Long-term antidepressant treatment

Background (age, sex, occupation, baseline function)

60-year-old female
Works part-time

History of presentation/reason for review

Identified from ‘long-term antidepressant use” search using STU within the GP practice and invited for review. Receiving paroxetine 20mg daily for over two years
At review tells you her mood is good and asks if she can stop her antidepressant

Current medical history and relevant co-morbidities

Mixed anxiety and depression following death of son four years ago

Current medication and drug allergies (include OTC preparation and herbal remedies)

Paroxetine 20mg tablets – one tablet daily (approximately 2.5 years)
Temazepam 10mg tablets – one tablet at night (approximately 3 years - does not over order)
Drug allergies: Nitrofurantoin – rash

Lifestyle and current function (including frailty score for >65yrs) alcohol/smoking/diet/physical activity

Lives alone
No alcohol
Good concentration, appetite and weight stable, sleeping well
Helps to look after grandson to support her daughter-in-law
Looking forward to the future and seeing her grandson growing up
No thoughts of suicide/deliberate self-harm

“What matters to me” (patient ideas, concerns and expectations of treatment)

Would like to stop antidepressant as has been taking a long time
Ask individual to complete questions to prepare for the review (PROMs)

Results e.g., biochemistry, other relevant investigations or monitoring

Note: local lab reference ranges may vary

Blood tests at diagnosis (including TFT’s) all within normal range

Most recent relevant consultations

Urinary tract infection six months previously

7 Steps: Person specific issues to address for case study

1. Aims: What matters to the individual about their condition(s)?

Review diagnoses and consider:

Therapeutic objectives of drug therapy
Management of existing health problems
Prevention of future health issues, including lifestyle advice
Ask individual to complete Patient Reported Outcomes Measures (PROMS) before the review

Person specific actions

Would like to stop her antidepressant, as has been taking for over two years

2. Need: Identify essential drug therapy

Identify essential drugs (not to be stopped without specialist advice*)

Drugs that have essential replacement functions
Drugs to prevent rapid symptomatic decline

* with advice from healthcare professional with specialist interest

Person specific actions

No essential medicines
If reducing or stopping paroxetine or temazepam, consider gradual reduction to avoid withdrawal symptoms

3. Does the patient take unnecessary drug therapy?

Identify and review the continued need for drugs

what is medication for?
with temporary indications
with higher than usual maintenance doses
with limited benefit/evidence for use
with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific actions

Temazepam no longer needed
- insomnia – related to bereavement, sleep now improved
- temazepam loses efficacy after two to four weeks. Licensed for a maximum of four weeks
Paroxetine no longer needed
- completed six-month course of treatment. Mood improved

4. Effectiveness: Are therapeutic objectives being achieved?

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

to achieve symptom control
to achieve biochemical/clinical targets
to prevent disease progression/exacerbation
is there a more appropriate medication to achieve goals?

Person specific actions

Ensure appropriate non-pharmacological options discussed to maintain wellbeing

5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?

Identify individual safety risks by checking for

appropriate individual targets
drug-disease interactions
drug-drug interactions (see ADR table)
monitoring mechanisms for high-risk drugs
risk of accidental overdosing

Identify adverse drug effects by checking for

specific symptoms/laboratory markers
cumulative adverse drug effects (see ADR table)
drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Person specific actions

Temazepam – increased risk of cognitive effects, falls, lower mood, etc. Plan to stop
Paroxetine – GI bleed risk, emotional blunting, etc. Risk of withdrawal effects higher than with other antidepressants. Plan appropriate reduction schedule

6. Sustainability: Is drug therapy cost-effective and environmentally sustainable?

Identify unnecessarily costly drug therapy by

considering more cost-effective alternatives, safety, convenience

Consider the environmental impact of

Inhaler use
Single use plastics
Medicines waste
Water pollution

Person specific actions

Temazepam dose reduction and stop - oral solution significantly more expensive than tablets. Consider switch to diazepam to aid reduction - longer half-life and a number of preparations available

7. Patient centeredness: Is the patient willing and able to take drug therapy as intended?

Does the person understand the outcomes of the review?

Consider teach-back
Involve the adult where possible. If deemed to lack capacity, discuss with relevant others, e.g. welfare guardian, power of attorney, nearest relative if one exists. Even if adult lacks capacity, adults with Incapacity Act still requires that the adult’s views are sought. Ensure “Adults with Incapacity Documentation” in place

Ensure drug therapy changes are tailored to individual’s preferences. Consider

is the medication in a form they can take?
is the dosing schedule convenient?
what assistance is needed?
are they able to take medicines as intended?

Agree and communicate plan

discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
include lifestyle and holistic management goals
inform relevant health and social care providers of changes in treatments across the transitions of care

Ask individual to complete post-review PROMS questions after their review

Agreed plan

Continue non-pharmacological support to maintain recovery: physical activity, minimise social isolation, etc. Signpost to resources e.g. local groups or online support
Temazepam to reduce and stop, due to lack of efficacy and risk of ADR:.
- switch to diazepam 10mg at night and reduce by 1mg every two to four weeks.
- alternative: Temazepam 10mg/5ml oral solution, reducing by 1mg (0.5ml) every two to four weeks. (oral solution higher acquisition cost)
Paroxetine withdrawal schedule options (after stopping temazepam):
- reduce to 10mg daily for four weeks, then 5mg daily for four weeks, then stop.
- if problematic withdrawal or apprehensive: switch to equivalent dose of fluoxetine (20mg/5ml) oral solution for seven days, then reduce by 4mg (1ml) every four weeks

Key concepts in this case

Benzodiazepines are associated with an increased risk of depression and are only licensed for a maximum of four weeks use. Stopping temazepam is a priority due to increased risk of avoidable ADRs. Reducing temazepam may require gradual reduction to assist with stopping.
Switching from a short acting SSRI to a longer half-life SSRI may enable reduction and stopping.
Paroxetine is associated with withdrawal effects. Therefore, have a range of options and agree the most appropriate approach to reducing and stopping, to improve chances of a successful withdrawal

Click on the table image to view a PDF version of the full 7 steps table for case study 4.