A new study published in BMJ Open investigates the factors that influence healthcare professionals’ (HP) decision-making around discussing antidepressant discontinuation with their patients. The results of the thematic analysis of the three qualitative interviews, including the perspectives of 39 participants, indicate differing reasons for why HPs approach or disregard antidepressant discontinuation with their patients.
“Five themes were identified and covered who is responsible for broaching the subject of discontinuation, how fear of relapse can dissuade HPs from discontinuing, familiarity with the patient as enabling conversations around withdrawal, the lack of information and support for HPs, and organizational barriers and enablers,” write the researchers, led by Dr. Hannah Bowers of the University of Southampton in the UK.
As the rate of antidepressant prescription has risen since the introduction of selective serotonin reuptake inhibitors (SSRIs) in the ’80s, research has emerged to explain this increase and better understand factors that extend the duration of use. Some 10% of adults take antidepressants, primarily due to general practitioners (GPs) prescribing more often and for more time.
While some individuals might take antidepressants as part of a long-term treatment approach, research suggests some 30-50% continue with no guideline-based indication for continuation. Reasons for prioritizing discontinuation conversations include the burden of side effects, including “weight gain, sexual dysfunction, sleep disturbance, and gastrointestinal bleeding, which increase with longer-term use.”
In older patients, side effects include “increased risk of falls, fractures, seizures, stroke, and hyponatremia.” Also, long-term use may cause “emotional blunting, impaired self-confidence, and increased dependence on health services.”
Bowers and colleagues note previous research found “time constraints and fear of relapse” as barriers facilitating discontinuation conversations, along with one study that revealed some GPs placed the responsibility on patients to initiate the discussion. The aims of the current study were then to expand on these factors in detail, mainly to understand what is shaping decision-making around antidepressant discontinuation for HPs in the UK.
The authors conducted three focus group interviews containing 7-10 participants, as well as three individual interviews offered to psychotherapists, an underrepresented group in this sample, and one GP. The focus groups were informed by the REDUCE program (REviewing long term anti-Depressant Use by Careful monitoring in Everyday practice) and Normalisation Process Theory (NPT), which explains what motivates implementation processes in the work of the participants. The following five themes were extracted from the interviews utilizing a thematic analysis approach.
- Who is responsible for broaching the subject of discontinuation?
There were opposing views on who is responsible for initiating discontinuation conversations, HP or patient? A smaller number of HPs named it as the patients’ responsibility. For example, one participant stated, “’ Look, one of the things about depression is that you lose control and the worst thing is to come to see the doctor, and the doctor takes over control. So, as far as I’m concerned, you’re in control of these tablets and it’s your choice as to when you want to stop it, but usually, the recommendation is six months after you’ve been well’. I think most people—I haven’t audited it—at that stage, do come back round about six months-ish and are keen to stop and usually that works okay.’”
An opposing view is exemplified in a psychotherapist’s claim that “patients may be reluctant to broach the subject due to expectations of how the doctor may respond or perceiving the doctor to be more knowledgeable about the situation.”
Others took the stance of having a shared responsibility with their patients that it would be too much responsibility to fall on just the HP.
- Risk of destabilizing the current situation
Some HPs shared their fear around potentially destabilizing the individual, as well as an assumption that the individual may hold that same fear.
For example, one GP shared, “I think for a lot that are on them, there is a massive fear factor about stopping because they remember how awful they felt. They don’t want to feel like that. They feel well again, and they just think, well, you know, I’d rather just keep the status quo.”
- Continuity and knowing the patients makes it easier to discuss discontinuation
Some HPs named that if you are the initial prescriber of the medication, there is more responsibility on you to prompt discontinuation discussions. Other discussion enablers included “knowledge of the patient’s experience with antidepressants, their triggers for depression, why they started their medication, and how things have changed since the initial prescription.”
- HP’s confidence in their skills and knowledge
A lack of confidence and understanding of the discontinuation process was identified as a barrier. Some HPs named a need for more support and information, one stating, “I don’t think there’s a lot of resources out there to kind of what to say and how to do it.”
- Organizational barriers and enablers to discussing discontinuation
HPs also named the healthcare system as a barrier that prevents discontinuation conversations, “ten-minute consultations not being long enough, and not having the time for review appointments.” They explained that patients can “get lost in the system” and that there may be inconsistent recommendations across care.
This study provides the first evidence of HP’s perspectives on antidepressant discontinuation in UK primary care. More studies are warranted, with a broader scope of professionals and cultural contexts, to be able to generalize results across systems.
Bowers et al. respond to the five identified themes, beginning with acknowledging the relational work that goes into negotiating the decision-making. They suggest systemic changes to clarify responsibility and decision-making, such as a designated person to initiate discontinuation discussions to reduce confusion as patients change providers.
Towards addressing the fear of relapse, Bowers and colleagues name the usefulness of reassuring HPs that the risk may be decreased with adequate psychological support throughout discontinuation since tapering with psychological support has been found to lower long-term depression relapse rates beyond antidepressant maintenance.
Regarding privileging patients’ agency, they reiterate that depression and long-term antidepressant use may reduce the experience of agency and that providers may need to take responsibility to initiate conversations.
Finally, regarding current lapses of knowledge around discontinuation, they write that there is a need to “provide improved guidance and enhanced accessibility to and awareness of guidance on discontinuation, including specific guidance on reducing the doses of different antidepressants.”
Bowers H.M., et al. (2019) Helping people discontinue long-term antidepressants: views of health professionals in UK primary care. BMJ Open. DOI:10.1136/bmjopen-2018-027837 (Link)