Benefits to the individual

This quality prescribing advice is intended to encourage supportive and constructive discussions between individuals and prescribers when reviewing antidepressants and their ongoing need. Where appropriate, the fears and apprehensions associated with initiation, continuing, reducing or stopping antidepressants should be considered and treatment tailored to the individual’s needs.  

As with all medicines – not just antidepressants – it is important to routinely and proactively monitor and review the ongoing needs and rationale for continued medicine use. Use the 7-Steps medication review process. For some individuals this may be on annual basis as part of their long-term conditions review (diabetes, asthma, etc.) while others may require more frequent reviews. However, it is known that long-term antidepressant use is increasing,^2,3 and that the longer someone receives an antidepressant the less frequently it, or the condition it is treating, is reviewed.^4,5 This can lead to inappropriate long-term prescribing for some individuals.

A large proportion of people with depression (receiving an antidepressant) have other comorbidities such as diabetes, cardiovascular disease, respiratory disease and therefore receive multiple prescribed medicines (known as polypharmacy).^6,7

This is shown in the figure and table below comparing the likelihood in the most affluent and most deprived areas. These individuals may also be frail and more likely to experience adverse drug effects and avoidable harms. Therefore, proactively reviewing antidepressant therapy creates an opportunity for a holistic person-centred assessment and review of the condition and medicine needs using the 7-Steps process. This can help reduce avoidable medication-related harms. 

 Comorbidities comparison between most affluent and most deprived deciles⁶

Key:

• CHD – Coronary heart disease
• Di – Diabetes
• COPD - Chronic obstructive pulmonary disease
• HF - Heart failure
• S/TIA - Stroke/TIA
• AF - Atrial fibrillation
• PC - Painful condition
• Dep – Depression
• A – Anxiety
• Dem - Dementia

This guidance focuses on the quality prescribing of antidepressants to result in improvements in care. The 7-Steps medication review process promotes a shared decision-making approach to medicine reviews and places the individual at the centre, to ensure prescribing is effective and appropriate for them. People will be encouraged to self-manage their condition where appropriate and be asked ‘what matters to you?’⁸ to support a holistic approach to care in line with the Scottish Government’s polypharmacy guidance.⁹

Some prescribers may be less comfortable reviewing psychotropic medicines such as antidepressants and individuals may be fearful of reducing and stopping antidepressant therapy. This may be due to concerns about relapse or recurrence of their illness, and/or experiencing antidepressant discontinuation/withdrawal symptoms, all of which may result in inappropriate long-term use where treatment is no longer required.^5,10-16 Proactive medicines reviews also create an opportunity for people to be directed to and access non-pharmacological and psychological interventions, which may be needed to achieve better longer-term outcomes.^2,17

Overall, proactive medicines reviews will help to:

• reduce inappropriate medicines use e.g. where medicines are no longer needed
• reduce avoidable adverse drug effects and harms
• optimise care and outcomes
• enable people to take the medicines they need
• direct to non-pharmacological interventions where appropriate

Where appropriate, and when applied to practice, this prescribing advice may help provide structure to support people who are anxious about reducing and/or stopping antidepressant therapy, and who worry about discontinuation/withdrawal symptoms.