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New guide to support safe antidepressant deprescribing
The new addition to the RACGP’s First do no harm guide walks GPs through a best practice approach to deprescribing antidepressants.
In 2023–24, antidepressants were dispensed to 14% of Australians, with 92% of these scripts being prescribed by GPs.
With mental health being one of the top presentations in general practice, a new step-by-step RACGP guide has been released to support GPs in patient care.
The next topic covered as part of the RACGP’s First do no harm: A guide to choosing wisely in general practice looks at long-term use of antidepressants without careful review and comes with a patient resource.
It guides GPs on a best practice approach to deprescribing antidepressant medications, for example serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs), to minimise withdrawal syndrome and relapse as well as providing information on conducting reviews, medication harms and risks, alternatives and additional resources.
In 2023–24, antidepressants were dispensed to 14% of the Australian population, with 92% of these scripts prescribed by GPs.
Although most guidelines recommend that these medications be used for only 6–12 months for an episode of anxiety or depression, the average duration of use is four years, the RACGP guide explains.
Associate Professor Caroline Johnson, who sits on the RACGP Expert Committee – Quality Care and its Mental Health Working Group, said regardless of whether initiation is justified, evidence suggests the increase in antidepressant use is due largely to rising long-term use (longer than 12 months).
‘That is, people not stopping antidepressants, in many cases despite no longer experiencing symptoms of depression and anxiety at a threshold that warrants ongoing treatment,’ she told newsGP.
‘While some patients may need long-term medication, there are harms to be considered, including withdrawal symptoms, increased risk of falls, hyponatremia, GI side effects and interactions with other medications.’
The new guide emphasises that GPs should not continue or discontinue prescribing medication for anxiety and depression without careful review and shared decision-making with the patient.
However, under specified circumstances, GPs can:
- continue to prescribe the medication, establish regular reviews at appropriate intervals, based on individual patient factors
- when considering deprescribing the medication, use shared decision-making with any active members of the care team.
The guide also gives GPs a green light to:
- discuss the risk of antidepressant withdrawal syndrome with the patient when initially prescribing antidepressants, as part of informed consent
- use shared decision-making during reviews to assess whether the medication remains clinically indicated and if the benefits outweigh the potential risks of continuing
- continue to use non-pharmacological management and, where possible, avoid medications that may worsen mood
- continue to provide all patients with education about their condition, management options and the risks associated with SSRI/SNRI withdrawal, side effects and relapse
- particularly consider deprescribing for patients whose original indication was mild to moderate or where their symptoms of anxiety or depression were short term
- when deprescribing, adopt a tapering approach and arrange regular follow-up during and after weaning
- educate the patient and their supports about safe tapering, potential withdrawal effects and signs of relapse.
Deprescribing, the guide explains, should be a process of planned and supervised dose reduction until treatment ceases, and implemented when the ‘potential harms of continuing outweigh the current or anticipated benefits of continuing’, or when the patient indicates that they would like to stop taking the medication.
Associate Professor Johnson said planning for deprescribing should ideally start at the time of prescribing.
‘As GPs we often fall into the understandable trap of prescribing in response to patient distress when time is limited,’ she said.
‘Prescribing decisions should never be rushed, time should be taken to confirm your patient meets the diagnostic thresholds where medication is most likely to be of benefit, and explaining the importance of continuity of care to your patient can help ensure the use of these medications is optimised.’
Associate Professor Johnson also points to the need for GPs to listen to patients and be pro-active in conversations about deprescribing.
‘Research has shown that patients report feeling dismissed by their GP when they describe symptoms consistent with antidepressant withdrawal,’ she said.
‘GPs report often waiting until the patient asks about deprescribing. Long-term users, especially those on higher doses of medications, can experience significant withdrawal symptoms, broad in nature, and often at very low doses.’
A
patient resource is also available to support patient communication.
‘Having resources at your fingertips is a good idea, as it can help with managing time and the overload of information in a standard consultation,’ Associate Professor Johnson said.
‘I often use my browser to quickly create a QR code of a relevant page for the patient to scan, so they get the right resources at point-of-care without wasting any time printing or the cost of sharing via SMS.’
First do no harm was launched in 2022, born out of an understanding that overdiagnosis, interventions with insufficient evidence, and overused tests can lead to patient harm, wasted resources and misunderstandings around health literacy.
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