Reviewing long-term antidepressants in routine practice
Johnson CF et al. Reviewing long-term antidepressants can reduce drug burden: a prospective observational cohort study.17
GPs were asked to proactively review a proportion of their practice patients prescribed the same antidepressant continuously long-term (≥2 years), as current guidelines advise up to two years’ treatment for some individuals with depression. Amitriptyline was excluded as it is more commonly used to treat neuropathic pain. Prescribing support pharmacists and technicians created the opportunity for proactive reviews by identifying potential patients for review, using data extraction tools, enabling >150-hour audits to be completed within two to four hours, November 2009 to March 2010. The GPs then decided which of their patients to review.
78 of 96 practices participated. 8.6% (33,312/388,656) of all registered patients were prescribed an antidepressant, 47.1% (15,689) were defined as long-term users and 2,849 (18%) were reviewed. 811 (28.5%) patients reviewed had a change in antidepressant therapy: 7% stopped, 13% reduced dose, 5% increased dose, and 3% changed antidepressant, resulting in 9.5% (95% CI = 9.1% to 9.8% P<0.001) reduction in prescribed daily dose and 8.1% reduction in prescribing costs. 6% were referred onwards, half to NHS mental health services. Pre-review SSRI doses were 10–30% higher than previously reported.
Since 2009, this work has continued as a local prescribing initiative, enabling over 8,000 people in more than 180 general practices to be reviewed between 2009/10 and 2014/15. However, this represents less than 2% (8,000/451,084) of people receiving long-term treatment, and lacked long-term follow-up to assess relapse and recurrence rates. (Estimate calculated from: previous studies indicate approximately 50% of people receive long-term treatment.20 Current medicines use in mental health indicates that 902,168 people received antidepressants in 2017/18. Therefore approximately 451,084 people are receiving long-term treatment in Scotland.)
Strengths
Enabled GPs to proactively review their own patients, enabling more people to be reviewed in a short period of time. Demonstrated use of electronic systems in enabling appropriate people to be identified and called for review.
Demonstrated the effectiveness of pharmacy general practice teams in supporting and facilitating proactive GP reviews.
Limitations
Prescribers were asked to use their own clinical judgement for reviewing and reducing antidepressants, however they did not have structured advice as outlined in this guideline which may help overcome some of the barriers outlined in 2.3 above. Limited numbers of people reviewed. Limited resources and long-term follow-up to assess longer-term impact.