Antidepressant deprescribing: an investigation of what, who, how and why it works in general practice

Problem

Antidepressants are the first line treatment for depression, however concerns about long-term use and side effects have prompted calls for the need to conduct routine deprescribing. GPs prescribe the most antidepressants making them key to this process. However, cessation is intricate due to psychological and physical barriers, hindering routine deprescribing in clinical practice. Patients express willingness to discontinue, yet often rely on GPs to start the conversation. However, reports indicate that this initiation from the GP seldom occurs. With patients taking greater responsibility for the management of their own healthcare, it is vital to offer evidence-based support for safe and effective self-management. This project aimed to identify the support or resources needed by general practice patients to discontinue their antidepressants when no longer clinically required.

Approach

The study comprised three components:

1. A comprehensive scoping review examining 50 deprescribing interventions, aimed at understanding the existing knowledge and resources available for deprescribing in general practice.

2. A thematic content analysis of the reasons provided by 178 antidepressant users for discontinuing their medication, conducted as part of a naturalistic longitudinal study of general practice patients with depressive symptoms.

3. A mixed-methods study, guided by the principles of Realist Evaluation, investigating the experiences and perceptions of 13 patients regarding the patient facing WiserAD approach to antidepressant deprescribing.

Findings

From study 1, the current literature was found to be focused on encouraging clinician led deprescribing efforts rather than empowering patients to broach to conversation. In study 2, patients were found to abruptly cease their medication without clinical support or supervision during periods of stable mental health and often mistook withdrawal for a recurrence of symptoms. The WiserAD pragmatic framework was formed from the results across each of the three studies and included: 1. Initiation of the deprescribing discussion; 2. Patient self-efficacy; 3. Provision of structured guidance; 4. Coaching and clinical advice; 5. Mood, sleep and activity tracking and; 6. Feelings of safety during the tapering period as key mechanisms for commencing and successful completing antidepressant deprescribing. Having established coping skills, prior knowledge and perceptions of antidepressants and stable mental health were found to be important contextual factors for patients deprescribing.

Consequences

This research provided valuable patient perspectives on antidepressant deprescribing in general practice, and the multifaceted considerations involved. The findings underscore the willingness of patients to cease their antidepressants when they are ready and feeling well. The results also emphasize the importance of proactive identification, patient agency, providing clear next steps to initiate deprescribing and clinical support throughout the tapering process. Implementation of the WiserAD framework in clinical practice may empower patients and GPs to engage in routine antidepressant deprescribing and curb long-term antidepressant use.