REDUCE programme to help people withdraw from inappropriate long-term antidepressant treatment

Problem

Antidepressant prescriptions have risen due to GPs prescribing longer courses, and the median length of treatment is now more than two years. However surveys suggest 30-50% of patients on long-term antidepressants have no evidence-based indication for continuing use. However practitioners need guidance to provide support for withdrawal, and patients need 24 hour support. The REDUCE programme aims to develop Internet support for patients and practitioners to facilitate antidepressant cessation.

Approach

The six-year REDUCE programme has five work streams: • A systematic review and qualitative synthesis of barriers and facilitators to withdrawal • Qualitative work with patients and practitioners to inform the development of the on-line intervention• Co-production of an internet-supported intervention plus telephone support from psychological practitioners• A one-year feasibility RCT of the approach• A three-year fully powered RCT to determine effectiveness and cost-effectivenessThe findings of work streams (WS) 1 and 2 will be presented, and their implications for work stream 3.

Findings

The qualitative evidence synthesis of barriers and facilitators included 21 studies. Thematic synthesis yielded nine themes: psychological and physical capabilities; perceptions of antidepressants and depression; the fear factor; intrinsic motivators and goals; the doctor as a navigator to discontinuation; information that supports decision-making; significant others; and support from other professionals.The systematic review of managing discontinuation included 15 studies: 12 had analysable results, with meta-analysis possible for 2 pairs of RCTs. There was no difference in cessation rates between CBT + taper (95%) and clinical management + taper (91%) but a lower risk of relapse with CBT + taper. There was no difference in relapse between mindfulness based cognitive therapy + tapering support and maintenance antidepressant medication. In WS2 19 patients were interviewed face to face and 37 health professionals (HPs) took part in focus groups. Themes from patient interviews included: impact of belief systems on the decision to withdraw (benefits of medication, fear of relapse and withdrawal symptoms), patient-practitioner interactions (uncertainty about whether to ask about coming off), and influence of family and friends.Themes from the HP focus groups included: supporting patients rather than making decisions for them, assessing risk and managing patient expectations, organisational factors, practitioner beliefs, need for psychological tools.

Consequences

The findings of WS1 and WS2 have highlighted key facilitators and barriers to antidepressant withdrawal. Draft content has been developed for the patient and practitioner intervention modules incorporating this evidence base, which will be presented at the conference.