More deprescribing needed in antidepressant users: Study

GPs need better support to safely deprescribe antidepressants, say the authors of a new national study that has revealed an increase in long-term use of the medications over 10 years, particularly among younger people.
  
Researchers from the University of South Australia said the prevalence of long‐term antidepressant use in the 10–24 age group was ‘a particularly concerning finding’, rising by 110% from 2014 to 2023, while the duration of treatment with antidepressants also rose by 53%.
 
Chair of RACGP Specific Interests Psychological Medicine, Dr Cathy Andronis, told newsGP she is ‘not surprised’ by the study results, given Australia’s use of antidepressants, the ‘youth mental health crisis’ and cuts to Medicare items for GPs.
 
‘Australia has always been a high prescribing nation for antidepressants for all age groups, but we also know that we’ve got a youth mental health crisis, and the number of people with mental health symptoms in the under 30 age group has grown significantly in the last five to 10 years,’ she said.
 
‘And the Government has taken the only [item] number in Medicare that was available in mental health care that is unrestricted.’
 
Dr Andronis said the Federal Government’s scrapping of Medicare item 2713 last month was a detrimental step that has impacted both GPs and patients, with many people choosing to stay on antidepressants as the more affordable option.
 
‘Doctors who are time pressured now don’t even have access to item numbers to support them doing that mental health care work,’ she said.
 
‘Access to good quality mental health care and counselling, whether it’s by a GP or psychologist, is now less accessible and more expensive, so it’s not surprising that people just stick to what seems like the easiest or most expedient option, which is just keep taking this medication.’
 
The study authors said the findings ‘raise concerns over potential overprescribing’, with 45% of people aged 10–24 years staying on antidepressants for more than 12 months, with a ‘substantial’ number still using them two years on.
 
The study’s lead author, Dr Lasantha Ranwala, said the findings also suggest inconsistency with guidelines from the Royal Australian and New Zealand College of Psychiatrists that recommend medication use be reviewed after 6–12 months.
 
‘While antidepressants play a role in managing moderate to severe depression, prolonged use can increase the risk of side effects and make withdrawal more difficult,’ he says.
 
‘Withdrawal symptoms are often misinterpreted as a return of the underlying condition, which can further extend treatment, exacerbating the problem.’
 
Dr Andronis said while deprescribing ‘sounds easy in practice’, it is a time-consuming process.
 
‘It involves having to have, at times, quite lengthy consultations to explain the process, to really do a thorough assessment to support the person through that potential withdrawal, but also to give them the tools and skills to replace what the drug has been doing chemically, to support them in the stress levels,’ she said.
 
‘At least there was a rebate to support GPs to do deprescribing, to give them the time to talk about alternatives to medication, to carefully assess patients and to review them more frequently if they’re having problems with withdrawal.
 
‘So [the Federal Government] has taken away this item number that supports doing that work.’
 
Published in Pharmacoepidemiology and Drug Safety, the study drew on the dispensing data of more than 300,000 antidepressant users from the Pharmaceutical Benefits Scheme from 2014–23.
 
Across the whole population, researchers found long-term antidepressant use increased from 66 to nearly 85 users per 1000 people between 2014 and 2022, but stabilised slightly in 2023.
 
They also found long-term users who were put on a lower dose remained constant over the decade – 17.9% in 2014 compared with 17.8% in 2023.
 
‘The extended treatment duration, coupled with limited medicine apparent dose reduction efforts, may suggest overprescription and underuse of deprescribing strategies,’ said the study authors. 
 
‘Healthcare providers might continue treatment through a cautious approach, driven by concerns about potential withdrawal effects and a reluctance to deprescribe, fearing destabilisation of well‐settled patients, even when clear clinical indications for continued use may be absent.’
 
Study co-author, Associate Professor Andrew Andrade, said clinicians need ‘stronger support systems’ to safely deprescribe antidepressants.
 
He said emerging technologies, such as predictive analytics, and clinical decision-support tools may also help GPs to identify when deprescribing is appropriate.
 
‘Smart technologies can help identify patients who are good candidates for tapering, coordinate timely access to non-pharmacological treatments, and provide clear, step-by-step guidance to clinicians and patients throughout the slow dose-reduction process,’ he said.
 
However, Dr Andronis said taking a patient’s clinical history is the ‘most clinically expedient’ way to assess a patient.
 
‘You don’t need technology to tell you if somebody’s depressed,’ she said.
 
‘You just need to ask them what problems they’re having and how they’re responding to medications and what they think about whether they want to stay on them or cease them.
 
‘And that’s a conversation.’

Last month the RACGP released a new guide for deprescribing antidepressant medications SSRIs and SNRIs, to aid GPs in minimising withdrawal symptoms and relapse in patients, as part of the college’s First do no harm guide.
 
With a patient resource for GPs to share also included, Dr Andronis said the guideline is ‘the most helpful’ resource for GPs.
 
‘All we need is a conversation with our patients, a clinical assessment, and then that guideline,’ she said.
 
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