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Helping people discontinue long-term antidepressants: views of health professionals in UK primary care.

ABSTRACT: OBJECTIVE:The aims of this paper were to identify, characterise and explain clinician factors that shape decision-making around antidepressant discontinuation in UK primary care. DESIGN:Four focus groups and three interviews were conducted and analysed using thematic analysis. PARTICIPANTS:Twenty-one general practitioners (GPs), four GP assistants, seven nurses and six community mental health team workers and psychotherapists took part in focus groups and interviews. SETTING:Participants were recruited from seven primary care regions and two National Health Service Trusts providing community mental health services in the South of England. RESULTS:Participants highlighted a number of barriers and enablers to discussing discontinuation with patients. They held a range of views around responsibility, with some suggesting it was the responsibility of the health professional (HP) to broach the subject, and others suggesting responsibility rested with the patients. HPs were concerned about destabilising the current situation, discussed how continuity and knowing the patient facilitated discontinuation talks, and discussed how confidence in their professional skills and knowledge affected whether they elected to raise discontinuation in consultations. CONCLUSIONS:Findings indicate a need to consider support for HPs in the management of antidepressant medication and discussions of discontinuation in particular. They may also benefit from support around their fears of patient relapse and awareness of when and how to initiate discussions about discontinuation with their patients.

SUBMITTER: Bowers HM

PROVIDER: S-EPMC6615882 | biostudies-other | 2019 Jul

REPOSITORIES: biostudies-other

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Helping people discontinue long-term antidepressants: views of health professionals in UK primary care.

Bowers Hannah M HM Williams Samantha J SJ Geraghty Adam W A AWA Maund Emma E O'brien Wendy W Leydon Geraldine G May Carl R CR Kendrick Tony T

BMJ open 20190704 7

<h4>Objective</h4>The aims of this paper were to identify, characterise and explain clinician factors that shape decision-making around antidepressant discontinuation in UK primary care.<h4>Design</h4>Four focus groups and three interviews were conducted and analysed using thematic analysis.<h4>Participants</h4>Twenty-one general practitioners (GPs), four GP assistants, seven nurses and six community mental health team workers and psychotherapists took part in focus groups and interviews.<h4>Set ...[more]

PMID: 31278099

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Project description:Clinical practice recommendations increasingly advocate that older patients' life expectancy be considered to inform a number of clinical decisions. It is not clear how primary care practitioners approach these recommendations in their clinical practice.To explore the range of perspectives from primary care practitioners on long-term prognosis, defined as prognosis regarding life expectancy in the range of years, in their care of older adults.A qualitative, semistructured interview study was conducted in a large group practice with multiple sites in rural, urban, and suburban settings. Twenty-eight primary care practitioners were interviewed; 20 of these participants (71%) reported that at least 25% of their patient panel was older adults. The audiorecorded discussions were transcribed and analyzed, using qualitative content analysis to identify major themes and subthemes. The study was conducted between January 30 and May 13, 2015. Data analysis was performed between June 10 and September 1, 2015.The constant comparative approach was used to qualitatively analyze the content of the transcripts.Of the 28 participants, 16 were women and 21 were white; the mean (SD) age was 46.2 (10.3) years. Twenty-six were physicians and 2 were nurse practitioners. Their time since completing clinical training was 16.0 (11.4) years. These primary care practitioners reported considering life expectancy, often in the range of 5 to 10 years, in several clinical scenarios in the care of older adults, but balanced the prognosis consideration against various other factors in decision making. In particular, patient age was found to modulate how prognosis affects the primary care practitioners' decision making, with significant reluctance among them to cease preventive care that has a long lag time to achieve benefit in younger patients despite limited life expectancy. The participants assessed life expectancy based on clinical experience rather than using validated tools and varied widely in their prognostication time frame, from 2 years to 30 years. Participants often considered prognosis without explicitly discussing it with patients and disagreed on whether and when long-term prognosis needs to be specifically discussed. The participants identified numerous barriers to incorporating prognosis in the care of older adults including uncertainty in predicting prognosis, difficulty in discussing prognosis, and concern about patient reactions.Despite clinical recommendations to increasingly incorporate patients' long-term prognosis in clinical decisions, primary care practitioners encounter several barriers and ambiguities in the implementation of these recommendations.

Project description:BackgroundDepression is a common mental health condition with considerable negative impact on health and well-being. Although antidepressants are recommended as first-line treatment, there is limited evidence regarding the cost effectiveness of long-term maintenance antidepressants for preventing relapse.ObjectivesOur objective was to calculate the mean incremental costs and quality-adjusted life-years (QALYs) over 12 months of discontinuing long-term antidepressant medication in well patients compared with maintenance, using patient-level trial data.MethodsWe conducted a cost-utility analysis of 478 participants from 150 UK general practices recruited to a randomised, double-blind trial (ANTLER). QALYs were calculated from EQ-5D-5L and 12-Item Short Form survey (SF-12) results, with primary analysis using the EQ-5D-5L value set for England. Resource use was collected from primary care patient electronic medical records and self-completed questionnaires capturing mental-health-related resource use. Costs were calculated by applying standard UK unit costs to resource use. Adjustments were made for baseline variables.ResultsParticipants randomised to discontinuation had significantly worse utility scores at 3 months (- 0.032; 95% confidence interval [CI] - 0.053 to - 0.011) but no significant difference in QALYs (- 0.011; 95% CI - 0.026 to 0.003) or costs (£3.11; 95% CI - 41.28 to 47.50) at 12 months. The probability that discontinuation was cost effective compared with maintenance was 12.9% at a threshold of £20,000 per QALY gained.ConclusionsDiscontinuation of antidepressants was unlikely to be cost effective compared with maintenance for currently well patients on long-term antidepressants. However, this analysis provides no information on the wider impact of antidepressants. Our findings provide information on the potential impact of discontinuing long-term maintenance antidepressants and facilitate improving guidance for shared patient-clinician decision making.Trial registrationEudraCT number 2015-004210-26; ISRCTN number ISRCTN15969819.

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Project description:IntroductionIn the UK, primary care is seen as the optimal context for delivering care to an ageing population with a growing number of long-term conditions. However, if it is to meet these demands effectively and efficiently, a more precise understanding of existing care processes is required to ensure their configuration is based on robust evidence. This need to understand and optimise organisational performance is not unique to healthcare, and in industries such as telecommunications or finance, a methodology known as 'process mining' has become an established and successful method to identify how an organisation can best deploy resources to meet the needs of its clients and customers. Here and for the first time in the UK, we will apply it to primary care settings to gain a greater understanding of how patients with two of the most common chronic conditions are managed.Methods and analysisThe study will be conducted in three phases; first, we will apply process mining algorithms to the data held on the clinical management system of four practices of varying characteristics in the West Midlands to determine how each interacts with patients with hypertension or type 2 diabetes. Second, we will use traditional process mapping exercises at each practice to manually produce maps of care processes for the selected condition. Third, with the aid of staff and patients at each practice, we will compare and contrast the process models produced by process mining with the process maps produced via manual techniques, review differences and similarities between them and the relative importance of each. The first pilot study will be on hypertension and the second for patients diagnosed with type 2 diabetes.Ethics and disseminationEthical approval has been provided by East Midlands-Leicester South Regional Ethics Committee (REC reference 18/EM/0284). Having refined the automated production of maps of care processes, we can explore pinch points and bottlenecks, process variants and unexpected behaviour, and make informed recommendations to improve the quality and efficiency of care. The results of this study will be submitted for publication in peer-reviewed journals.

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Helping people discontinue long-term antidepressants: views of health professionals in UK primary care.

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Helping people discontinue long-term antidepressants: views of health professionals in UK primary care.

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