General practitioners’ perspectives on discontinuation of long-term antidepressants in nursing homes

Figures & data

Table

Interview Guide Part 1: - Try to remember at least 1 patient for whom discontinuing long term antidepressant use (>1 year) was successful 1. What was your experience and what was the process? - Try to remember at least 1 patient for whom discontinuing long term antidepressant use (>1 year) was NOT successful 2. What was your experience and what was the process? [‘Prompts’: why did you discontinue, who started the conversation, how did it go, what worked well, what didn’t work so well, what was the role of other health professionals, psychological and physical capabilities of the patient …] Part 2: 3. Which factors and circumstances make antidepressants (AD) discontinuation possible, in your opinion? Why? 4. Which factors and circumstances are barriers to AD discontinuation in your opinion? Why? [“Prompts: necessary knowledge, skills and attitude are needed, perception of depression and monitoring of AD psychological and physical capabilities of the patient, consequences and impact of discontinuation of AD, what was the role of other health professionals/family/friends, influence of practice related issues, influence of external factors …”] 5. Which factors and circumstances make AD discontinuation in the nursing home different from AD discontinuation in adults living at home? Why? 6. Which factors and circumstances make AD discontinuation in nursing homes possible in your opinion? Why? 7. Which factors and circumstances are barriers to AD discontinuation in nursing homes, in your opinion? Why? Part 3: 8. What support would you need to discontinue AD in more of your patients? Why? [prompts: knowledge and attitude (guidelines/e-learning, training),  resources, external factors, role of other health professionals/others]

Table 1. Demographics of the 20 FPs.

Age (range in years, years)
25–35	5
35–45	4
45–55	7
55–65	3
>65	1
Average	44.6
Sex
Female	12
Male	8
Area
Rural	10
Urban	10
Type of practice
Solo	5
Duo	3
Group	10
Community health centre	2
Coordinating FP in nursing home
Yes	5
No	15

Table 2. Quotes illustrating each of the themes.

Reluctance to rock the boat: not worth taking the risk
The fear of making things worse
Risk of destabilizing the fragile balance of the older patient	‘If I take away the AD they can get very emotional and feel like there’s no point in living anymore.’ (GP13, F, 53y)
Living in a nursing home as a depressive enhancing situation	‘I think we often too quickly jump to the conclusion that if you are old you are depressed. As a doctor and as a society, we seem to think it comes with life.’ (GP11, F, 58y)
Benefit of the doubt	‘I have had some people in the nursing home where I noticed they were feeling down, in that case I start an AD and feel they improve. But are they improving due to the medication or are they adjusting to life in the nursing home and are they happier because of that?’ (GP18, M, 31y) ‘Some patients are tired of life, they don’t feel like doing anything. Some of them really insist on it in the hope of achieving something with [the AD]. In that case I stop all psychotropic medicines except the antidepressant; you never know if it still does something.” (GP9, M, 47y)
Discontinuation perceived as a negative intervention	‘Especially when they are already quite old I think, is it still worth the trouble to do something about it? My reasoning in those cases tends to be along the lines of; is there any harm in them taking it, should we really take this away from them after all these years, they don’t seem to have had issues with it, should I really be taking it away from them in the end?” (GP20,F,32y)
Limited alternatives to support discontinuation
Limited alternatives to support discontinuation	‘That is something I try to discuss with the nurses: keep an eye on that person, talk with them a little more. But the issue in nursing homes is that there is no time to do anything other than the basic care.” (GP2, F, 35y)
It takes at least three to tango
Request from nursing staff and relatives to start AD or pressure to continue	‘Those people are there, are bored, are at the end of their life and are complaining to their family about the food, the toilet visits that are delayed, not getting any visitors,… Some residents are very negative towards their family and then the family will ask “can’t you give them something to be happier”. That is a request we get a lot.’ (GP12, F, 50y)
Importance of the opinion of the family and the nursing staff	‘I haven’t explicitly asked residents, no. Are you happier, I don’t ask that. If the daughter has no issues, then everything is fine.’ (GP3, F, 58y)
Time and energy consuming process to involve the family and nursing staff	‘There are many people in the nursing home with dementia for whom the treatment could be stopped. Why am I not doing it? A lack of time I guess. You need to discuss it with the nurses and relatives before you can change anything in the medication. It takes a lot of energy and actually the resident doesn’t realise it, but the relatives, well most of them, keep an eye on it. You need to get them on board. Sometimes that is difficult, very difficult; sometimes it is not.’ (GP8, F, 42)
Nursing staff and relatives as supporting partner in the discontinuation process	‘When stopping I also ask the nursing staff to let me, as well as the family, know if they see any changes in the behaviour.’ (GP 6, M, 48)
Opening the door: triggers to discontinue the AD
Medication review as an opportunity?
AD as a safe drug	‘If somebody falls, they often break a hip. Then I focus more on benzos. I must say that I am happy if it is only escitalopram, yes. If it doesn’t help, it doesn’t hurt too much either. In contrast to a benzo, you know that those don’t do anything anymore after so many years.’ (GP 4, M, 32)
Deprescribing of the AD is not a priority	‘In any case with polypharmacy you try to stop there, there often is an AD too and in a lot of people it can be stopped but I also think that the more medication they take the more difficult it is to stop the AD. I would consider [stopping] a statin, something for the stomach, something for blood pressure and sometimes an antipsychotic, but certainly not the antidepressant, that is really the last thing.’ (GP 2, F, 35y)
Severe health problems as trigger for discontinuation
	‘It works best when people are very ill. In that case I see things going wrong and wonder if all this medication is really necessary. In these cases the family is more likely to say “ok we’ll try it and we’ll see what happens”.’ (GP 10, M, 65y)
Dementia makes discontinuation easy
	‘We do taper in those suffering from dementia, that is much easier, because you want to improve their quality of life and the less medication they need to take the better, and when you notice that their cognitive functioning is deteriorating, in those cases you do not see value in an AD anymore. This is maybe the easiest group as you do not get any resistance.’ (GP 8, F, 42y)