Antidepressant prescribing in general practice: A call to action

ABSTRACT

Productivity Commission inquiry report (2020) recommended as a 'priority reform' that we '[ajddress adverse outcomes from prescribing practices of mental health medication'.1 The report states that 'while antipsychotic prescribing in aged care facilities is one element of this ... arguably a greater concern, given its frequency, is antidepressant prescribing'.1 The report recommends that general practitioner (GP) 'mental health training and professional development' be improved to increase 'adherence to evidence-based clinical practices (including the clinical appropriateness of GP's [sic] prescribing practices for mental health medication, management of medication side effects and de-prescribing)'.1 This article discusses antidepressant prescribing in Australian general practice, adverse drug effects and withdrawal symptoms, and the changes we might make to improve patient outcomes. According to the most recent Bettering the Evaluation and Care of Health (BEACH) survey data, 12.4% of general practice encounters are mental health-related, and most of these encounters are managed with medication (61.6%).7 Clinical guidelines recommend psychological therapies for mild depression and anxiety, and 6-12 months of antidepressant therapy for a single episode of moderateto-severe depression.8'9 Yet in Australia the average duration of therapy is now approximately four years,4 and half of users are long-term users.5 There is also concerning variation in antidepressant prescribing, with rates higher for people in lower socioeconomic or inner regional areas and nearly double in older (>65 years) when compared with younger people.10 Nearly one in three older Australians admitted to residential care in 2008-15 was taking antidepressants on admission, and this only increased after admission.11 There remains ongoing debate about what constitutes appropriate prescribing, but every GP knows that antidepressants cannot treat common social issues such as grief, loneliness, unemployment or poverty. Reviewing and stopping medication when it is no longer indicated is an essential part of good prescribing practice, but in the time-pressured context of general practice it is sometimes overlooked and has been described as 'swimming against the tide'.25 Barriers for GPs include time constraints, reluctance to destabilise a stable situation and poor access to non-pharmaceutical alternatives;barriers for patients include an expectation that doctors would suggest stopping if it were warranted, fear of relapse and unpleasant withdrawal symptoms.24 Ready access to social, financial and psychological supports will be part of the equation, but helping patients to stop antidepressants is also important, especially as the withdrawal process can be complex, often requiring slow tapering, tailored support and regular follow-up (Table 2).26-28 The Productivity Commission recommends 'more research focused in these areas, and uptake of its resulting lessons among treating clinicians'.1 As the fallout from the COVID-19 pandemic continues, there has never been a more pressing time to address the issue of unnecessary and potentially harmful prescribing of antidepressants in general practice. Authors Katharine A Wallis MBChB, PhD, MBHL, Dip Obst, FRNZCGP, FACRRM, General Practitioner and Associate Professor, Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Qld Maria Donald PhD, Senior Research Fellow, Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Qld Joanna Moncrieff MD, Psychiatrist and Professor of Psychiatry, Division of Psychiatry, University College London, London, UK Competing interests JM is co-investigator on a grant-funded study investigating ways to help people reduce antidepressants (REDUCE study funded by UK's National Institute for Health Research) and co-chairperson of the Critical Psychiatry Network, and a board member of the Council for Evidence-based Psychiatry.