Development of an intervention for antidepressant deprescribing in primary care

Vukas, Jochen (2025): Development of an intervention for antidepressant deprescribing in primary care: qualitative assessment of implementation factors and systematic guideline review. Dissertation, LMU München: Medizinische Fakultät

Abstract

Introduction Antidepressant use has increased globally in recent decades. This rise suggests growing de-tection and acceptance of underlying indications (especially depression) but also raises con-cerns about potential overprescribing. The acute treatment of a depressive episode with antidepressants is a clearly recommended therapeutic option in cases of moderate, and particularly severe, symptomatology. However, the increase in antidepressant prescriptions has also been attributed to overly rapid and uncriti-cal prescribing without integration into a comprehensive treatment plan, to a growing use be-yond clearly defined depressive syndromes (e.g., for the long-term treatment of sleep disor-ders), and to prolonged use (> 2 years after remission) without regular re-evaluation. In such cases, the clinical benefit is partly disputed, whereas potential risks - such as sexual dysfunc-tion in younger individuals and an increased risk of falls in older adults - must be taken into account. Moreover, some patients report emotional numbing (“emotional blunting”) during anti-depressant treatment. It remains a matter of debate whether this phenomenon represents a pharmacological side effect or residual (or ongoing) symptoms of depression. Aim and components of this work: Consistent with the UK’s Medical Research Council’s (MRC) Framework on the development and evaluation of complex interventions, the aim of this doctoral thesis was to develop a struc-tured intervention approach to systematically identify clinical situations in which a re-evaluation of continued antidepressant medication may be warranted in the context of long-term care in general practice. The intervention is specifically intended to counteract the overly casual use of antidepressants without regular evaluation of their benefits and risks.The specific objectives of this project were : [1] to investigate implementation determinants relevant to routine care (i.e., potential barriers and facilitators) for the clinical identification of situations in which re-evaluation of ongoing antidepressant pharmacotherapy may be appropriate, as well as to explore the potential for deprescribing within physician–patient-centred decision-making processes; [2] to conduct a guideline- and evidence-based analysis of national and international recom-mendations with the aim of supporting the consensus-based development of a practice-oriented set of indicators intended to facilitate the structured review of existing antidepressant medication; [3] to design a general practice–applicable intervention (based on the indicator-set) for review-ing antidepressant treatment in the German primary care context, in particular through the de-velopment of a study protocol to pilot the intervention in preparation for a future randomized controlled trial. Methods For the development of the intervention, we followed the updated 2021 version of the MRC Framework for the development and evaluation of complex interventions. Our focus was on the development phase of the framework. For objective [1], we initially conducted qualitative semi-structured interviews with general prac-titioners to explore above mentioned implementation factors. The development of the interview guide was based on the Capability-Opportunity-Motivation-Behaviour (COM-B) framework by Michie et al. (2014). The target behaviour in this context was the critical review of an antidepres-sant prescription, potentially followed by a shared decision-making process regarding continu-ation or discontinuation.Subsequently, we developed intervention components to overcome barriers that hinder the target behaviour. The domains of the Theoretical Domains Framework (TDF) were matched to the appropriate intervention functions (IFs), which were then linked to possible behaviour change techniques (BCTs). For objective [2], we conducted a systematic review of clinical practice guidelines, extracting all recommendations regarding appropriate treatment durations and strategies to avoid adverse drug reactions (ADRs) from antidepres-sants. The results of the systematic review contributed to the consensus-based development of an indicator set specifying potential deprescribing indications for antidepressants (1). Based on the indicator-set, a checklist was created to assist general practitioners in in identifying situ-ations in which a critical re-evaluation of antidepressant medication is indicated. For objective [3], the results generated from objectives [1] and [2] were used to develop a study protocol in accordance with the CONSORT guidelines and The CRISP checklist. Results Factors influencing behaviour either in favour of or against a critical review and the discontinua-tion of antidepressants were identified in a qualitative, semi-structured interview study involving 20 general practitioners from the Southeast Bavaria region, including the city of Munich. The findings revealed that more statements were made regarding barriers than facilitators. In prac-tice, identified facilitators for critical re-evaluation and potential discontinuation of antidepres-sants included self-confidence and professional experience. The most frequently cited barriers were a lack of interdisciplinary collaboration, uncertainties in making decisions about discontin-uation, and insufficient or absent digital tools to support decision-making. Furthermore, inter-views revealed frustration and disappointment regarding collaboration with other professional groups and political regulations. General practitioners were also asked to share their views on what measures might improve medication safety with regard to identifying situations in which a re-evaluation of ongoing anti-depressant pharmacotherapy - including the option of discontinuation - may be warranted.. Suggested strategies included shared decision-making, fostering good relationships with pa-tients, utilizing online tools as decision aids, and implementing more comprehensive practice management software, capable of indicating a potentially unfavourable benefit–risk ratio of ongoing antidepressant treatment.. Through a prioritization process based on the two frameworks, the Behaviour Change Wheel (BCW) and the Theoretical Domains Framework (TDF), we selected a checklist as an appropri-ate intervention component to enable general practitioners to efficiently identify patients who may potentially benefit from optimising their antidepressant medication - such as through switching, dose reduction, or discontinuation. This checklist was complemented by an empow-erment brochure for patients, aimed at actively involving them in the decision-making process. The literature review included 14 eligible guidelines from Australia, Canada, Germany, New Zea-land, the United Kingdom, and the United States, with the quality of the guidelines rated as good to very good. We extracted 173 statements with recommendations or warnings regarding the avoidance or cautiousness of antidepressant therapy, as well as general information on interactions without specific action recommendations. Among the 14 included guidelines, we found 11 specific statements regarding when antidepressant therapy should be discontinued, The majority of recommendations related to the use of selective serotonin reuptake inhibitors (SSRIs). The strongest warnings were associated with monoamine oxidase inhibitors (MAOIs). Overall, we noted inconsistencies in the statements concerning adverse effects and high-risk scenarios. In the review, we extracted points of departure for the discontinuation of antidepressants based on the warnings and recommendations from the guidelines. The results contributed to the de-velopment of an indicator set as part of a separate doctoral thesis. This set included criteria for the detection of situations in wich a critical re-evaluation of antidepressant therapy is indicat-ed.This indicator set was utilized in the creation of a checklist intended for use by general prac-titioners. A protocol for a pilot study to assess the feasibility, acceptance, and utility of the intervention was developed based on the CONSORT statement and the CRISP checklist. Conclusion Within the scope of this dissertation, we developed an intervention based on a qualitative inter-view study, a systematic review, and structured frameworks, aimed at assisting German general practitioners in effectively identifying patients who could benefit from re-evaluation (as-sassment of the benefit-risk ratio, continuation or discontinuation of antidepressant medica-tion). To assess the feasibility, acceptability, and usefulness of the intervention, we proposed a pilot study protocol, which has since been approved by the ethics committee of the medical faculty at LMU Munich.

• Dokumententyp: Dissertationen (Dissertation, LMU München)
• Keywords: Deprescribing, medication review, adverse drug reactions, high risk prescribing, long-term pre-scribing, intervention
• Themengebiete: 600 Technik, Medizin, angewandte Wissenschaften ; 600 Technik, Medizin, angewandte Wissenschaften > 610 Medizin und Gesundheit
• Fakultäten: Medizinische Fakultät
• Sprache der Hochschulschrift: Englisch
• Datum der mündlichen Prüfung: 31. Oktober 2025
• 1. Bericht­erstatter:in: Dreischulte, Tobias