Weaning off antidepressants: How can GPs help?

Recent figures indicate around one in eight Australians have a current prescription for antidepressants, with GPs supplying both the majority of mental health services, as well as mental health-related medication.
 
However, there are also many reasons a patient may choose to stop taking antidepressant medication – sometimes with dire consequences.
 
Just last month, an Adelaide mother pleaded guilty to spiking her four children’s chocolate milk with sleeping pills, having stopped taking antidepressants six months earlier. The 47-year-old had been using antidepressants for around 20 years and her mental health declined after weaning off the medication, which the judge described as a major contributor to the incident.
 
Melbourne University psychiatrist Associate Professor Judy Hope told newsGP these cases can be extremely complex, especially for GPs who are restricted to the confines of a primary healthcare system geared towards heavy patient loads and shorter consultation times.
 
‘GPs are at the coalface of looking after people and mental health issues, but they’re also often under a lot of pressure to make decisions and to manage patients in quite short time frames, which puts them at a disadvantage,’ she said.
 
‘They have a really tough job out there managing mental health issues. A lot of the advice I can provide comes with a caveat because I understand the challenges and restrictions GPs face.
 
‘Ideally, the key to helping patients wean off long-term antidepressants is understanding what the early warning signs are, regular monitoring, and having a clear plan ahead of time about what to do if trouble is brewing.’
 
According to Associate Professor Hope, when treating a patient who wants to stop taking antidepressants, particularly those who have been on the medication for an extended period, it is important to assess the nature of the previous depressive illness, especially psychotic or melancholic features, as well any history of previous risk, such as suicidal or homicidal ideation or attempt.
 
‘It’s also vital to try and consider the level of monitoring and support that the person has already – in particular, when this is absent – and what the implications of relapse in relation to risk are,’ she said.
 
‘This is especially relevant to patients who are in positions of responsibility for others affected by their actions, such as carers of children or the elderly, or pilots, commercial drivers, healthcare professionals, etcetera.’
 
There is no upper limit of time for taking antidepressants, and Associate Professor Hope said the type of condition being treated is more likely to impact on the risk of relapse, rather than the drug itself when antidepressants are stopped.
 
‘Patients are more likely to wish to cease if they are experiencing adverse effects of antidepressants. The recommended duration of treatment is at least one year for a single episode of unipolar depression, and three years for recurrent depression,’ she said.
 
‘Many patients with very serious previous depressions, or those with risk features, choose to stay on treatment indefinitely as a preventive measure.
 
‘However, it can be really difficult if a patient would like to stop medication, but the practitioner does not think this is clinically wise or appropriate.’
 
In these situations, Associate Professor Hope believes it is vital to try to understand why a person may wish to stop, and to offer alternatives such as reducing or switching medications if appropriate.
 
If possible, arranging a longer appointment to discuss the pros and cons, ideally in a motivational interviewing framework, can also be beneficial, or failing that a referral to a psychiatrist can help.
 
Another strategy is to ask to involve a person trusted by the patient, such as a family member, into the discussion and decision; however, Associate Professor Hope concedes this is not always possible.
 
‘Even as a specialist I have trouble getting patients to bring in their family and talk to loved ones directly,’ she said.
 
‘A lot of people say, “I don’t want to talk about my mental health issues with my family – I barely want to talk to you about it, let alone discuss it with anybody else in my life”.
 
‘It can be a real challenge, and yet those are the people who ultimately are really involved and play a major role in keeping a patient safe.’
 
If the patient decides to go ahead with ceasing medication, regardless of any clinical concerns, Associate Professor Hope says this should be done slowly, over weeks to months, and that loved ones should be informed or involved about their plan if possible.
 
It is also important to provide advice about what patients can expect, such as the discontinuation symptoms of antidepressants, and the possible time frame of relapse – which in some instances can be delayed by weeks or months.
 
‘The patient should also be made aware of the chances of risk of relapse of depression, which depends on the type of depression and previous history of relapse off antidepressants,’ Associate Professor Hope said.
 
‘It’s also helpful for the GP and patient to construct a list of early warning signs of relapse of depression, such as sleep disturbance, fatigue or loss of interest; along with a response plan that should be executed if any early warning signs occur, such as returning for urgent review by the GP.
 
‘Ideally, a crisis plan should also be given that details how to get help, be it emergency services, emergency support lines such as Lifeline, or the number to a local mental health crisis response team.’
 
Following cessation, regular medical review is required to identify and treat a relapse, should it occur.
 
More information on the use and cessation of antidepressants by patients with mental health issues can be found in the Royal Australian and New Zealand College of Psychiatrists’ Clinical Practice Guidelines for Mood Disorders and on the NPS website.

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