Easier to Refill Than Review: Antidepressant Prescribing in Primary Care

A new article published in Research in Social and Administrative Pharmacy finds that time constraints, conflicting priorities, and fear of relapse of mental health issues were the main barriers to healthcare professionals assisting in the discontinuation of antidepressants.

The chief enabler of stopping antidepressant use was knowledge and skills about how to discontinue these drugs and access to support safely. The current work, led by Bethany Atkins from the University of Leicester in the UK, additionally finds that the most common interventions for increasing antidepressant discontinuation rates include training for healthcare professionals (HCPs) and increased availability of information about tapering. These interventions showed mixed results in increasing discontinuation rates.

The authors write:

“Provision of knowledge and skills to HCPs around antidepressant treatment and discontinuation, as well as access to alternatives to antidepressants to provide to patients, are both enablers that require addressing in an intervention to support primary care HCPs to discontinue antidepressants that are no longer needed. Insufficient time, lack of access to alternatives to antidepressants, fear of relapse and an expectation that patients initiate antidepressant discontinuation discussions are barriers reported in the research literature … However, existing interventions fail to address the barriers that HCPs report, which may explain the limited success in increasing antidepressant discontinuation.”

The goal of the current research was to investigate the barriers and enablers for HCPs in assisting with antidepressant discontinuation for service users diagnosed with “common mental disorders” (CMDs). The authors also wanted to evaluate what interventions exist in the literature for increasing these discontinuation rates. They decided to use a scoping review approach in which they mapped the key concepts, evidence, and gaps in the current literature around HCPs assisting in the discontinuation of antidepressants for people diagnosed with CMDs.

To be included in the current work, studies had to have HCPs as their participants, report on barriers and enablers or interventions around HCPs assisting with antidepressant discontinuation, be original, peer-reviewed research published in English, and be focused on the primary care setting, discontinuation of antidepressants prescribed for one or more of the following CMD diagnoses:

• Mild to moderate depression
• Generalised anxiety disorder (GAD)
• Obsessive-compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Panic disorder
• Social anxiety disorder

Studies that included discontinuation of antidepressants prescribed for a condition other than a CMD diagnosis, conference abstracts, reviews, editorials, case reports, and non-research letters were excluded from the current study.

In total, 17 studies were included in the current research. Nine studies discussed barriers and enablers to HCPs assisting in antidepressant discontinuation. Eight studies examined interventions for HCPs designed to increase antidepressant discontinuation rates.

The barrier and enabler studies were conducted between 2010 and 2022, and nearly half were from the UK (4). The remaining five studies came from Australia, Ireland, Belgium, Norway, and the Netherlands. Eight of nine studies were qualitative and used semi-structured interviews to collect data. One study was quantitative and used an online survey. All included studies examined general practitioner perspectives. Five studies focused exclusively on general practitioners’ perspectives; two included service users; one included nurses; and one included perspectives from many different healthcare and mental healthcare professionals.

The included intervention studies were conducted between 2012 and 2023 in the Netherlands (4), the UK (3), and Australia (1). Four studies were randomized controlled trials (RCTs), two were completed RCTs, one was a cohort study, and one was a qualitative report on the development of an intervention. All the included intervention studies had a primary outcome measure of antidepressant discontinuation at 6-12 months. One study also used the Patient Health Questionnaire to evaluate depressive symptoms among service users as a primary outcome measure.

Barriers

Time constraints were cited by a majority of studies as a barrier to HCPs helping with antidepressant discontinuation. HCPs reported having little time to evaluate prescriptions and short consultations without enough time to provide the support needed for quitting these drugs. They also described repeat prescriptions as “easier” compared to discontinuation.

HCPs said medication reviews were uncommon, and when they occurred, discontinuation was not a priority. Additionally, two studies cited limited access to support resources and a disconnection between the care offered by general practitioners and psychiatrists as barriers. In general, HCPs were not concerned about the safety of antidepressant use.

HCPs feared relapse in service users’ mental health problems. This was especially true for older service users. Continuing to prescribe antidepressants was generally viewed as “less risky.” HCPs worried that any potential relapse would be blamed on them. They also felt pressure from nurses and relatives to continue prescribing antidepressants.

HCPs generally believed the responsibility for raising the topic of discontinuation rested with the service users and their families. This assumption acted as another barrier to discontinuation. They also reported that discontinuation of antidepressants was the responsibility of the initial prescriber.

“Weak” HCP-service user relationships were another barrier cited in the included studies, along with inconsistencies in recommendations between providers. HCPs’ lack of knowledge around discontinuation and unclear tapering guidelines also acted as barriers to HCPs helping service users quit these drugs. Service user reluctance, including one study that reported service users adopting antidepressant drug use as part of their identity, was another significant barrier.

Enablers

HCPs reported access to additional support as a leading enabler of antidepressant discontinuation. HCP training and education were also viewed as key enablers. Continuity of care, a strong HCP-service user relationship, knowledge of service user experience, and being involved with the initial prescription were all mentioned by HCPs as enablers in their assisting service users in quitting antidepressant drugs. Adjustments in prescribing systems and practice policies to make it more difficult to issue repeat prescriptions were also mentioned as enablers.

Interventions

Neither of the two RCTs included in the current work found that their investigated interventions were successful in increasing antidepressant discontinuation rates. Tapering support materials, paired with mindfulness-based cognitive therapy, did not increase discontinuation rates. Giving nurses tapering information and offering service users consultations had limited success in improving discontinuation rates. Discontinuation rates further increased when tapering information and consultations were paired with mindfulness-based cognitive therapy.

Letters written to general practitioners advising them to discontinue antidepressants, along with tapering advice, resulted in a decrease in discontinuation rates. Prompting general practitioners to review service users’ conditions and medications was moderately successful in increasing discontinuation rates. This resulted in one in four service users having their antidepressant prescription altered. However, the authors note that only 7% of service users stopped taking these drugs, and just 12.8% reduced their dose.

The authors acknowledge two main limitations to the current work. They examined only studies published in English, limiting inclusion of data from non-English-speaking countries. They only included peer-reviewed studies, which may have missed relevant information from other sources. Additionally, the studies included were all from high-income Western countries, greatly limiting generalizability to different populations.

Service users commonly report adverse effects of antidepressants. This includes reduced interpersonal function, adverse emotional effects, long-lasting sexual dysfunction, doubled risk of agitation and violence, increased morbidity and mortality, and increased risk of suicide at all ages. While these and other significant adverse effects are common in the literature, clinical trials often underreport the harms of antidepressant drugs.

Antidepressants are no better than a placebo for the vast majority of service users and are associated with minimal benefits. One study found that antidepressants are “largely ineffective and potentially harmful.” As a result of the numerous harms and negligible benefits, some researchers have said it’s time to stop recommending antidepressants for depression.

Antidepressant withdrawal has been linked to severe, life-altering consequences. Slow tapering is likely the best way to limit withdrawal when stopping these drugs.

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Atkins, B., Maden, M., Birt, L., Tromans, S., Swithenbank, Z., Kersey, O. R., Smith, P., & Scott, S. (2025). Primary care healthcare professionals supporting patients to discontinue antidepressants: A scoping review of barriers, enablers and interventions. Research in Social and Administrative Pharmacy, 21(6), 431–443. (Link)