Antidepressants in primary care: limited value at the first visit

Arroll, Bruce; Roskvist, Rachel; Moir, Fiona; Harwood, Matire; Eggleton, Kyle; Dowrick, Christopher; Cuijpers, Pim

doi:10.1002/wps.21057

Cited by 2 publications

(1 citation statement)

References 11 publications

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“…For example, in one prospective cohort study, antidepressant use could be stopped, reduced, or switched (deprescribed) in almost one-quarter (23.2%) of antidepressant users [ 6 ]. Potential indications for stopping antidepressants in primary care include their use in mild forms of depression (where benefits are limited [ 1 , 7 , 8 ]), their long-term use for non-psychiatric illnesses such as primary sleep disorders [ 9 , 10 ], and excessive treatment durations [ 5 , 11 – 13 ]. Newer generation antidepressants (e.g., selective serotonin reuptake inhibitors (SSRIs) and selective serotonin-norepinephrine reuptake inhibitors (SNRIs)) are generally considered safer than traditional ones (e.g., tricyclic antidepressants (TCAs)) [ 14 ].…”

Section: Introductionmentioning

confidence: 99%

Deprescribing of antidepressants: development of indicators of high-risk and overprescribing using the RAND/UCLA Appropriateness Method

Brisnik,

Vukas,

Jung-Sievers

et al. 2024

BMC Med

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Background Antidepressants are first-line medications for many psychiatric disorders. However, their widespread long-term use in some indications (e.g., mild depression and insomnia) is concerning. Particularly in older adults with comorbidities and polypharmacy, who are more susceptible to adverse drug reactions, the risks and benefits of treatment should be regularly reviewed. The aim of this consensus process was to identify explicit criteria of potentially inappropriate antidepressant use (indicators) in order to support primary care clinicians in identifying situations, where deprescribing of antidepressants should be considered. Methods We used the RAND/UCLA Appropriateness Method to identify the indicators of high-risk and overprescribing of antidepressants. We combined a structured literature review with a 3-round expert panel, with results discussed in moderated meetings in between rounds. Each of the 282 candidate indicators was scored on a 9-point Likert scale representing the necessity of a critical review of antidepressant continuation (1–3 = not necessary; 4–6 = uncertain; 7–9 = clearly necessary). Experts rated the indicators for the necessity of review, since decisions to deprescribe require considerations of patient risk/benefit balance and preferences. Indicators with a median necessity rating of ≥ 7 without disagreement after 3 rating rounds were accepted. Results The expert panel comprised 2 general practitioners, 2 clinical pharmacologists, 1 gerontopsychiatrist, 2 psychiatrists, and 3 internists/geriatricians (total N = 10). After 3 assessment rounds, there was consensus for 37 indicators of high-risk and 25 indicators of overprescribing, where critical reviews were felt to be necessary. High-risk prescribing indicators included settings posing risks of drug-drug, drug-disease, and drug-age interactions or the occurrence of adverse drug reactions. Indicators with the highest ratings included those suggesting the possibility of cardiovascular risks (QTc prolongation), delirium, gastrointestinal bleeding, and liver injury in specific patient subgroups with additional risk factors. Overprescribing indicators target patients with long treatment durations for depression, anxiety, and insomnia as well as high doses for pain and insomnia. Conclusions Explicit indicators of antidepressant high-risk and overprescribing may be used directly by patients and health care providers, and integrated within clinical decision support tools, in order to improve the overall risk/benefit balance of this commonly prescribed class of prescription drugs.

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