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Brisnik V, Vukas J, Jung-Sievers C, Lukaschek K, Alexander GC, Thiem U, Thürmann P, Schüle C, Fischer S, Baum E, Drey M, Harder S, Niebling W, Janka U, Krause O, Gensichen J, Dreischulte T. Deprescribing of antidepressants: development of indicators of high-risk and overprescribing using the RAND/UCLA Appropriateness Method. BMC Med 2024; 22:193. [PMID: 38735930 PMCID: PMC11089726 DOI: 10.1186/s12916-024-03397-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/18/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Antidepressants are first-line medications for many psychiatric disorders. However, their widespread long-term use in some indications (e.g., mild depression and insomnia) is concerning. Particularly in older adults with comorbidities and polypharmacy, who are more susceptible to adverse drug reactions, the risks and benefits of treatment should be regularly reviewed. The aim of this consensus process was to identify explicit criteria of potentially inappropriate antidepressant use (indicators) in order to support primary care clinicians in identifying situations, where deprescribing of antidepressants should be considered. METHODS We used the RAND/UCLA Appropriateness Method to identify the indicators of high-risk and overprescribing of antidepressants. We combined a structured literature review with a 3-round expert panel, with results discussed in moderated meetings in between rounds. Each of the 282 candidate indicators was scored on a 9-point Likert scale representing the necessity of a critical review of antidepressant continuation (1-3 = not necessary; 4-6 = uncertain; 7-9 = clearly necessary). Experts rated the indicators for the necessity of review, since decisions to deprescribe require considerations of patient risk/benefit balance and preferences. Indicators with a median necessity rating of ≥ 7 without disagreement after 3 rating rounds were accepted. RESULTS The expert panel comprised 2 general practitioners, 2 clinical pharmacologists, 1 gerontopsychiatrist, 2 psychiatrists, and 3 internists/geriatricians (total N = 10). After 3 assessment rounds, there was consensus for 37 indicators of high-risk and 25 indicators of overprescribing, where critical reviews were felt to be necessary. High-risk prescribing indicators included settings posing risks of drug-drug, drug-disease, and drug-age interactions or the occurrence of adverse drug reactions. Indicators with the highest ratings included those suggesting the possibility of cardiovascular risks (QTc prolongation), delirium, gastrointestinal bleeding, and liver injury in specific patient subgroups with additional risk factors. Overprescribing indicators target patients with long treatment durations for depression, anxiety, and insomnia as well as high doses for pain and insomnia. CONCLUSIONS Explicit indicators of antidepressant high-risk and overprescribing may be used directly by patients and health care providers, and integrated within clinical decision support tools, in order to improve the overall risk/benefit balance of this commonly prescribed class of prescription drugs.
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Affiliation(s)
- Vita Brisnik
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany
- Graduate Program "POKAL - Predictors and Outcomes in Primary Care Depression Care", (DFG - GrK 2621), Munich, Germany
| | - Jochen Vukas
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany
- Graduate Program "POKAL - Predictors and Outcomes in Primary Care Depression Care", (DFG - GrK 2621), Munich, Germany
| | - Caroline Jung-Sievers
- Graduate Program "POKAL - Predictors and Outcomes in Primary Care Depression Care", (DFG - GrK 2621), Munich, Germany
- Institute of Medical Data Processing, Biometrics and Epidemiology (IBE), Faculty of Medicine, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Karoline Lukaschek
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany
- Graduate Program "POKAL - Predictors and Outcomes in Primary Care Depression Care", (DFG - GrK 2621), Munich, Germany
| | - G Caleb Alexander
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ulrich Thiem
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Geriatrics, Albertinen-Haus, Hamburg, Germany
| | - Petra Thürmann
- Chair of Clinical Pharmacology, Faculty of Health, Department of Medicine, University Witten/Herdecke, Witten, Germany
- Philipp Klee-Institute of Clinical Pharmacology, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - Cornelius Schüle
- Department of Psychiatry and Psychotherapy, LMU University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Fischer
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany
- Psychiatric Services Lucerne, Lucerne, Switzerland
| | - Erika Baum
- Institute of General Practice and Family Medicine, Philipps University Marburg, Marburg, Germany
| | - Michael Drey
- Department of Medicine IV, Geriatrics, LMU University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Harder
- Institute for Clinical Pharmacology, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | - Wilhelm Niebling
- Department of Medicine, Division of General Practice, Medical Center, University of Freiburg, Freiburg, Germany
| | - Ulrike Janka
- Department of Psychiatry and Psychotherapy, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Olaf Krause
- Institute of General Practice and Palliative Medicine, Medical School Hannover, Hannover, Germany
| | - Jochen Gensichen
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany
- Graduate Program "POKAL - Predictors and Outcomes in Primary Care Depression Care", (DFG - GrK 2621), Munich, Germany
| | - Tobias Dreischulte
- Institute of General Practice and Family Medicine, LMU University Hospital, LMU Munich, Munich, Germany.
- Graduate Program "POKAL - Predictors and Outcomes in Primary Care Depression Care", (DFG - GrK 2621), Munich, Germany.
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Amrein MA, Hengartner MP, Näpflin M, Farcher R, Huber CA. Prevalence, trends, and individual patterns of long-term antidepressant medication use in the adult Swiss general population. Eur J Clin Pharmacol 2023; 79:1505-1513. [PMID: 37668659 PMCID: PMC10618304 DOI: 10.1007/s00228-023-03559-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/24/2023] [Indexed: 09/06/2023]
Abstract
PURPOSE Antidepressant use has increased in many European countries, mostly driven by longer treatment duration. The aim of this study was to provide prevalence rates of long-term users of antidepressants for the Swiss population over the last decade and to investigate associated factors for longer use. METHODS We examined the prevalence rates of individuals with at least one prescription for antidepressants using longitudinal health claims data for 2013 to 2021. We defined short- (< one year), medium- (one-two years), and long-term users (> two years) for 2015 to 2019. We applied a binary logistic regression model to investigate the effects of population (gender, age, area of living, language, health insurance plan, and nursing home) and treatment characteristics (psychiatric or psychotherapeutic care) on long-term compared to short- and medium-term users in 2019. RESULTS In 2021, 9% of the Swiss population (n = 770,698) received at least one antidepressant prescription, which remained stable since 2013. In 2019, the proportion of long-term users was 57.4%, with steady increase since 2015. The proportion of medium- and short-term users has decreased. Older age, being a woman, living in an urban area, living in a nursing home, being enrolled in a standard care plan, and receiving psychiatric or psychotherapeutic care were factors positively associated with being a long-term user. CONCLUSION The proportion of long-term users in Switzerland is high and steadily increasing. Given the ongoing debate about the confounding effects of relapse and withdrawal, more research is needed to investigate longer use of antidepressants that could indicate overprescribing.
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Affiliation(s)
- Melanie A Amrein
- Department of Health Sciences, Helsana Group, Zurich, Switzerland.
| | - Michael P Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences, Zurich, Switzerland
| | - Markus Näpflin
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Renato Farcher
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Carola A Huber
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
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