The number of people in the UK taking antidepressants is growing (McCarthy, 2013) and there is evidence to suggest that a 30-50% of patients might be taking antidepressants for longer than they need to (Cruickshank et al., 2008; Piek et al., 2014). The reasons for this are not totally clear; after all, the doctor has to write a repeat prescription and the patient has to agree to keep taking it.

Recent guidance from the Royal College of Psychiatrists describes the symptoms people experience when stopping an antidepressant and some ways to reduce or avoid these symptoms.

Emma Maund and colleagues at the University of Southampton attempted with this study to explore the underlying reasons for stopping antidepressants, and systematically review the qualitative evidence base on the factors that influence a doctor’s or patient’s decision to continue or cease antidepressant medication (Maund et al, 2019).

Methods

For this systematic review, the authors exhaustively searched multiple research databases, combed reference lists, citations and related articles, and contacted experts in the field.

In brief, studies were included if they were qualitative studies about the attitudes, beliefs, feelings, and perceptions of continuing or discontinuing antidepressants in adults who have been on treatment for at least 6 months.

Studies were explicitly excluded if they were not published in English, were survey data (so, not strictly qualitative research), or were primarily about the initial 6 months of treatment (which the authors say is more about adherence or non-adherence to prescribed treatment, rather than continuation or discontinuation of treatment already in progress).

Data analysis was done using thematic analysis, which is one of the most common methods of analysing qualitative data. Essentially, one of the authors read each included study and identified recurrent key themes across the study participants when they thought about whether they should continue or stop antidepressants. The meaning behind these concepts were discussed between authors and their colleagues. Although the authors aimed to include the perceptions of both mental health professionals and service users, they only included the latter due to insufficient data.

Results

Twenty-two studies were included in the review, capturing a broad range of patients, i.e. the perspectives of females, young people (19-24), and older patients above 75 years old.

The authors identified 9 themes with associated subthemes of barriers and facilitators to stopping antidepressants (see also details in the table below):

• Psychological and physical capabilities to discontinue antidepressants
  • Acquired coping skills, such as mindfulness or information on discontinuation, confidence and life stability acted as facilitators
  • While perceived dependence or problematic past experiences of discontinuation acted as a barrier. [Patient:] “It’s psychological that dependence. You’re afraid everything will go wrong if you don’t take your medicine”
• Perception of antidepressants, i.e. how service users characterised the antidepressants, their positive/negative effect and their feelings for using them
  • Good views on the effects of the medication acted as a barrier
  • While side effects was a facilitator
    
• Fears in relation to stopping or continuing antidepressants
  • Specifically the fear of dependence acted as a facilitator
  • While the fear of relapse as a barrier to discontinuation. “I don’t dare to stop, the fear that all will come back as it was before”
    
• Intrinsic motivators and goals, including individual needs for autonomy, competence and priorities
  • Self-identity acted as an important factor and could be seen as both barrier and facilitator (‘old and disabled self’ vs. ‘true and healthy’)
• The doctor as a navigator to maintenance or discontinuation, and their recommendation and/or approval towards the chosen action
  • Support and guidance acted as a facilitator
  • While work practices (i.e. lack of time, inadequate information and/or support) were considered as a barrier
• Perceived cause of depression, and beliefs on the long-term effects depression may have. For example, if the service-user believed depression was caused by a chemical imbalance in the brain, they consider it a long-term condition needing a long-term treatment.
• Aspects of information that support decision-making, including benefits and risks
  • While insufficient information may act as a barrier
  • The opposite was identified as a facilitator
• Support from significant others (i.e. life partner, family, friends) and their role in encouraging or discouraging discontinuation
  • Some may put pressure on service-users to continue or discontinue
  • While others may support them by monitoring their symptoms during the discontinuation process
• Support from other health professionals (i.e. psychologists/psychiatrists), as sources of additional guidance to facilitate discontinuation.

Themes	Barriers (subthemes)	Facilitators (subthemes)
Psychological and physical capabilities	Dependence Experience of problematic discontinuation Life circumstances difficult Routine Intermittent need Coping strategies ineffective	Confidence in capability to discontinue Coping strategies effective Life circumstances stable Acceptable experience of dose reduction Knowledge to taper
Perception of antidepressants	Positive effect Natural/benign characterisation Lack of concern over side effects	Ineffectual Experience of unacceptable side effects Negative/ unnatural characterisation Unhappy about long-term use
Fears	Fear of relapse Fear of withdrawal effects Fear – miscellaneous	Fear of addiction Fear of potential side effects
Intrinsic motivators and goals	Self-identity (disabled, ‘good mother/ daughter’, old) Threat to stability Irrational Goal priority is benefit of continuing to significant others Goal is management rather than cure	Self-identity (healthy, ‘good mother/daughter’) Desire to function without antidepressants Feeling better Self-stigma of taking antidepressants
The doctor as a navigator to maintenance or discontinuation	Doctor’s work practices Doctor’s work issues – lack of time Doctor recommends continuation Doctor’s responsibility to initiate discussions about discontinuation Lack or inadequacy of doctor support/guidance	Doctor’s support/guidance Doctor recommends/ approves discontinuation
Perceived cause of depression	Long-term condition and treatment Aetiology – Biochemical	Aetiology – Life circumstances, seasonal
Aspects of information that support decision-making	Incongruent information about discontinuation of antidepressants Insufficient information on how to discontinue and of risks and benefits of discontinuation	Information on how to discontinue and what to expect
Significant others – a help or a hindrance	Pressure to continue	Pressure to discontinue Support/Guidance
Support of other health professionals	No subthemes	Support

Conclusions

The authors concluded:

Barriers and facilitators to discontinuing antidepressant use are numerous and complex, and likely to require detailed conversations between patients and their GPs. Moreover, these conversations are more likely to happen if GPs raise the issue of discontinuation. Further research is needed from a health professional perspective including, but not limited to GPs.

Strengths and limitations

Strengths

• The search method was impressively thorough. They used previously validated search parameters, which were very comprehensive and use their own supplementary appendix.
• Over 20 studies were included, which is large number for a review of qualitative studies. Also, why look at qualitative research? Well, qualitative research is about gathering and exploring people’s opinions, experiences, and feelings (instead of objective numbers and statistics) and these tend to be the things that usually matter to service-users on a personal level.
• The included studies focused on the perspectives from a variety of different patient cohorts. Converging themes from diverse patient groups gives the synthesis more credibility and make the results more generalisable for the overall clinical population taking antidepressants.

Limitations

• The authors eloquently acknowledge that “the process of synthesising qualitative studies is inherently interpretive. Our synthesis is one possible interpretation of the data. It is possible that another research team may generate another interpretation of this set of studies.” Thus, this leaves space for alternative comprehension of the presented data if analysed by another research team.
• Unfortunately, there were not enough studies about the perspectives of health professionals in order to conduct a meaningful thematic analysis. Therefore, the results were limited to the patient perspective, although it’s important to state that some interesting snippets from GP perspectives are included in the paper.
• The authors transparently acknowledged that only one of the researchers performed the coding, generated analytical themes, and developed the subthemes and these were refined through discussion between two other researchers. If a second researcher independently engaged in the same initial coding work, the findings could have been cross-validated with increased confidence.
  

  Qualitative research is about gathering and exploring people’s opinions, experiences, and feelings (instead of objective numbers and statistics) and these tend to be the things that usually matter to patients on a personal level.

Implications for practice

A sign of good qualitative research is when it resonates with the reader and, for us, this systematic review did just that.

In clinical practice, doctors have frequently heard patients and colleagues express the themes synthesised in this review. Patients are scared of becoming depressed again if their antidepressant is stopped and doctors are also afraid of causing a depressive relapse. So, if a patient is doing well and not suffering from intolerable side effects, the simple default position is: don’t rock the boat!

The art of prescribing is as complex, as the art of de-prescribing. As a budding psychiatrist, we are highly trained to recognise when to start antidepressant treatment. However, it’s a little trickier to decide when to stop them and there’s actually very little guidance on when or how to do this. Yet, in my short career, I feel that the most powerful and informative model that helps me decide whether I should start and stop a particular treatment (including antidepressants) lies in what we call “formulation.” In psychiatry, the formulation is a set of explanatory hypotheses that attempts to understand a patient’s presenting symptoms in the context of their whole life and not merely as a diagnosis. In practice, what this means is that I strive to constantly learn about a patient’s life and what’s important to them to better understand their predisposing, precipitating, perpetuating, and protective factors (often separated in biological, psychological, and social domains) and take note if there are changes to these in follow-up appointments. For instance, if there was an identifiable precipitant to a patient’s first and only depressive episode (e.g. loss of a job, accumulating of debt, unexpected death of a loved one, social isolation), but this is now resolved (e.g. stable job, paid off debts, grief counselling, has new friends), it might be worth stopping an antidepressant and following them up closely. On the other hand, I’d probably be more hesitant to recommend ceasing an antidepressant in a patient with a strong family history of depression who has had multiple severe depressive relapses that come out of the blue.

As a doctor, this review is a reminder of themes I ought to explore with my patients to enhance my formulation, personalise their treatments, and enrich my practice.

Statement of interests

None.

Links

Primary paper

Maund E, Dewar-Haggart R, Williams S, Bowers H, Geraghty AWA, Leydon G, et al. Barriers and facilitators to discontinuing antidepressant use: A systematic review and thematic synthesis. J Affect Disord. 2019; 245: 38-62.

Other references

McCarthy, M., 2013. Antidepressant use has doubled in rich nations in past 10 years. BMJ 347, f7261.

Ambresin G, Palmer V, Densley K, Dowrick C, Gilchrist G, Gunn JM. What factors influence long-term antidepressant use in primary care? Findings from the Australian diamond cohort study. J Affect Disord. 2015;176:125-32.

Cruickshank, G., MacGillivray, S., Bruce, D., Mather, A., Matthews, K., Williams, B., 2008. Cross-sectional survey of patients in receipt of long-term repeat prescriptions for antidepressant drugs in primary care. Mental Health Family Med. 105–109.

Piek, E., Kollen, B.J., van der Meer, K., Penninx, B.W.J.H., Nolen, W.A., 2014. Maintenance use of antidepressants in dutch general practice: non-guideline concordant. PLoS One 9, e97463.

Burn W, Horowitz MA, Roycroft G, Taylor D. (2020) Stopping antidepressants. Royal College of Psychiatrists, 2020.

Photo credits

• Photo by Anastasia Dulgier on Unsplash
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