BackgroundThe apparent rise of antidepressant use seems to be explained to a large extent by an increase in long-term use. Both professionals and patients appear reluctant to discontinue antidepressant medication (ADM). It is not known what factors determine this reluctance.AimThis study aimed to identify factors that enable the shared decision-making process about discontinuation of ADM between long-term users and their GPs.Design and settingConcept-mapping study of a purposive sample of both patients and professionals from primary and secondary mental health care in the Netherlands.MethodConcept mapping was used to conceptualise and structure the topics relevant to the discontinuation process from the perspective of both patients and professionals. Participants generated topics in brainstorming sessions and subsequently prioritised and sorted them. Multidimensional scaling and hierarchical cluster analyses were used for the cluster topics.ResultsThirty-seven patients and 27 professionals generated 50 separate topics. Hierarchical cluster analysis revealed six clusters of topics: ‘Process of discontinuation’, ‘Expectations’, ‘Professional guidance’, ‘Current use’, ‘Environment’, and ‘Side effects’. Patients and professionals came up with largely similar topics. Nevertheless, a difference was found between these groups regarding the perceived importance of professional guidance.ConclusionThis study yielded an informed selection of the topics that seem most important to discuss when considering whether to discontinue ADM. As perspectives of both patients and professionals were combined, the topics may provide patients and GPs with a broader and more balanced scope of factors to consider, and thus facilitate a better shared decision-making process.

Background Antidepressant use continues to rise, mainly explained by an increase in the proportion of patients receiving long term treatment. Although treatment guidelines recommend discontinuation after sustained remission, discontinuing antidepressants appears to be challenging for both patients and general practitioners (GPs). Mindfulness-Based Cognitive Therapy (MBCT) is an effective intervention that reduces the risk of relapse in recurrent depression and might facilitate discontinuation by teaching patients to cope with withdrawal symptoms and fear of relapse. The current study aims to investigate the effectiveness of the combination of Supported Protocolized Discontinuation (SPD) and MBCT in comparison with SPD alone in successful discontinuation of long-term use of antidepressants in primary care. Methods This study involves a cluster-randomized controlled trial conducted in primary care patients with long-term use antidepressants with baseline and 6, 9 and 12 months follow-up assessments. Patients choosing to discontinue their medication will be offered a combination of SPD and MBCT or SPD alone. Our primary outcome will be full discontinuation of antidepressant medication (= 0 mg) within 6 months after baseline assessment. Secondary outcome measures will be the severity of withdrawal symptoms, symptoms of depression and anxiety, psychological well-being, quality of life and medical and societal costs. Discussion In theory, stopping antidepressant medication seems straightforward. In practice however, patients and their GPs appear reluctant to initiate and accomplish this process. Both patients and professionals are in need of appropriate tools and information to better support the process of discontinuing antidepressant medication. Trial registration ClinicalTrials.gov PRS ID: NCT03361514 retrospectively registered October 2017.

ObjectivesThis study aimed to explore predictors and outcomes associated with different trajectories of discontinuing antidepressant medication (ADM), in recurrently depressed individuals after participation in mindfulness-based cognitive therapy (MBCT). Facilitators and barriers of discontinuation were explored qualitatively.DesignMixed-methods study combining quantitative and qualitative data, drawn from a randomised controlled trial.SettingTwelve secondary and tertiary psychiatric outpatient clinics in the Netherlands.ParticipantsRecurrently depressed individuals (N=226) who had been using ADM for at least 6 months and in partial or full remission. Regardless of trial condition, we made post-hoc classifications of patients’ actual discontinuation trajectories: full discontinuation (n=82), partial discontinuation (n=34) and no discontinuation (n=110) of ADM within 6 months after baseline. A subset of patients (n=15) and physicians (n=7) were interviewed to examine facilitators and barriers of discontinuation.InterventionsAll participants were offered MBCT, which consisted of eight weekly sessions in a group.Primary and secondary outcome measuresDemographic and clinical predictors of successful discontinuation within 6 months, relapse risk within 15 months associated with different discontinuation trajectories, and barriers and facilitators of discontinuation.ResultsOf the 128 patients assigned to MBCT with discontinuation, only 68 (53%) fully discontinued ADM within 6 months, and 17 (13%) discontinued partially. Predictors of full discontinuation were female sex, being employed and lower levels of depression. Relapse risk was lower after no discontinuation (45%) or partial discontinuation (38%), compared with full discontinuation (66%) (p=0.02). Facilitators and barriers of discontinuation were clustered within five themes: (1) pre-existing beliefs about depression, medication and tapering; (2) current experience with ADM; (3) life circumstances; (4) clinical support and (5) mindfulness.ConclusionsDiscontinuing antidepressants appears to be difficult, stressing the need to support patients and physicians in this process. MBCT may offer one of these forms of support.Trial registration numberClinicalTrials.gov Registry (NCT00928980); post-results.

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