The struggles of antidepressant deprescribing

5 minute read

After 20 to 30 years of conflicting information, mostly provided by pharma companies, new deprescribing guidelines should help support GPs.

The Maudsley Deprescribing Guidelines will hopefully better support GPs deprescribe antidepressants, after decades of misinformation, says the RACGP’s psychological medicine group chair. 

According to a recent study, published in the Australian Journal of Primary Health earlier this month, patients are turning to online support groups due to a perceived lack of clinical support and information when weaning off antidepressants. 

The mixed-method online survey found that patients were turning to “peer support” – online help and education through the likes of Facebook groups – due to feelings of exclusion from shared decision-making about their treatment, unaddressed withdrawal symptoms and perceived lack of clinician skill around deprescribing. 

Speaking to The Medical Republic, chair of the RACGP’s psychological medicine special interest group Dr Cathy Andronis said online support was “part of the modern world”. 

“The world is moving so quickly that the general media publishes things before the journals, let alone by the time it filters through our regulatory authorities,” she said. 

Dr Andronis said she hoped that GPs were helping patients validate the reputability of the information and support they were receiving.  

“Just because something is real support for the patient, it doesn’t mean it’s good support,” she said. 

According to Dr Andronis, it is “fairly universal” for patients to choose to stop various types of medication of their own accord, including antidepressants, without GP input. 

“I would say that probably half our patients just stop drugs on their own,” she said. 

“Many patients don’t even fill out their scripts. 

“So it does happen, but it’s better if it happens with support from the GP so any potential problems – withdrawal effect or relapse – can be monitored. 

“That conversation should be part of the prescribing process because it’s part of informed consent.” 

Deprescribing with the help of a GP, as well as monitoring symptoms, allows integration of other management mechanisms for a patient’s mental health, said Dr Andronis. 

“Prescriptions are only one part of the management of a person’s distress. 

“We know in mental health that even though [antidepressants] play a large part in practice, particularly in some countries, including Australia where we prescribe in relatively large numbers, in reality that’s only part of the treatment for mental health problems.  

“The majority of treatment is about changing lifestyle by taking account of predisposing, perpetuating factors that may be causing the problem or making it worse and helping people to figure out through motivational interviewing, what changes they can make that will improve their life.  

“That can be done with the help of a psychologist or any other mental health professional as well – it’s best to be done as a team approach.” 

Dr Andronis said it was important for prescribers to make it clear from the get-go that antidepressants only treat symptoms and to track their effectiveness. 

“It’s really about taking the time to work out and having the patience to see what works and what doesn’t work,” she said. 

“Most importantly, we really have to be very clear, always when we prescribe, that there are risks and what those risks are.” 

Dr Andronis said it could be hard as a prescriber to remain aware of all possible risks, both of prescribing and deprescribing. 

“We only know the risks that are published, or that we’ve heard about,” she said. 

“We should be talking about deprescribing in a careful, calculated and patient way. 

“We know that at least a third, or maybe half, of patients can go off medications very quickly and don’t appear, or don’t complain about, any withdrawal effects beyond the very short term.  

“But we also know that some people, especially if they’ve been on high doses, have [deprescribed] very quickly or have been on [antidepressants] for a very long time, are at high risk of withdrawal effects, and that these withdrawal effects can last a long time. 

“It’s very difficult to predict for a particular person, how deprescribing will play out.” 

Dr Andronis said GPs should look to the new Maudsley Deprescribing Guidelines, which can be purchased online or should be available through institutions or libraries. 

“They’ve only been out in Australia for a month or two and are very, very comprehensive, very useful and very detailed for all the common drugs that we have in this country and more.  

“They have a very easy outline of how we should be deprescribing drugs in people.” 

Dr Andronis said she hoped that the new guidelines would help improve understanding of antidepressant deprescribing among clinicians. 

“They go against a lot of information that we have had widely distributed to GPs for the last 20 to 30 years, which has been predominantly information provided by drug companies and a handful of studies. 

“[These studies] haven’t focused on the deprescribing or withdrawal effects, which have been very poorly researched until very recently.” 

Ultimately the processes of deprescribing was very individual and should centre around clear communication with patients, said Dr Andronis. 

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