Accepted Manuscript - BJGP -BJGP.2020.0913
Accepted Manuscript
British Journal of General Practice
GPs’ insights about discontinuing long-term antidepressant
use: a qualitative study
Donald, Maria; Partanen, Riitta; Sharman, Leah; Lynch, Johanna;
Dingle, Genevieve; Haslam, Catherine; van Driel, Mieke
DOI: https://doi.org/10.3399/BJGP.2020.0913
To access the most recent version of this article, please click the DOI URL in the line above.
Received 07 October 2020
Revised 21 December 2020
Accepted 06 January 2021
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Accepted Manuscript - BJGP -BJGP.2020.0913
GPs’ insights about discontinuing long-term antidepressant use: a qualitative study
Maria Donald
1
, BA(Hons), PhD, Senior Research Fellow
Riitta Partanen
2
, MBBS, FRACGP, DRANZCOG, GP and Associate Professor
Leah Sharman
3
, BPsyc(Hons), PhD, Postdoctoral Research Fellow
Johanna Lynch
1
, MBBS, FRACGP, FASPM, Grad Cert (Grief and Loss), PhD, GP and Senior Lecturer
Genevieve A. Dingle
3
, BA, BSc(Hons), PhD (ClinPsych), Associate Professor in Clinical Psychology
Catherine Haslam
3
, BSc(Psychology), MClinPsy, PhD, Professor
Mieke van Driel
1
, MD, MSc, FRACGP, PhD, GP and Professor of General Practice
The University of Queensland
1. Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Herston, QLD
4029, Australia.
2. Rural Clinical School, Faculty of Medicine, The University of Queensland, Hervey Bay, QLD
4655, Australia.
3. School of Psychology, Faculty of Health and Behavioural Sciences, The University of
Queensland, St Lucia, QLD 4072, Australia.
Corresponding author: Dr Maria Donald
Primary Care Clinical Unit, Faculty of Medicine
The University of Queensland
Level 8, Health Sciences Building
Royal Brisbane and Women’s Hospital Campus
Brisbane QLD 4029
[email protected]
Accepted Manuscript - BJGP -BJGP.2020.0913
1
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 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.
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’, speaks to the complex decision-making GPs undertake in determining
whether a patient is ready to discontinue. The second, ‘A journey taken together’ captures 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’ describes what GPs
would like to see change to better support them and their patients to discontinue antidepressants.
Conclusions
GPs see discontinuation of long-term antidepressant use as more than a simple deprescribing
decision. It begins with considering a patients’ 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.
Keywords
Antidepressant discontinuation; long-term antidepressant use; general practice; qualitative
research; depression
How this fits in
Most antidepressant prescriptions are generated in general practice and discontinuation is
challenging. Understanding GPs’ insights into decision-making around discontinuing long-term
antidepressant use is needed to underpin change. This study points to discontinuation as a journey
for the GP-patient dyad that is not a simple deprescribing decision but is built on relationship and
grounded in enabling social context.
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INTRODUCTION
Evidence suggests a steady rise in antidepressant use reported in the UK, Netherlands, USA and
Australia can be explained by an increase in long-term use.
1-6
While antidepressants can be effective
in major depression,
7
meta-analytic evidence indicates they are no more effective than placebo in less
severe depressive disorders.
8-10
Indeed, an emerging body of research suggests considering treatment
discontinuation for some long-term users.
11-14
Prolonged use is a concern because of the potential for
avoidable side effects and serious adverse events, including upper gastro-intestinal bleeding,
hyponatremia, stroke, falls and fractures,
15-17
alongside emotional numbing, weight gain, sleep
disturbance, sexual dysfunction,
18,19
and loss of personal agency.
20
General practice is the setting in which depression is most commonly treated and antidepressants
initiated and maintained.
2,21,22
And whilst most long-term use is associated with recurrent depression,
one third of long-term users are in remission with no clear reason for continued use.
21,23
This suggests
considerable scope within general practice for treatment re-evaluation and discontinuation of
antidepressants.
Effective change in prescribing practices must be built upon an understanding of general
practitioners’ (GP) and patients’ perspectives and the context in which it takes place. A 2010 UK study
found a widespread belief among GPs and patients in the efficacy of antidepressants and only few
concerns about side effects, resulting in little impetus for change.
24
A more recent systematic review
synthesised the patient perspective.
25
Barriers include patient dependence, unpleasant withdrawal
symptoms, and fear of relapse. Also, when patients hold the view that depression is a long-term
condition, biological in nature, and are pessimistic about its curability, they are more reluctant to
consider discontinuation. Key facilitators for patients include confidence in one’s ability to cope, a
self-identity focused on being healthy or one’s true-self, and a sense of stability in life circumstances
as well as guidance and support from significant others, including their prescribing doctor. Despite
this central role in initiating discontinuation, GPs may continue to prescribe as they are reluctant to
disturb the therapeutic alliance.
24
This patient-GP dyad has been highlighted in other research.
26
Nevertheless, in their review Maund et al
25
argue there are insufficient data to capture the GP
perspective, a gap that the present paper—exploring GPs’ insights about long-term antidepressant
use—addresses.
METHOD
Setting, participants and recruitment
A convenience sample of GPs was recruited through advertising in two Australian Primary Health
Networks’ newsletters, emails to professional networks, and flyers distributed through university
teaching networks and GP practices. Interested GPs contacted the research team via email and
further information describing the rationale for the research was provided via an information sheet.
All GPs provided informed, written consent to participate and were provided the questions prior to
interview allowing them the opportunity to consider their viewpoints.
Data collection
Interviews were semi-structured and informed by published literature on long-term antidepressant
prescribing
24,26
and the clinical experience of the research group. The interview guide (Box 1) was
piloted with two GPs (data not included in analysis) and revised before study commencement. The
interviews were conducted by telephone or face-to-face by four authors (all female) with previous
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interview experience, including two with training in psychology (MD and LS) and two GP clinician-
researchers (RP and JL). Interviews continued until data saturation occurred; with no new ideas
identified in responses. Interviewers recorded field notes during and after interviews. All interviews
were audio-recorded, transcribed verbatim, checked, and anonymised.
Analysis
Data were analysed using reflexive thematic analysis, an approach appropriate for identifying
patterns of meaning across data and suitable for questions related to understanding people’s
experiences.
27,28
Two members of the research team (MD and RP), independently read a selection of
transcriptions, coding and adding notes as they familiarised themselves with the data. Initial codes
were created through collaboration of these two principal coders. They then continued to analyse
the data by reading and re-reading all transcripts with regular review of the codes, combining,
clustering and collapsing them, ultimately generating prototype themes. Four further (JL, LS, GD and
CH) authors read and coded a pragmatically selected subset of transcripts. Team agreement was
sought as the themes were reviewed, refined and reordered ensuring a concise and meaningful
representation of the data. NVivo (version 12) was used to aid data management and analysis.
RESULTS
Twenty-two interviews were conducted between June and September 2019. Interviews lasted
between 20-60 minutes (mean 35), 16 were by telephone and 6 face-to-face. Participants were aged
between 33-73 years (mean 47), with 13 male and 9 female, 16 practiced in the state of Queensland
(with 2, 3 and 1 located in New South Wales, Victoria and South Australia respectively), and the
number of years since graduation ranged from 5-34 years. Practice postcodes indicated all GPs worked
in either urban (n=11) or inner-regional (n=11) settings. A review of GP practice websites indicated six
GPs had a specific interest in mental health.
Three main themes provide the overarching structure under which GPs’ insights are discussed within
each subtheme. Table 1 lists these with a summary statement reflecting the focus of each subtheme.
Theme 1. Not a simple deprescribing decision
GPs emphasised discontinuing long-term antidepressant use was broader than a medical
deprescribing decision. This theme describes the thorough exploration of the patient’s context, the
complexities involved in shared decision-making, and extensive consideration required to assess
preparedness for discontinuation.
Assessing patient preparedness
Personal and social circumstances were viewed as equally important as recovery from depression in
assessing patient readiness. Having a stable relationship, employment, presence of social supports,
low financial stress, awareness of triggers, engagement in self-care and healthy lifestyle were
repeatedly advocated as critical:
‘And so it’s normally at a stage when they’re quite stable mentally and they feel pretty good in
themselves, they haven’t really needed any other psychological interventions and that’s usually
when I find they’re more responsive to coming off therapy when there’s no other crises going on in
their life.’(GP04:M:38yrs)
Patient reluctance was a potent barrier to GPs broaching the topic of discontinuation. They used
language to describe this reluctance such as ‘pretty adamant’(GP20), ‘once they’ve made up their
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mind’(GP14), and ‘hesitant’(GP05). GPs acknowledged patient relationships with antidepressants may
undermine their preparedness and noted patients need to want to stop. In particular, several GPs felt
the relationship some patients have with their antidepressant is part of their identity and this may be
a barrier:
‘I think the single biggest factor is really the patient factor. If the patient really finds that they like
the sedation, they’ve got a sense of ‘I can’t change’…, ‘This is who I am.’ And ‘It’s expensive and I
haven’t got time….And I don’t want to change my lifestyle because if I do there are other
consequences and it’s just a bit too hard.’(GP10:F:54yrs)
Failed previous attempts can moderate patients’ future readiness, raising the level of concern among
GPs about enabling unsuccessful attempts:
‘Because if you stop them at the wrong time you lose the opportunity to stop them again in the
future sometimes.’(GP12:M:36yrs)
There were circumstances where GPs would not attempt discontinuation even if indicated. They
mentioned the importance of respecting patients’ preference to remain on their medication. A few
GPs indicated that for older patients who have been on antidepressants for a long-time (in some cases
decades) ‘getting depressed again is usually not worth the risk’(GP09). Others suggested dose
reduction rather than discontinuation was an adequate outcome in some circumstances, particularly
when the patient is reluctant to cease, is in an unsafe environment, has inadequate social supports,
or has experienced significant trauma:
‘If a patient wasn’t willing. I mean I’d have the conversation with them and I’d try to explain it. But
for example this elderly lady that I’m thinking of… she just didn’t feel like she could manage without
it. And I felt that what I understood of her childhood trauma and the fact that I was meeting her in
her seventies, I had to just trust her judgement on that. And that maybe she did have quite profound
ongoing impacts of that trauma that meant she needed to continue the medication or at least felt
that she did. So I just had to respect her decision on it.’(GP07:F:46yrs)
Subjective and relational decision-making
GPs described their decision-making in intuitive and relational terms. They mentioned trust, being
aware of the person’s situation and highlighted the subjective nature of the decision-making:
‘So you feel like you really are doing this alone and there’s not really clear guidelines about when
you should stop medication; it’s all a little bit subjective. …So it is sort of based on intuition and a
good relationship with the patient so that is sometimes not as clear-cut as following a guideline
and that might also be what stops us discontinuing it. It’s quite a subjective area. (GP14:F:33yrs)
GPs repeatedly likened the process of antidepressant discontinuation to smoking cessation or
dependence management, with one GP describing them as ‘modern day mother’s little helper’ and a
‘crutch’ (GP10), while another said:
‘But to me it’s a little bit like quitting smoking, they’ve got to be ready to want to stop, even if you
tell them about the side effects and that they don’t need to be on it as many times as you want but
if they’re not ready then in my experience it won’t go very well.’(GP14:F:33yrs)
Strength of the GP-patient alliance influences decision-making about whether to raise discontinuation,
or challenge a patient’s reluctance to try or indeed try again. A weak therapeutic alliance is a barrier:
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‘Are they my regular patient…are they likely to come back to me? I don’t think that...if there was
you know the inability to follow-up easily that I would do it’(GP22:F:52yrs)
Weighing up benefits and risks
GPs agreed there are many benefits and few risks to ceasing long-term use when no longer indicated.
The reversal or removal of side effects, the removal of emotional numbing, reduced medication
burden, reduced polypharmacy risks and removing the burden of cost are all motivators for
discontinuation. Many GPs’ emphasised the empowering effect of being released from medication
reliance. They felt discontinuing could increase a patient’s well-being by virtue of them being able to
manage symptoms and recognising they were in control rather than feeling the medication was
controlling the symptoms:
‘The patient gains new life, they feel like ‘I don’t need it! I’ve regained my life. I don’t need to be
dependent on anything.’(GP16:M:62yrs)
Few GPs expressed concern about the risk of suicide, the risk of relapse was the most common
concern:
‘The risks are that you can make a stable situation unstable and so that is a risk that you have to
weigh up.’(GP22:F:52yrs)
Theme 2. A journey taken together
GPs emphasised there is no standardised approach, it is about finding the appropriate strategy for
each patient. Discontinuation was described as a journey taken together with ongoing discussions
over time to review progress and better prepare patients to optimise outcomes. Making clear to
patients they are not doing this alone is key and requires being fluid and responsive to the patient and
their circumstances.
Planting the seed for change
Joint reflection with patients about why antidepressants were initiated and using the right language,
can increase the likelihood of successful discontinuation. GPs used tentative language such as ‘broach
the subject’ (GP14), or said they ‘keep bringing it up’ (GP19) with the patient from time to time. They
considered themselves to be planting the seed:
‘So I would say ‘Can we consider getting you off this?’ And either acting on the thought there if
they’re agreeable or planting the seed that maybe next time we could do that or in a few months’
time when their life’s treating them a bit better to give it a go.’(GP11:M:38yrs)
GPs argued for setting-up a period of preparation where enablers of success could be put in place:
‘We plan the timing of the first step down, we make sure it’s a good time in their life… not at a
stressful time.’(GP20:F:58yrs)
Some GPs use standardised tools for identifying symptom change as part of the discussion with
patients about discontinuation:
‘I don’t want to spend too much time on tools, … I find it’s a useful measurement to discuss with the
patients about how effective the antidepression treatment is. So if I can say - look your K10 when
we started you on the antidepressants you were thirty-five and now you’re down to twenty-two… I
think it’s having a good effect.’(GP10:F:54yrs)
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Co-designing a personalised plan
Gradual tapering was mentioned almost universally as critical for discontinuation. Many GPs
recognised that tapering plans need to be personalised as weaning periods are hard to establish due
to variation in antidepressant type and dose, the message was clear—they go as slow as needed and
generally slower than withdrawal regimes suggest:
‘I just go slow as I think the patient [needs]… and look we might get to a dose that’s not therapeutic
but it’s sort of a more just easing them back in to nothing and just showing them that they can do
this without the medication.’(GP14:F:33yrs)
Being proactive about relapse planning is central to the process. Talking to patients about how they’ll
recognise if they’re not doing well, possible warning signs, and what they might do if they notice these
signs, such as calling on social supports, returning to the GP or re-engaging with mental health support
were all mentioned as important:
‘And I really like them to have at least talked about their other strategies they might use to manage
things given that life does throw people curve balls. …Trying to out loud describe what they might
do to both prevent and also monitor things…What are their early warning signs?…What might they
do if they notice that? When would they come back to see me, when would they go and see their
counsellor? Would they call on their support people? Just having a bit of a plan around
that.’(GP20:F:58yrs)
GPs felt inadequate discontinuation planning meant patients may mistake withdrawal for relapse so
preparing patients by helping them distinguish between withdrawal and relapse is key, as is preparing
patients for the possibility that ceasing long-term use may be uncomfortable:
‘I warn patients as much as possible about the fact that they will get some withdrawal… I’ll also
suggest to them that it will be uncomfortable but it’s likely to be short-term... I try to distinguish
between the immediate sort of two-week [withdrawal] effect rather than the two-month [relapse]
effect and tell them what might feel different about those scenarios and... that one is quite highly
expected and the other...hopefully won’t happen.’(GP10:F:54yrs)
Care continues during and after discontinuation
Regular review during discontinuation enables symptom monitoring and reinforcing the importance
of adhering to lifestyle measures, such as exercise, diet, sleep hygiene, social supports, and possibly
psychological support. The value of frequent and regular review was stressed:
‘But if they’ve been on it for a long period of time then I’ll want to see them every two weeks or
even every week depending on how comfortable they feel. Because if they’re not supported at the
cessation stage then they will most likely say I will need to be on this for the rest of my life’.(GP19:
M:33yrs)
GPs had mixed opinions about whether a patient who was feeling ‘well’ would want to engage with
psychological support. Some felt reengaging with psychological support and social groups may make
discontinuation more successful:
‘I won’t say a better time but it might be at a time that if they’re better they’re actually more likely
to go along [to non-pharmacological support]. Whereas at the beginning stage it’s very hard …
when people don’t have motivation to get out of bed... So maybe when they’re recovered it’s
better.’(GP11:M:38yrs)
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Theme 3. Supporting change in GPs’ prescribing practices.
This theme conveys GPs’ ideas about the individual, practice and societal changes needed to support
them to discontinue long-term antidepressants.
Redressing repeat prescribing as the quick fix
Providing a script for antidepressants was seen as an easy GP action that might allay symptoms as well
as comfort patients. For example, one GP noted it was often easy to ‘let sleeping dogs lie’ and ‘don't
fix it if it ain’t broke’(GP02). Prescribing and repeat prescribing were viewed in some cases as easier
than attempting to address patients’ often complicated economic, social and personal issues through
lifestyle change and talking therapies:
‘So I suppose it is easier to prescribe a medication than it is to counsel, look at non-pharmacological
things. It may feel like you’re doing more by giving a medication than just saying oh we’ll try these
other things.’(GP02:M:56yrs)
GPs saw antidepressants used in a way that ‘disempowered’(GP10) and caused ‘learned
helplessness’(GP10) and wanted to redress the approach to them as a panacea for all distress. In
particular, GPs felt it was imperative to be clear about the limited duration of antidepressant use on
their commencement, thereby avoiding any pre-established beliefs patients may have about
antidepressants being for life, and priming them for the discontinuation conversation in future:
‘So when I do start someone on antidepressants I say ‘Well I don't believe this should be something
you take forever... I intend to review it every three months and then to come off after you’ve been
stable for at least six months.’(GP17:M:36yrs)
While patients’ attitudes and reluctance to discontinue can reinforce and encourage the use of
antidepressants as a quick fix, GPs also commented on the need to redress their own ‘set and
forget’(GP22) attitude:
‘There is a little bit of an underlying rule that once you start this medication nobody thinks to stop
it.’(GP14:M:33yrs)
Inadequate evidence to support discontinuation
GPs distinguished between evidence about side effects and evidence about adverse health outcomes
of long-term use. The former has a strong evidence-base well-articulated by GPs. Yet, there was an
awareness that despite the widespread use of antidepressants, there was limited research
investigating potentially adverse health outcomes of long-term use. GPs felt it was difficult to have the
conversation with patients or justify to them they should come off antidepressants without being able
to communicate the harms of long-term use:
‘I think that long-term evidence is actually quite limited about any harms of long-term use. It is very
difficult because most of the trials with antidepressants are short-term.’(GP09:M:54yrs)
Practice-based change
Most GPs felt they had sufficient knowledge and experience to provide adequate advice to patients
around discontinuation. Yet increased education for GPs in a variety of mediums, patient handouts
and better support for GPs were all mentioned as potentially helpful. Opportunities for auditing and
benchmarking was a common recommendation:
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‘I think… clinical audits are good things… maybe not an in depth clinical audit but just something as
part of a continuous professional development program.’(GP02:M:56yrs)
They spoke about removing well-known service delivery obstacles that interfere with their ability to
deliver comprehensive and independent mental health care in general practice:
‘I worry that it has something to do with the push to do six minute medicine and that this is the
easier option sometimes than spending time with the patient and talking with the patient... I hope
we’re educating our GPs better than that and we’re empowering them to do more without
medication’.(GP22:F:52yrs)
GPs pointed out there is conflicting advice about the rate at which antidepressants should be reduced.
Some preferred to be guided by their own clinical experience and protocols. Current guidelines
provide little clear advice for managing patients who are long-term users:
‘So in terms of guidelines, I’m not aware of any if there’s any.’(GP16:M:62yrs)
Several GPs mentioned the ongoing influence of the pharmaceutical industry in general practice and
its potential contribution to medication overuse, including long-term use of antidepressants:
‘And just finally I think that the biological model of management of depression and anxiety has
been so strong for so long that drug companies are really at the centre and core of all of this and
that unfortunately the majority of doctors are getting their education from drug companies directly
or indirectly.’(GP10:F:54yrs)
Solutions beyond general practice
Having better access to affordable psychologists, including in-house psychologists and other non-
pharmacological supports at the point of discontinuation were seen as enhancers of success:
‘… we’ve got access to psychologists but it’s not ready access….’ (GP08:F)
Although being interviewed about a clinical deprescribing process, GPs were repeatedly drawn to
make non-medical observations about the use of antidepressants and many sought solutions within
the broader social and policy environment. Some believed there was a need to shift the conversation
to one that considered how mental health and antidepressants were viewed in the community, and
how current attitudes and beliefs could contribute to a culture of over-prescribing and low rates of
discontinuation:
‘It’s probably nothing to do with doctors, its’ actually changing the conversation in our society
about what causes anxiety and why… the management of anxiety base line is not a medication, it’s
not a drug, but it’s about finding ways to manage it by changing your lifestyle.’(GP10:F:54yrs)
DISCUSSION
Summary
Effective change in long-term antidepressant prescribing must be built upon an understanding of GPs’
and patients’ perspectives yet few studies have explored GPs’ perspectives. Our study aimed to
address this gap. The study revealed that discontinuation of long-term antidepressants is more than
a simple deprescribing decision. It requires a thorough exploration of the patient’s social and personal
circumstances, beliefs, and potential risks and benefits to assess preparedness. The GPs interviewed
in this study described discontinuation as a journey taken together with the patient, involving ongoing
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9
discussions over time to review goals and prepare patients by setting-up adequate support before,
during and after discontinuation to optimise outcomes. GPs stressed the need for better support to
undertake the complex and time-consuming work involved in ceasing long-term use and redressing
the ‘set and forget’ attitude originating in the ease/convenience of prescribing and repeat prescribing,
as well as gaining evidence of the harms of long-term use, and seeking solutions within broader social
and policy environments.
Strengths and limitations
The collection of in-depth data grounded in GPs’ experiences of discontinuing long-term
antidepressant use with their patients was a strength of this study. Although some GPs interviewed
had a specific interest in mental health, recruitment methods allowed for GPs with a range of skills to
be included. Nevertheless, given the nature of our sampling method we may not have fully captured
the breadth of opinion and knowledge especially of GPs with limited experience in working with
patients in this context or interest in being interviewed about it. The findings reflect the views of GPs
working in urban and regional contexts and may not reflect the experiences of rural GPs. They also
capture an Australian GPs’ perspective; though, the non-health-system related themes are likely
relevant to GPs in other health systems. Multiple interviewers allowed flexibility in scheduling of
interviews and use of a semi-structured interview schedule with regular interviewer meetings
supports consistency in approach. However, this could be a strength as it may have added to the
diversity of opinions captured. Likewise, data analysis was undertaken not only by GPs but also by
those with a background in mental health providing broader perspectives.
Comparison with existing literature
Most studies have focused on the patient perspective of long-term antidepressant use and suggest a
key barrier to discontinuation is a patient’s belief that their GP is responsible for initiating discussions
about discontinuation.
25
And while this underlines the need for GP vigilance in raising the idea of
discontinuation with patients, our findings highlight the complex decision-making GPs go through in
deciding whether to raise the issue. The few previous studies investigating GPs’ perspectives show
that patients’ difficult life circumstances are a barrier to GPs initiating discontinuation.
25
The extent
to which GPs in our study considered life circumstances in assessing patient preparedness for
discontinuation reinforces this and highlights the social and relational nature of shared decision-
making in this context. Aligning our findings with those of Wentink et al
29
who call for a comprehensive
Decision Aid to facilitate more confident shared decision-making, and emphasising, as others have,
that respect for individual agency, an appreciation of context and a respectful empathic approach to
practice, are essential to delivering patient-centred care.
30
Our findings further align with Wentnick et al in that discontinuation was expressed by GPs as a
journey or ‘Process of discontinuation’
29
, highlighting the steps or ‘practicalities’
29
of discontinuation
including planting the seed, a tailored plan of action with gradual dose reduction and proactive
relapse planning, and ensuring care continues during and after discontinuation. Gradual
personalised tapering was mentioned almost universally as important for discontinuation supporting
previous research suggesting an approach where GPs tailor care to individual needs, may be better
than a standardised schedule.
29
Several GPs interviewed in our study stressed the need to warn
patients about the possibility of unpleasant withdrawal reactions when stopping antidepressants. A
2015 review by Davies and Read found withdrawal symptoms are quite common, can be severe, and
often last from weeks to several months.
31
While there is ongoing discussion about the incidence
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10
and severity of antidepressant withdrawal effects, there is increasing acknowledgment that
withdrawal symptoms are variable with calls to update treatment guidelines and for prescribers to
advise patients about the possibility of withdrawal reactions.
31,32
The emphasis GPs in this study placed on patients regaining a sense of empowerment and control,
reinforces research showing patient’s self-identity as ‘healthy’ or regaining their ‘true-self’ can
facilitate discontinuation.
24
Despite this acknowledgment repeat prescribing of antidepressants was
seen as an easy GP action contributing to set and forget attitudes and concomitant overprescribing.
Previous research showing lack of time for GP review as an important barrier to discontinuation,
24,26,33
is consistent with our findings and emphasises GPs need the clinical time for complex contextual and
relational decision-making around discontinuing antidepressants. Although the GPs interviewed in this
study recognised that, ultimately a culture shift within and beyond the profession is necessary if
attitudes to antidepressant use are to change.
Implications for practice and research
The implications for GPs and patients arising from this research are numerous and contribute to a
small but growing body of research that can inform safe and effective ways to support discontinuing
long-term antidepressant use in general practice.
24
Stopping unnecessary long-term use needs to start
at initiation and GP education and training must give adequate attention to prescribing, repeat
prescribing and deprescribing. A request for a repeat prescription should never be considered a ‘just
a script’ consultation, it should always come with a review of whether this medication is still required.
Resetting the ‘set and forget’ attitude for both GPs and patients is critical and could be assisted by
prescribing audits to facilitate review of antidepressant use.
The findings confirm the commitment in primary care to assessment of the whole person
34
and
support a generalist (not simply psychiatric) decision-making process at the time of initial diagnosis
and prescription.
35
The findings suggest that GPs should be recognised, remunerated, and offered
clinical time to do their complex contextual and relational decision-making around diagnosis,
prescribing and deprescribing of antidepressants. Future research could build on this work, to design
and test multi-modal interventions that assist GPs and the GP-patient dyad to navigate the multi-
layered journey of antidepressant discontinuation. Aligning assessment and treatment of depression
with generalist approaches to the person could build GP confidence in the complex relational and
contextual decision-making skills that underpin the collaborative process of discontinuation of
antidepressants.
Accepted Manuscript - BJGP -BJGP.2020.0913
11
Funding
This research was funded by The University of Queensland through a Faculty of Health and Behavioural
Sciences and Faculty of Medicine seeding grant to encourage cross Faculty collaboration.
Ethical approval
Ethical approval was obtained for the study from The University of Queensland Medicine Low and
Negligible Risk Ethics Sub-Committee (approval number: 2019000948)
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
Acknowledgements
We wish to thank the GPs who participated in this study.
Accepted Manuscript - BJGP -BJGP.2020.0913
12
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Box 1. Interview topic guide
Experiences and Opinions
Can you think of a patient for whom discontinuing long-term antidepressant use was
successful and describe the experience and the process used? (long-term >2 years)
Now can you think of a patient for whom discontinuing long-term antidepressant use
was unsuccessful and describe how the experience was different and why you think
the attempt was unsuccessful?
We know distinguishing between relapse and withdrawal symptoms can be
challenging, can you talk a little about your experience with this in relation to
discontinuing long-term antidepressant use?
Can you describe your monitoring and reviewing process for patients on
antidepressant therapy?
In general terms, what do you think about the role of antidepressants in treating
depression?
Decision-making
What factors play a role in your decision to continue or discontinue long-term
antidepressant use?
What do you see as the risks of stopping long-term antidepressant treatment?
What do you see as the benefits of stopping long-term antidepressant treatment?
Support for GPs
To what extent do you feel you have sufficient knowledge and experience to advise
patients correctly and to help them with discontinuing antidepressants?
What would you need to discontinue long-term antidepressant use with more
patients?
Non-pharmacological support for patients*
What non-pharmacological interventions do you refer patients to?
Are you aware of any low-intensity non-pharmacological interventions (such as online
CBT, guided self-help, wellbeing apps or websites) for patients and do you ever
suggest them to your patients?
The idea of social prescribing in general practice (or community referral to social
groups) is gaining momentum as a model of care, do you have any thoughts about it
and its use in supporting patients who are discontinuing long-term antidepressant
use?
*To be investigated in a separate paper
Accepted Manuscript - BJGP -BJGP.2020.0913
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Table 1 Themes and subthemes
Theme 1: Not a simple deprescribing decision
Focus
Patients’ life circumstances are as important as recovery from
depression in assessing patient preparedness for
discontinuation. GPs acknowledged patient relationships with
antidepressants that can disrupt preparedness to
discontinue.
GPs described decision-making about discontinuation in
intuitive and relational terms.
GPs recognised patient empowerment and sense of recovery
as potent motivators for ceasing long-term use.
Theme 2: A journey taken together
Focus
GPs valued a process of careful preparation for
discontinuation.
A tailored plan of action enables GPs and patients to increase
the likelihood of successful discontinuation: a gradual dose
reduction plan and proactive relapse plan are considered
crucial.
GPs emphasised regular review and encouragement of social
and lifestyle supports during and beyond discontinuation.
Theme 3: Supporting change in GPs’ prescribing practices
Focus
GPs expressed distrust in prescribing norms and felt a need to
shift away from set and forget attitudes.
Discussions with patients about discontinuation would be
facilitated by better evidence about the harms of long-term
use.
GPs expressed well-communicated ideas about practice level
change that would help them discontinue antidepressants.
Discontinuation of long-term antidepressant use at the level
of the GP-patient alliance will be leveraged by action at the
broader system level (e.g. social and policy).