REDUCE (Reviewing long-term antidepressant use by careful monitoring in everyday practice) internet and telephone support to people coming off long-term antidepressants: protocol for a randomised controlled trial

Kendrick, Tony; Geraghty, Adam W A; Bowers, Hannah; Stuart, Beth; Leydon, Geraldine; May, Carl; Yao, Guiqing; O’Brien, Wendy; Glowacka, Marta; Holley, Simone; Williams, Samantha; Zhu, Shihua; Dewar-Haggart, Rachel; Palmer, Bryan D.; Bell, Margaret; Collinson, Sue; Fry, Imogen; Griffiths, Gareth; Gilbody, Simon; Moore, Michael; Macleod, Una; Little, Paul; Dowrick, Christopher

doi:10.1186/s13063-020-04338-7

Cited by 15 publications

(17 citation statements)

References 32 publications

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“…Under normal circumstances such a sample size would prohibit submission to a journal. In the current abnormal circumstances (COVID-19), however, with no further recruitment possible, or appropriate, we hoped our data, however limited, may be helpful to government officials, professional bodies, and researchers, 47 planning for implementation of the hugely important PHE Report once these circumstances abate.…”

Section: Discussionmentioning

confidence: 99%

A survey of UK general practitioners about depression, antidepressants and withdrawal: implementing the 2019 Public Health England report

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Renton

Harrop

et al. 2020

Therapeutic Advances in Psychopharmacology

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Background: In 2019, a literature review indicated that more than half of people who try to come off antidepressants experience withdrawal effects. Both the National Institute of Health and Care Excellence and the Royal College of Psychiatrists updated their positions in line with that review, and Public Health England published a 152-page report called Dependence and withdrawal associated with some prescribed medicines: an evidence review. The report made several recommendations relevant to general practice. Method: In order to facilitate implementation of these recommendations, an online survey was designed to explore United Kingdom general practitioner (GP) experiences, opinions, knowledge and needs in relation to depression, ADs and withdrawal. A total of 66 GPs had completed the survey when COVID-19 occurred. Results: In keeping with previous findings, this small sample of GPs had a predominantly psycho-social perspective on the causes of, and treatments for, depression. They broadly considered ADs effective for moderate/severe depression and ineffective for minimal/mild depression, for which they preferred psychological therapies and social prescribing. There was a marked lack of consistency in GPs’ knowledge about the incidence and duration of withdrawal effects. Only a minority (29%) felt their knowledge about withdrawal was ‘adequate’ and fewer (17%) believed this about their ‘Ability to distinguish between withdrawal effects and return of the original problem (e.g. depression)’. Two-thirds (68%) would like more training on these matters. Conclusion: It is hoped that even this small sample will be helpful when designing, and seeking funding for, GP training programmes, and when implementing the PHE recommendations for support services, based in the primary care system, for the millions of people contemplating or initiating withdrawal from ADs every year in the UK.

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Section: Discussionmentioning

confidence: 99%

A survey of UK general practitioners about depression, antidepressants and withdrawal: implementing the 2019 Public Health England report

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Renton

Harrop

et al. 2020

Therapeutic Advances in Psychopharmacology

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“…RP-PG-1214-20004), has identified barriers and facilitators to stopping antidepressants through qualitative research with patients and practitioners 49,68 and used this to inform the design of Internet patient and practitioner support packages aimed at helping patients discontinue antidepressants. 69 The intervention consists of GP or NP and patient access to Internet programmes designed to support antidepressant withdrawal, plus three patient telephone calls from a psychological wellbeing practitioner. Control patients receive usual care without Internet or telephone support, but patients are also prompted to seek a review of their antidepressant treatment and may also decide to try to taper it off in discussion with their GP or NP.…”

Section: Psychological Support For Patients To Manage Without Drug Treatmentmentioning

confidence: 99%

“…It is powered as a non-inferiority trial and the primary outcome is depressive symptoms on the PHQ-9 questionnaire at six months. 69 In Australia another primary care RCT called STOPS (STructured Online intervention to Promote and Support antidepressant deprescribing in primary care), is going to provide on-line guidance (called WiserAd) and practice nurse support to patients (personal communication, Jane Gunn, University of Melbourne; https:// medicine.unimelb.edu.au/research-groups/general-practice-research/ mental-health-program/stops-a-randomised-trial-of-a-structured-onlineintervention-to-promote-and-support-antidepressant-de-prescribing-inprimary-care).…”

Section: The Need For More Researchmentioning

confidence: 99%

“…In England the REDUCE programme, funded by the National Institute for Health Research (NIHR; grant reference no. RP‐PG‐1214‐20004), has identified barriers and facilitators to stopping antidepressants through qualitative research with patients and practitioners 49,68 and used this to inform the design of Internet patient and practitioner support packages aimed at helping patients discontinue antidepressants 69 . The intervention consists of GP or NP and patient access to Internet programmes designed to support antidepressant withdrawal, plus three patient telephone calls from a psychological wellbeing practitioner.…”

Section: Strategies To Reduce Long‐term Antidepressant Usementioning

confidence: 99%

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Strategies to reduce use of antidepressants

Kendrick

2020

Brit J Clinical Pharma

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Antidepressant prescribing has increased year on year since the introduction of the selective serotonin reuptake inhibitors (SSRIs) in the 1980s. More than 10% of adults in England are now taking antidepressants for depression/anxiety, with a median length of treatment of more than 2 years, but antidepressants can cause side effects and withdrawal symptoms which increase with longer use. Surveys of antidepressant users suggest 30-50% have no evidence-based indication to continue, but coming off antidepressants is often difficult due to fears of relapse, withdrawal symptoms and a lack of psychological treatments to replace maintenance treatment and prevent relapse. GPs should not prescribe antidepressants routinely for mild depressive/anxiety symptoms. Patients starting antidepressants should be advised that they are to be taken for a limited period only, and that there is a risk of withdrawal problems on stopping them. Prescribers should actively review long-term antidepressant use and suggest coming off them slowly to patients who are well. The relationship between SSRI dose and serotonin transporter receptor occupancy suggests that hyperbolic tapering regimes may be helpful for patients with troubling withdrawal symptoms who cannot stop treatment within 4-8 weeks, and tapering strips can allow carefully titrated slower dose reduction over some months. Internet and telephone support to patients wanting to reduce their antidepressants is being trialled in the REDUCE programme. More research is needed to establish the incidence of withdrawal symptoms in representative samples of patients coming off antidepressants, and large randomised controlled trials are needed to test different tapering strategies.

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“…[8][9][10] Indeed, an emerging body of research suggests considering treatment discontinuation for some long-term users. [11][12][13][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][16][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.…”

Section: Introductionmentioning

confidence: 99%

Long-term antidepressant use in general practice: a qualitative study of GPs’ views on discontinuation

et al. 2021

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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.

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REDUCE (Reviewing long-term antidepressant use by careful monitoring in everyday practice) internet and telephone support to people coming off long-term antidepressants: protocol for a randomised controlled trial

Cited by 15 publications

References 32 publications

A survey of UK general practitioners about depression, antidepressants and withdrawal: implementing the 2019 Public Health England report

A survey of UK general practitioners about depression, antidepressants and withdrawal: implementing the 2019 Public Health England report

Strategies to reduce use of antidepressants

Long-term antidepressant use in general practice: a qualitative study of GPs’ views on discontinuation

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