman
- The University of Queensland, Herston, Brisbane, QLD, 4072, Australia
| | - Ian Scott
- The University of Queensland, Herston, Brisbane, QLD, 4072, Australia
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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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Nizet P, Evin A, Brociero E, Vigneau CV, Huon JF. Outcomes in deprescribing implementation trials and compliance with expert recommendations: a systematic review. BMC Geriatr 2023; 23:428. [PMID: 37438697 DOI: 10.1186/s12877-023-04155-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Deprescribing, defined as discontinuing or reducing the dose of medications that are no longer needed or for which the risks outweigh the benefits is a way to reduce polypharmacy. In 2022, the US Deprescribing Research Network (USDeN) published recommendations concerning the measurement of outcomes for deprescribing intervention studies. The objectives of this systematic review were to identify the outcome categories used in deprescribing intervention trials and to relate them to the previously published recommendations. METHODS We searched MEDLINE, Embase, PsychInfo, and the Cochrane library from January 2012 through January 2022. Studies were included if they were randomized controlled trials evaluating a deprescribing intervention. After data extraction, outcomes were categorized by type: medication outcomes, clinical outcomes, system outcomes, implementation outcomes, and other outcomes based on the previously published recommendations. RESULTS Thirty-six studies were included. The majority of studies focused on older adults in nursing homes and targeted inappropriate medications or polypharmacy. In 20 studies, the intervention was a medication review; in seven studies, the intervention was educational or informative; and three studies based their intervention on motivational interviewing or patient empowerment. Thirty-one studies presented a medication outcome (primary outcome in 26 studies), 25 a clinical outcome, 18 a system outcome, and seven an implementation outcome. Only three studies presented all four types of outcomes, and 10 studies presented three types of outcomes. CONCLUSIONS This review provides an update on the implementation of gold standard deprescribing studies in clinical practice. Implementation outcomes need to be developed and specified to facilitate the implementation of these practices on a larger scale and clinical outcome need to be prioritized. Finally, this review provides new elements for future real-life deprescribing studies.
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Affiliation(s)
- Pierre Nizet
- Nantes Université, CHU Nantes, 44000, Pharmacie, France.
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France.
| | - Adrien Evin
- Nantes Université, CHU Nantes, Service de Soins Palliatifs Et de Support, 44000, Nantes, France
| | - Emma Brociero
- Nantes Université, CHU Nantes, 44000, Pharmacie, France
| | - Caroline Victorri Vigneau
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France
- Nantes Université, CHU Nantes, Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Jean-François Huon
- Nantes Université, CHU Nantes, 44000, Pharmacie, France
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France
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9
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Long-term antidepressant use in general practice: a qualitative study of GPs' views on discontinuation. Br J Gen Pract 2021; 71:e508-e516. [PMID: 33875415 PMCID: PMC8074642 DOI: 10.3399/bjgp.2020.0913] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/06/2021] [Indexed: 01/03/2023] Open
Abstract
Background There is considerable concern about increasing antidepressant use, with Australians among the highest users in the world. Evidence suggests this is driven by patients on long-term use, rather than new prescriptions. Most antidepressant prescriptions are generated in general practice, and it is likely that attempts to discontinue are either not occurring or are proving unsuccessful. Aim To explore GPs’ insights about long-term antidepressant prescribing and discontinuation. Design and setting A qualitative interview study with Australian GPs. Method Semi-structured interviews explored GPs’ discontinuation experiences, decision-making, perceived risks and benefits, and support for patients. Data were analysed using reflexive thematic analysis. Results Three overarching themes were identified from interviews with 22 GPs. The first, ‘not a simple deprescribing decision’, spoke to the complex decision-making GPs undertake in determining whether a patient is ready to discontinue. The second, ‘a journey taken together’, captured a set of steps GPs take together with their patients to initiate and set-up adequate support before, during, and after discontinuation. The third, ‘supporting change in GPs’ prescribing practices’, described what GPs would like to see change to better support them and their patients to discontinue antidepressants. Conclusion GPs see discontinuation of long-term antidepressant use as more than a simple deprescribing decision. It begins with considering a patient’s social and relational context, and is a journey involving careful preparation, tailored care, and regular review. These insights suggest interventions to redress long-term use will need to take these considerations into account and be placed in a wider discussion about the use of antidepressants.
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10
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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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11
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The effects of social group interventions for depression: Systematic review. J Affect Disord 2021; 281:67-81. [PMID: 33302192 DOI: 10.1016/j.jad.2020.11.125] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/25/2020] [Accepted: 11/27/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is a growing prevalence of prolonged antidepressant use globally. Social group interventions may be an effective way to manage mild to moderate depression, especially with patients seeking to discontinue antidepressant use. This systematic review evaluates studies that used social group interventions to manage depression. METHODS Studies published up to June 2019 in nine bibliographic databases were identified using search terms related to depression, social interventions, and social participation. Formal therapies for depression (cognitive behaviour therapy, music therapy) were excluded as they have been reviewed elsewhere. RESULTS 24 studies met inclusion criteria; 14 RCTs, 6 non-randomised controlled trials and 4 pre-post evaluations. In total, 28 social group programs were evaluated, 10 arts-based groups, 13 exercise groups and 5 others. Programs ranged in 'dose' from 5 to 150 hours (M = 31 hours) across 4 to 75 weeks (M = 15 weeks) and produced effect sizes on depression in the small to very large range (Hedge's g = .18 to 3.19, M = 1.14). A regression analysis revealed no participant variables, study variables or intervention variables were related to effect size on depression. LIMITATIONS Risks of bias were found, primarily in the non-randomised studies, which means the findings must be regarded as preliminary until replicated. CONCLUSION These findings indicate that social group interventions are an effective way to manage mild to moderate depression symptoms in a variety of populations. This approach may also help to prevent relapse among patients tapering off antidepressant medication.
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12
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Huijbers MJ, Wentink C, Simons E, Spijker J, Speckens A. Discontinuing antidepressant medication after mindfulness-based cognitive therapy: a mixed-methods study exploring predictors and outcomes of different discontinuation trajectories, and its facilitators and barriers. BMJ Open 2020; 10:e039053. [PMID: 33177138 PMCID: PMC7661362 DOI: 10.1136/bmjopen-2020-039053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/15/2020] [Accepted: 09/30/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES This study aimed to explore predictors and outcomes associated with different trajectories of discontinuing antidepressant medication (ADM), in recurrently depressed individuals after participation in mindfulness-based cognitive therapy (MBCT). Facilitators and barriers of discontinuation were explored qualitatively. DESIGN Mixed-methods study combining quantitative and qualitative data, drawn from a randomised controlled trial. SETTING Twelve secondary and tertiary psychiatric outpatient clinics in the Netherlands. PARTICIPANTS Recurrently depressed individuals (N=226) who had been using ADM for at least 6 months and in partial or full remission. Regardless of trial condition, we made post-hoc classifications of patients' actual discontinuation trajectories: full discontinuation (n=82), partial discontinuation (n=34) and no discontinuation (n=110) of ADM within 6 months after baseline. A subset of patients (n=15) and physicians (n=7) were interviewed to examine facilitators and barriers of discontinuation. INTERVENTIONS All participants were offered MBCT, which consisted of eight weekly sessions in a group. PRIMARY AND SECONDARY OUTCOME MEASURES Demographic and clinical predictors of successful discontinuation within 6 months, relapse risk within 15 months associated with different discontinuation trajectories, and barriers and facilitators of discontinuation. RESULTS Of the 128 patients assigned to MBCT with discontinuation, only 68 (53%) fully discontinued ADM within 6 months, and 17 (13%) discontinued partially. Predictors of full discontinuation were female sex, being employed and lower levels of depression. Relapse risk was lower after no discontinuation (45%) or partial discontinuation (38%), compared with full discontinuation (66%) (p=0.02). Facilitators and barriers of discontinuation were clustered within five themes: (1) pre-existing beliefs about depression, medication and tapering; (2) current experience with ADM; (3) life circumstances; (4) clinical support and (5) mindfulness. CONCLUSIONS Discontinuing antidepressants appears to be difficult, stressing the need to support patients and physicians in this process. MBCT may offer one of these forms of support. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT00928980); post-results.
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Affiliation(s)
| | | | - Esther Simons
- Primary and Community Care, Radboudumc, Nijmegen, The Netherlands
| | - Jan Spijker
- Expertise Centre for Depression, Pro Persona Locatie Tarweweg, Nijmegen, Gelderland, The Netherlands
| | - Anne Speckens
- Psychiatry, Radboudumc, Nijmegen, Gelderland, The Netherlands
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13
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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: 33] [Impact Index Per Article: 8.3] [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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14
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Aubert CE, Kerr EA, Maratt JK, Klamerus ML, Hofer TP. Outcome Measures for Interventions to Reduce Inappropriate Chronic Drugs: A Narrative Review. J Am Geriatr Soc 2020; 68:2390-2398. [DOI: 10.1111/jgs.16697] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/05/2020] [Accepted: 06/05/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Carole E. Aubert
- Department of General Internal Medicine, Bern University Hospital University of Bern Bern Switzerland
- Institute of Primary Health Care University of Bern Bern Switzerland
- Veterans Affairs Center for Clinical Management Research Ann Arbor Michigan USA
- Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor Michigan USA
| | - Eve A. Kerr
- Veterans Affairs Center for Clinical Management Research Ann Arbor Michigan USA
- Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor Michigan USA
- Department of Internal Medicine University of Michigan Ann Arbor Michigan USA
| | - Jennifer K. Maratt
- Department of Medicine Indiana University School of Medicine Indianapolis Indiana USA
- Richard L. Roudebush Veterans Affairs Medical Center Indianapolis Indiana USA
| | - Mandi L. Klamerus
- Veterans Affairs Center for Clinical Management Research Ann Arbor Michigan USA
| | - Timothy P. Hofer
- Veterans Affairs Center for Clinical Management Research Ann Arbor Michigan USA
- Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor Michigan USA
- Department of Internal Medicine University of Michigan Ann Arbor Michigan USA
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15
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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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16
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Lunghi C, Antonazzo IC, Burato S, Raschi E, Zoffoli V, Forcesi E, Sangiorgi E, Menchetti M, Roberge P, Poluzzi E. Prevalence and Determinants of Long-Term Utilization of Antidepressant Drugs: A Retrospective Cohort Study. Neuropsychiatr Dis Treat 2020; 16:1157-1170. [PMID: 32440131 PMCID: PMC7213896 DOI: 10.2147/ndt.s241780] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 04/09/2020] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Antidepressant consumption has risen in recent years, driven by longer treatment duration. The objective of this study was to measure the prevalence of antidepressant long-term and chronic use in the Bologna area, Italy, and to identify their main determinants. MATERIALS AND METHODS We conducted a retrospective claims-based cohort study by using the Bologna Local Health Authority data. A cohort of 18,307 incident users of antidepressant drugs in 2013 was selected, and subjects were followed for three years. A long-term utilization was defined as having at least one prescription claimed during each year of follow-up, while chronic utilization was defined as claiming at least 180 defined daily doses per year. Factors associated with chronic and long-term use were identified by univariate and multivariate logistic regressions. RESULTS In our cohort, 5448 (29.8%) and 1817 (9.9%) subjects were dispensed antidepressants for a long-term course and in a chronically way, respectively. Older age, antidepressant polytherapy, polypharmacy, and being prescribed the first antidepressant by a hospital physician were all factors independently associated with chronic and long-term prescriptions of antidepressant drugs. Results were reported separately for men and women. CONCLUSION Antidepressant long-term and chronic prescriptions are common in the Bologna area. Because longer treatment should be clinically motivated, these results strongly prompt the need to evaluate the actual relevance, as they may indicate potentially inappropriate prescription patterns.
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Affiliation(s)
- Carlotta Lunghi
- Department of Health Sciences, Université Du Québec À Rimouski, Lévis, Québec, Canada.,Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,Groupe De Recherche PRIMUS, Centre De Recherche Du CHUS, Université De Sherbrooke, Sherbrooke, Canada
| | - Ippazio Cosimo Antonazzo
- Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Sofia Burato
- Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Emanuel Raschi
- Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Violetta Zoffoli
- Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Emanuele Forcesi
- Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Elisa Sangiorgi
- Drug Policy Service, Emilia Romagna Region Health Authority, Bologna, Italy
| | - Marco Menchetti
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Pasquale Roberge
- Groupe De Recherche PRIMUS, Centre De Recherche Du CHUS, Université De Sherbrooke, Sherbrooke, Canada.,Faculty of Medicine and Health Sciences, Université De Sherbrooke, Sherbrooke, Québec, Canada
| | - Elisabetta Poluzzi
- Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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17
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Groot PC, van Os J. How user knowledge of psychotropic drug withdrawal resulted in the development of person-specific tapering medication. Ther Adv Psychopharmacol 2020; 10:2045125320932452. [PMID: 32699604 PMCID: PMC7357127 DOI: 10.1177/2045125320932452] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 05/14/2020] [Indexed: 12/16/2022] Open
Abstract
Coming off psychotropic drugs can cause physical as well as mental withdrawal, resulting in failed withdrawal attempts and unnecessary long-term drug use. The first reports about withdrawal appeared in the 1950s, but although patients have been complaining about psychotropic withdrawal problems for decades, the first tentative acknowledgement by psychiatry only came in 1997 with the introduction of the 'antidepressant-discontinuation syndrome'. It was not until 2019 that the UK Royal College of Psychiatrists, for the first time, acknowledged that withdrawal can be severe and persistent. Given the lack of a systematic professional response, over the years, patients who were experiencing withdrawal started to work out practical ways to safely come off medications themselves. This resulted in an experience-based knowledge base about withdrawal which ultimately, in The Netherlands, gave rise to the development of person-specific tapering medication (so-called tapering strips). Tapering medication enables doctors, for the first time, to flexibly prescribe and adapt the medication required for responsible and person-specific tapering, based on shared decision making and in full agreement with recommendations in existing guidelines. Looking back, it is obvious that the simple practical solution of tapering strips could have been introduced much earlier, and that the traditional academic strategy of comparisons from randomised trials is not the logical first step to help individual patients. While randomised controlled trials (RCTs) are the gold standard for evaluating interventions, they are unable to accommodate the heterogeneity of individual responses. Thus, a more individualised approach, building on RCT knowledge, is required. We propose a roadmap for a more productive way forward, in which patients and academic psychiatry work together to improve the recognition and person-specific management of psychotropic drug withdrawal.
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Affiliation(s)
- Peter C Groot
- User Research Centre NL, Utrecht University Medical Centre Postbus 85500, Utrecht 3508 GA, The Netherlands
| | - Jim van Os
- UMC Utrecht Brain Centre, Utrecht, The Netherlands
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18
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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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19
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Lopez-Montoyo A, Quero S, Montero-Marin J, Barcelo-Soler A, Beltran M, Campos D, Garcia-Campayo J. Effectiveness of a brief psychological mindfulness-based intervention for the treatment of depression in primary care: study protocol for a randomized controlled clinical trial. BMC Psychiatry 2019; 19:301. [PMID: 31619196 PMCID: PMC6796394 DOI: 10.1186/s12888-019-2298-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 09/20/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Depressive symptoms are quite prevalent in Primary Care (PC) settings. The treatment as usual (TAU) in PC is pharmacotherapy, despite the high relapse rates it produces. Many patients would prefer psychotherapy, but specialized services are overloaded. Studies that apply Mindfulness-Based Interventions (MBIs) for the treatment of depression have obtained significant improvements. Brief low-intensity approaches delivered from PC could be a promising approach. This study aims to compare a low-intensity mindfulness intervention for the treatment of depression in PC using different intervention formats - a face-to-face MBI delivered in a group and the same MBI individually applied on the Internet - to a control group that will receive PC medical treatment as usual. METHODS A randomized controlled clinical trial will be conducted in PC, with about 120 depressed patients allocated (1:1:1) to three groups: "face-to-face MBI + TAU", "Internet-delivered MBI + TAU", and "TAU alone". The MBI programs will be composed of four modules. The primary outcome will be depressive symptoms, measured through the Beck Depression Inventory, assessed at pre- and post-treatment and 6- and 12-month follow-ups. Other outcomes will be mindfulness, happiness, affectivity, quality of life, and the use of healthcare services. Intention-to-treat analysis using linear mixed models adjusted for baseline scores and routine sociodemographic analysis that could show baseline differences will be conducted. Per-protocol secondary outcome analyses will also be performed. DISCUSSION This is the first Spanish RCT to apply a low-intensity face-to-face MBI (plus TAU) to treat depression in PC settings compared to TAU (alone). Moreover, this study will also make it possible to evaluate the same MBI program (plus TAU), but Internet-delivered, considering their cost-effectiveness. Positive results from this RCT might have an important impact on mental health settings, helping to decrease the overload of the system and offering treatment alternatives beyond antidepressant medication through high-quality, flexible PC interventions. TRIAL REGISTRATION Clinical Trials.gov NCT03034343 . Trial Registration date 24 January 2017, retrospectively registered.
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Affiliation(s)
- Alba Lopez-Montoyo
- Universitat Jaume I, Av. Vicente Sos Baynat s/n, 12006, Castellón, Spain
| | - Soledad Quero
- Universitat Jaume I, Av. Vicente Sos Baynat s/n, 12006, Castellón, Spain.
- CIBER de Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Madrid, Spain.
| | - Jesus Montero-Marin
- Primary Care Prevention and Health Promotion Research Network (RedIAPP), Zaragoza, Spain
- University of Zaragoza, Zaragoza, Spain
| | - Alberto Barcelo-Soler
- University of Zaragoza, Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), Zaragoza, Spain
| | | | - Daniel Campos
- Universitat Jaume I, Av. Vicente Sos Baynat s/n, 12006, Castellón, Spain
- Aragón Health Research Institute (IIS Aragón), Zaragoza, Spain
| | - Javier Garcia-Campayo
- Department of Psychiatry, University of Zaragoza, Zaragoza, Spain
- Psychiatry Service, Miguel Servet Hospital, Zaragoza, Spain
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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: 179] [Impact Index Per Article: 35.8] [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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Abstract
Withdrawal reactions when coming off antidepressants have long been neglected or minimised. It took almost two decades after the selective serotonin reuptake inhibitors (SSRIs) entered the market for the first systematic review to be published. More reviews have followed, demonstrating that the dominant and long-held view that withdrawal is mostly mild, affects only a small minority and resolves spontaneously within 1-2 weeks, was at odd with the sparse but growing evidence base. What the scientific literature reveals is in close agreement with the thousands of service user testimonies available online in large forums. It suggests that withdrawal reactions are quite common, that they may last from a few weeks to several months or even longer, and that they are often severe. These findings are now increasingly acknowledged by official professional bodies and societies.
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Eveleigh R, Speckens A, van Weel C, Oude Voshaar R, Lucassen P. Patients' attitudes to discontinuing not-indicated long-term antidepressant use: barriers and facilitators. Ther Adv Psychopharmacol 2019; 9:2045125319872344. [PMID: 31516691 PMCID: PMC6724488 DOI: 10.1177/2045125319872344] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/02/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Long-term antidepressant use has increased exponentially, though this is not always according to guidelines. Our previous randomized controlled trial (RCT) showed that participants using antidepressants long term without a proper indication were apprehensive to stop: only half were willing to attempt to discontinue their antidepressant use. The objective of this study was to explore participants' barriers and facilitators for stopping long-term antidepressant use without a current proper indication. METHODS Semistructured interviews with participants from the intervention group of our RCT, a cluster-RCT in general practice in the Netherlands. The latter study was a stop trial with patients on long-term antidepressant use without a current indication (no psychiatric diagnosis). Participants of the intervention group of the RCT had been provided with advice to stop antidepressants. Participants of the current interview study were purposively sampled (from the intervention group of the RCT) to ensure diversity in age, sex, and intention to discontinue the antidepressant. Analysis was performed as an iterative process, based on the constant comparative method. Data collection proceeded until saturation was reached. RESULTS A total of 16 participants were interviewed. Fear (of recurrence, relapse, or to disturb the equilibrium) was the most important barrier; prior attempts fueled these anticipations. Also prominent as a barrier was the notion that antidepressants are necessary to counter a deficiency of serotonin. Facilitators were information on duration of usage given at the time of first prescription and confidence in a successful attempt. We found many participants struggling between barriers and facilitators to discontinue and participants not discontinuing while experiencing no barriers (ambivalence). CONCLUSION Fear is an important motive for patients considering discontinuation of antidepressants. Serotonin deficiency as explanation for antidepressant effectiveness promotes life-long use and hinders discontinuation of antidepressant treatment. The prospect of discontinuation at first prescription can facilitate a future discontinuation attempt. General practitioners should be aware of their patients' fears, expectations, and attributions toward antidepressant use/discontinuation, and of new developments in taper methods.
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Affiliation(s)
- Rhona Eveleigh
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Anne Speckens
- Department of Psychiatry, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Chris van Weel
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Richard Oude Voshaar
- University Centre for Psychiatry and Interdisciplinary Center for Psychopathology of Emotion Regulation (ICPE), University Medical Centre Groningen, The Netherlands
| | - Peter Lucassen
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, Netherlands
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