‘Never change a winning team’: GPs’ perspectives on discontinuation of long-term antidepressants

Figures & data

Table 1. Demographics of the 20 FPs.

Age (range in years, years)		Female
25–35	5	3
35–45	4	3
45–55	7	4
55–65	3	2
>65	1	0
Average	44.6
Sex
Female	12
Male	8
Area
Rural	10	7
Urban	10	5
Type of practice
Solo	5
Duo	3
Group	10
Community health centre	2

Table 2. Themes and subthemes.

Success stories
Patient health issues	I recently had someone, a woman, aged 32, who wanted to stop [her antidepressant] because she wanted to get pregnant. Her antidepressant use had started around 8 years ago, I think, in response to a break-up resulting in a depression. That actually went pretty smoothly. I had never considered stopping antidepressant treatment before. She was motivated as well: she said ‘we want a child, it is not possible on AD, it is not allowed, so I am going to stop’. (GP3, female, 58 years)
Patient request	I am thinking of one patient in particular who has been using antidepressants for a very long time, it started with her previous GP. She contacted me of her own accord at a certain point and asked ‘can we stop this treatment doctor?’. I had previously mentioned the possibility on several occasions but had not attempted discontinuation because she dreaded it and thought she had reached a certain psychosocial stability, so I agreed with her. At the point where she reached out, she said ‘I want to try and stop’ and it worked well with a short tapering time of, I think, around a week. (GP1, man, 46 years)
Positive life events	When you think that removal of the tablet is not going to make a difference because they are busy with all sorts of things, e.g. they are happy because of a grandchild, you should do it.(GP8, female, 42 years)
Long-term antidepressant: is there a problem?
Safe and effective medication	‘they are feeling well now, so it probably has some effect, even if it is only placebo’ (GP18, female, 31 yr) Concerning the side effects, certainly in people who have been taking them for a while, it does not seems to me there are that many. If not much is happening in their life; no new medication, diseases or health issues, there is no incentive to discuss it. So, what is actually the problem? (GP4, man, 32 years)
Risk for relapse	You know, I do not discuss it anymore, what if they relapse? Then it is your responsibility. As doctors we tend to be a little scared of that relapse. (GP6, man, 48 years)
Routine prescribing	‘Yes for those people for whom it is routine medication. In that case you don’t think about it enough or maybe it is more that you don’t think it through… For example, someone on an antihypertensive or with high cholesterol, you know, you are not going to ask questions. Chances of them being cured of that are slim to none. The antidepressant is apparently part of that routine’. (GP14, female, 37 years)
Discontinuation of antidepressants is not simple
Is it worth the effort?
Discontinuation is futile/low priority/negative	When you start up medication, you expect a positive result, but with stopping nothing ‘happy’ is going to come from it, it is difficult to stop something, it is like stealing something from your patient. It is still something negative, if you start up medication and people feel better, stopping will not immediately affect the patient, initially it might even have a negative effect. (GP2, female, 35 years)
Discontinuation consumes energy and time	The problem is in the energy consumed by these consults; motivational issues, depression, sleeping issues,… you can’t have too many of them in one day, I don’t know how psychologists manage. This is something we discussed with the receptionist; don’t schedule too many of these consults in one day. It is not an easy group of patients, you’re more likely to discuss something in summer than in winter, there is less energy left over to discuss these things in the middle of flu season as well. (GP8, female, 42 years)
Is it my role?
Patients do not ask to discontinue the medication	When people have been taking antidepressant for years it is very difficult, they will say ‘doctor you have asked that already and I told you I am not experiencing side effects, I want to keep taking it’. Sometimes they even get a bit annoyed. Six months later you are asking the same question. That is hard. They might think you are messing with them. If you keep running into a brick wall you will give up at a certain point. (GP10, man, 65 years)
Locus of control with other clinician	Well, no, a lack of trust is not the right way to put it but the other doctor told them to take that medication. At that moment they have a consultation for something else that they trust you with but changing that other tablet will need to be tackled by the one who initiated the treatment. (GP15, man, 29 years)
‘GPs need help’
Collaborative management	If psychologists would indicate that patients have been stable for a long time that would help as well. If they would say: ‘I do not see any alarming signs anymore, they told me the following things had happened and they responded in this way, so I notice that there is an improved coping mechanism right now’. If you would get that kind of feedback you would feel more confident that it will work. (GP2, female, 35 years)
Information skills and tools	If I could print a leaflet and give it to the patient with some extra information, that would really help me. Right now you take away their antidepressant and send them on their way with nothing. Being able to give them something to take home would help. (GP20, female, 32 years)