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Wallis KA, Donald M, Horowitz M, Moncrieff J, Ware RS, Byrnes J, Thrift K, Cleetus M, Panahi I, Zwar N, Morgan M, Freeman C, Scott I. RELEASE (REdressing Long-tErm Antidepressant uSE): protocol for a 3-arm pragmatic cluster randomised controlled trial effectiveness-implementation hybrid type-1 in general practice. Trials 2023; 24:615. [PMID: 37770893 PMCID: PMC10537226 DOI: 10.1186/s13063-023-07646-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/12/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Many people experience withdrawal symptoms when they attempt to stop antidepressants. Withdrawal symptoms are readily misconstrued for relapse or ongoing need for medication, contributing to long-term use (> 12 months). Long-term antidepressant use is increasing internationally yet is not recommended for most people. Long-term use is associated with adverse effects including weight gain, sexual dysfunction, lethargy, emotional numbing and increased risk of falls and fractures. This study aims to determine the effectiveness of two multi-strategy interventions (RELEASE and RELEASE+) in supporting the safe cessation of long-term antidepressants, estimate cost-effectiveness, and evaluate implementation strategies. METHODS DESIGN: 3-arm pragmatic cluster randomised controlled trial effectiveness-implementation hybrid type-1. SETTING primary care general practices in southeast Queensland, Australia. POPULATION adults 18 years or older taking antidepressants for longer than 1 year. Practices will be randomised on a 1.5:1:1 ratio of Usual care:RELEASE:RELEASE+. INTERVENTION RELEASE for patients includes evidence-based information and resources and an invitation to medication review; RELEASE for GPs includes education, training and printable resources via practice management software. RELEASE+ includes additional internet support for patients and prescribing support including audit and feedback for GPs. OUTCOME MEASURES the primary outcome is antidepressant use at 12 months self-reported by patients. Cessation is defined as 0 mg antidepressant maintained for at least 2 weeks. SECONDARY OUTCOMES at 6 and 12 months are health-related quality of life, antidepressant side effects, well-being, withdrawal symptoms, emotional numbing, beliefs about antidepressants, depressive symptoms, and anxiety symptoms; and at 12 months 75% reduction in antidepressant dose; aggregated practice level antidepressant prescribing, and health service utilisation for costs. SAMPLE SIZE 653 patients from 28 practices. A concurrent evaluation of implementation will be through mixed methods including interviews with up to 40 patients and primary care general practitioners, brief e-surveys, and study administrative data to assess implementation outcomes (adoption and fidelity). DISCUSSION The RELEASE study will develop new knowledge applicable internationally on the effectiveness, cost-effectiveness, and implementation of two multi-strategy interventions in supporting the safe cessation of long-term antidepressants to improve primary health care and outcomes for patients. TRIAL REGISTRATION ANZCTR, ACTRN12622001379707p. Registered on 27 October 2022.
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Affiliation(s)
- Katharine A Wallis
- General Practice Clinical Unit, Medical School, The University of Queensland, Herston, Brisbane, QLD, 4072, Australia.
| | - Maria Donald
- General Practice Clinical Unit, Medical School, The University of Queensland, Herston, Brisbane, QLD, 4072, Australia
| | - Mark Horowitz
- NHS Foundation Trust, Research and Development Department, London, Northeast London, UK
| | | | - Robert S Ware
- Griffith University, Nathan, Brisbane, QLD, Australia
| | - Joshua Byrnes
- Griffith University, Nathan, Brisbane, QLD, Australia
| | - Karen Thrift
- General Practice Clinical Unit, Medical School, The University of Queensland, Herston, Brisbane, QLD, 4072, Australia
| | - MaryAnne Cleetus
- General Practice Clinical Unit, Medical School, The University of Queensland, Herston, Brisbane, QLD, 4072, Australia
| | - Idin Panahi
- General Practice Clinical Unit, Medical School, The University of Queensland, Herston, Brisbane, QLD, 4072, Australia
| | - Nicholas Zwar
- Faculty of Health Sciences and Medicine, Bond University, Robina, Gold Coast, QLD, Australia
| | - Mark Morgan
- Faculty of Health Sciences and Medicine, Bond University, Robina, Gold Coast, QLD, Australia
| | - Chris Freeman
- The University of Queensland, Herston, Brisbane, QLD, 4072, Australia
| | - Ian Scott
- The University of Queensland, Herston, Brisbane, QLD, 4072, Australia
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de Oliveira Costa J, Gillies MB, Schaffer AL, Peiris D, Zoega H, Pearson SA. Changes in antidepressant use in Australia: A nationwide analysis (2015-2021). Aust N Z J Psychiatry 2023; 57:49-57. [PMID: 35176912 DOI: 10.1177/00048674221079740] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Depression and anxiety affect 4-14% of Australians every year; symptoms may have been exacerbated during the COVID-19 pandemic. We examined recent patterns of antidepressant use in Australia in the period 2015-2021, which includes the first year of the pandemic. METHODS We used national dispensing claims for people aged ⩾10 years to investigate annual trends in prevalent and new antidepressant use (no antidepressants dispensed in the year prior). We conducted stratified analyses by sex, age group and antidepressant class. We report outcomes from 2015 to 2019 and used time series analysis to quantify changes during the first year of the COVID-19 pandemic (March 2020-February 2021). RESULTS In 2019, the annual prevalence of antidepressant use was 170.4 per 1000 women and 101.8 per 1000 men, an increase of 7.0% and 9.2% from 2015, respectively. New antidepressant use also increased for both sexes (3.0% for women and 4.9% for men) and across most age groups, particularly among adolescents (aged 10-17 years; 46-57%). During the first year of the COVID-19 pandemic, we observed higher than expected prevalent use (+2.2%, 95% CI = [0.3%, 4.2%]) among females, corresponding to a predicted excess of 45,217 (95% CI = [5,819, 84,614]) females dispensed antidepressants. The largest increases during the first year of the pandemic occurred among female adolescents for both prevalent (+11.7%, 95% CI = [4.1%, 20.5%]) and new antidepressant use (+15.6%, 95% CI = [8.5%, 23.7%]). CONCLUSION Antidepressant use continues to increase in Australia overall and especially among young people. We found a differential impact of the COVID-19 pandemic in treated depression and anxiety, greater among females than males, and greater among young females than other age groups, suggesting an increased mental health burden in populations already on a trajectory of increased use of antidepressants prior to the pandemic. Reasons for these differences require further investigation.
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Affiliation(s)
- Juliana de Oliveira Costa
- Medicines Policy Research Unit, Centre for Big Data Research in Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
| | - Malcolm B Gillies
- Medicines Policy Research Unit, Centre for Big Data Research in Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
| | - Andrea L Schaffer
- Medicines Policy Research Unit, Centre for Big Data Research in Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
| | - David Peiris
- The George Institute for Global Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
| | - Helga Zoega
- Medicines Policy Research Unit, Centre for Big Data Research in Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia.,Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Sallie-Anne Pearson
- Medicines Policy Research Unit, Centre for Big Data Research in Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
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Nishtala PS, Chyou TY. An Updated Analysis of Psychotropic Medicine Utilisation in Older People in New Zealand from 2005 to 2019. Drugs Aging 2022; 39:657-669. [PMID: 35829958 DOI: 10.1007/s40266-022-00965-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Psychotropic medicine utilisation in older adults continues to be of interest because of overuse and concerns surrounding its safety and efficacy. OBJECTIVE This study aimed to characterise the utilisation of psychotropic medicines in older people in New Zealand. METHODS We conducted a repeated cross-sectional analysis of national dispensing data from 1 January, 2005 to 31 December, 2019. We defined utilisation using the Anatomical Therapeutic Chemical classification defined daily dose system. Utilisation was measured in terms of the defined daily dose (DDD) per 1000 older people per day (TOPD). RESULTS Overall, the utilisation of psychotropic medicines increased marginally by 0.42% between 2005 and 2019. The utilisation increased for antidepressants (72.42 to 75.21 DDD/TOPD) and antipsychotics (6.06-19.04 DDD/TOPD). In contrast, the utilisation of hypnotics and sedatives (53.74-38.90 DDD/TOPD) and anxiolytics decreased (10.20-9.87 DDD/TOPD). The utilisation of atypical antipsychotics increased (4.06-18.72 DDD/TOPD), with the highest percentage change in DDD/TOPD contributed by olanzapine (520.6 %). In comparison, utilisation of typical antipsychotics was relatively stable (2.00-2.06 DDD/TOPD). The utilisation of venlafaxine increased remarkably by 5.7 times between 2005 and 2019. The utilisation of zopiclone was far greater than that of other hypnotics in 2019. CONCLUSIONS There was only a marginal increase in psychotropic medicines utilisation from 2005 to 2019 in older adults in New Zealand. There was a five-fold increase in the utilisation of antipsychotic medicines. Continued monitoring of psychotropic medicine utilisation will be of interest to understand the utilisation of antidepressants and antipsychotic medicines during the coronavirus disease 2019 pandemic year.
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Affiliation(s)
- Prasad S Nishtala
- Department of Pharmacy and Pharmacology, University of Bath, Claverton Down, Bath, BA2 7AY, UK. .,Centre for Therapeutic Innovation, University of Bath, Bath, UK.
| | - Te-Yuan Chyou
- Department of Biochemistry, University of Otago, Dunedin, Otago, New Zealand
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Van Leeuwen E, van Driel ML, Horowitz MA, Kendrick T, Donald M, De Sutter AI, Robertson L, Christiaens T. Approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults. Cochrane Database Syst Rev 2021; 4:CD013495. [PMID: 33886130 PMCID: PMC8092632 DOI: 10.1002/14651858.cd013495.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Depression and anxiety are the most frequent indication for which antidepressants are prescribed. Long-term antidepressant use is driving much of the internationally observed rise in antidepressant consumption. Surveys of antidepressant users suggest that 30% to 50% of long-term antidepressant prescriptions had no evidence-based indication. Unnecessary use of antidepressants puts people at risk of adverse events. However, high-certainty evidence is lacking regarding the effectiveness and safety of approaches to discontinuing long-term antidepressants. OBJECTIVES To assess the effectiveness and safety of approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults. SEARCH METHODS We searched all databases for randomised controlled trials (RCTs) until January 2020. SELECTION CRITERIA We included RCTs comparing approaches to discontinuation with continuation of antidepressants (or usual care) for people with depression or anxiety who are prescribed antidepressants for at least six months. Interventions included discontinuation alone (abrupt or taper), discontinuation with psychological therapy support, and discontinuation with minimal intervention. Primary outcomes were successful discontinuation rate, relapse (as defined by authors of the original study), withdrawal symptoms, and adverse events. Secondary outcomes were depressive symptoms, anxiety symptoms, quality of life, social and occupational functioning, and severity of illness. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. MAIN RESULTS We included 33 studies involving 4995 participants. Nearly all studies were conducted in a specialist mental healthcare service and included participants with recurrent depression (i.e. two or more episodes of depression prior to discontinuation). All included trials were at high risk of bias. The main limitation of the review is bias due to confounding withdrawal symptoms with symptoms of relapse of depression. Withdrawal symptoms (such as low mood, dizziness) may have an effect on almost every outcome including adverse events, quality of life, social functioning, and severity of illness. Abrupt discontinuation Thirteen studies reported abrupt discontinuation of antidepressant. Very low-certainty evidence suggests that abrupt discontinuation without psychological support may increase risk of relapse (hazard ratio (HR) 2.09, 95% confidence interval (CI) 1.59 to 2.74; 1373 participants, 10 studies) and there is insufficient evidence of its effect on adverse events (odds ratio (OR) 1.11, 95% CI 0.62 to 1.99; 1012 participants, 7 studies; I² = 37%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of abrupt discontinuation on withdrawal symptoms (1 study) is very uncertain. None of these studies included successful discontinuation rate as a primary endpoint. Discontinuation by "taper" Eighteen studies examined discontinuation by "tapering" (one week or longer). Most tapering regimens lasted four weeks or less. Very low-certainty evidence suggests that "tapered" discontinuation may lead to higher risk of relapse (HR 2.97, 95% CI 2.24 to 3.93; 1546 participants, 13 studies) with no or little difference in adverse events (OR 1.06, 95% CI 0.82 to 1.38; 1479 participants, 7 studies; I² = 0%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of discontinuation on withdrawal symptoms (1 study) is very uncertain. Discontinuation with psychological support Four studies reported discontinuation with psychological support. Very low-certainty evidence suggests that initiation of preventive cognitive therapy (PCT), or MBCT, combined with "tapering" may result in successful discontinuation rates of 40% to 75% in the discontinuation group (690 participants, 3 studies). Data from control groups in these studies were requested but are not yet available. Low-certainty evidence suggests that discontinuation combined with psychological intervention may result in no or little effect on relapse (HR 0.89, 95% CI 0.66 to 1.19; 690 participants, 3 studies) compared to continuation of antidepressants. Withdrawal symptoms were not measured. Pooling data on adverse events was not possible due to insufficient information (3 studies). Discontinuation with minimal intervention Low-certainty evidence from one study suggests that a letter to the general practitioner (GP) to review antidepressant treatment may result in no or little effect on successful discontinuation rate compared to usual care (6% versus 8%; 146 participants, 1 study) or on relapse (relapse rate 26% vs 13%; 146 participants, 1 study). No data on withdrawal symptoms nor adverse events were provided. None of the studies used low-intensity psychological interventions such as online support or a changed pharmaceutical formulation that allows tapering with low doses over several months. Insufficient data were available for the majority of people taking antidepressants in the community (i.e. those with only one or no prior episode of depression), for people aged 65 years and older, and for people taking antidepressants for anxiety. AUTHORS' CONCLUSIONS Currently, relatively few studies have focused on approaches to discontinuation of long-term antidepressants. We cannot make any firm conclusions about effects and safety of the approaches studied to date. The true effect and safety are likely to be substantially different from the data presented due to assessment of relapse of depression that is confounded by withdrawal symptoms. All other outcomes are confounded with withdrawal symptoms. Most tapering regimens were limited to four weeks or less. In the studies with rapid tapering schemes the risk of withdrawal symptoms may be similar to studies using abrupt discontinuation which may influence the effectiveness of the interventions. Nearly all data come from people with recurrent depression. There is an urgent need for trials that adequately address withdrawal confounding bias, and carefully distinguish relapse from withdrawal symptoms. Future studies should report key outcomes such as successful discontinuation rate and should include populations with one or no prior depression episodes in primary care, older people, and people taking antidepressants for anxiety and use tapering schemes longer than 4 weeks.
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Affiliation(s)
- Ellen Van Leeuwen
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Mieke L van Driel
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Mark A Horowitz
- Division of Psychiatry, University College London, London, UK
| | - Tony Kendrick
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - Maria Donald
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - An Im De Sutter
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Lindsay Robertson
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Thierry Christiaens
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
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Brett J, Karanges EA, Daniels B, Buckley NA, Schneider C, Nassir A, Zoega H, McLachlan AJ, Pearson SA. Psychotropic medication use in Australia, 2007 to 2015: Changes in annual incidence, prevalence and treatment exposure. Aust N Z J Psychiatry 2017; 51:990-999. [PMID: 28758432 DOI: 10.1177/0004867417721018] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine changes in annual patterns of psychotropic medication use in Australia from 2007 to 2015. METHODS We used a 10% sample of individual-level nationwide dispensing claims for concessional beneficiaries dispensed psychotropic medications (stratified by class, subclass) to investigate annual trends and changes in the incidence and prevalence of use, median annual duration of exposure, proportion of people with single psychotropic dispensing and median defined daily doses per person dispensed each medicine per year. RESULTS Over the study period, there was a 26.1% decrease in the incidence and a 2.6% increase in the prevalence of all psychotropic medicine use. We observed a decrease in the annual incidence and prevalence of antidepressants (11.6% and 16.8%, respectively) but increases in the median annual duration of exposure (7.4%). Amitriptyline had the highest proportion of single dispensings of all antidepressants throughout the study period (26.5% in 2015) and defined daily doses per person dispensed each medicine per year increased by 20% for antidepressants overall. Benzodiazepine use decreased across all measures over the study period apart from long-term use (exposure for >240 days of the year), which in 2015 was 23.6% of those dispensed a benzodiazepine. We observed a relative increase in the incidence and prevalence of antipsychotic use (14.2% and 26.8%, respectively), and haloperidol had the highest proportion of single dispensings of any antipsychotic throughout the study period (47.5% in 2015). We observed a relative increase in the incidence and prevalence of attention-deficit hyperactivity disorder medication use of 114.0% and 101.8%, respectively, over the study period. CONCLUSION Increasing doses and treatment durations of antidepressants warrants further investigation due to concerns about overuse. Single dispensings of amitriptyline and haloperidol may indicate off-label use and long-term use of benzodiazepines remains problematic. Despite increases in attention-deficit hyperactivity disorder medication use, prevalence of use is still much lower than the estimated prevalence of attention-deficit hyperactivity disorder in the adult population.
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Affiliation(s)
- Jonathan Brett
- 1 Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Emily A Karanges
- 1 Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Benjamin Daniels
- 1 Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Carl Schneider
- 3 Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Atheer Nassir
- 3 Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Helga Zoega
- 1 Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
- 4 Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Andrew J McLachlan
- 3 Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
- 5 Centre for Education and Research on Ageing, Concord Hospital, Sydney, NSW, Australia
| | - Sallie-Anne Pearson
- 1 Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
- 3 Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
- 6 Menzies Centre for Health Policy, The University of Sydney, Sydney, NSW, Australia
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