Lessons from the Netherlands for Australia: cross-country comparison of trends in antidepressant dispensing 2013-2021 and contextual factors influencing prescribing.

BACKGROUND: There is concern internationally about increasing antidepressant use. Most antidepressants are prescribed in general practice. The aim of this study was to compare trends in antidepressant dispensing in Australia and the Netherlands over the 9years from 2013 to 2021, and to explore reasons for differences. METHODS: A convergent mixed methods study including analysis of publicly available antidepressant dispensing data obtained from Australia's Pharmaceutical Benefits Scheme and Repatriation Pharmaceutical Benefits Scheme and the Dutch Foundation for Pharmaceutical Statistics and a search of relevant literature to compare contextual factors influencing prescribing were undertaken. RESULTS: In 2013, antidepressant dispensing rates in Australia were nearly twice as high as those in the Netherlands (82.5 versus 44.3DDD/1000/day) and increased to be more than twice as high by 2021 (115.6 versus 48.8DDD/1000/day). Antidepressant dispensing increased by 40% in Australia over the nine study years, but by only 10% in the Netherlands. Our scan of the literature confirms that while population factors, health system structure, and clinical guideline recommendations are largely consistent across the two countries, a multifaceted approach in the Netherlands involving improved access to non-pharmacological alternatives, initiatives targeting safer antidepressant prescribing, and tight regulation of pharmaceutical industry influence on prescribers, has successfully curtailed increasing antidepressant use. CONCLUSIONS: Australia may learn from the Netherlands' approach to redress increasing antidepressant use.

RELEASE (REdressing Long-tErm Antidepressant uSE): protocol for a 3-arm pragmatic cluster randomised controlled trial effectiveness-implementation hybrid type-1 in general practice.

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.

3-Domains screening toolkit for medical assessment of older drivers: Feasibility study in Australian general practice.

BACKGROUND AND OBJECTIVES: Some general practitioners (GPs) find the older driver medical assessment challenging, citing clinical uncertainty and concerns about communicating the need for further testing or driving cessation while maintaining a trusting therapeutic relationship. A screening toolkit could help support GP decision making and communication about fitness to drive. The aim of this study was to investigate the feasibility, acceptability and utility of the 3-Domains screening toolkit for the medical assessment of older drivers in Australian general practice. METHOD: A prospective mixed-methods study was conducted in nine general practices in south-east Queensland. Participants were older drivers (age ≥75 years) attending annual driving licence medical assessment, GPs and practice nurses. The 3-Domains toolkit comprises three screening tests (Snellen chart visual acuity, functional reach, road signs recognition). We evaluated the feasibility, acceptability and utility of the toolkit. RESULTS: Practices used the toolkit in 43 older driver medical assessments (age 75-93 years; combined predictive score 13-96%). Twenty-two semistructured interviews were conducted. Older drivers felt reassured by the thorough assessment. GPs said the toolkit fitted into practice workflows, informed clinical judgement and supported conversations about fitness to drive while preserving therapeutic relationships. DISCUSSION: The 3-Domains screening toolkit is feasible, acceptable and useful for the medical assessment of older drivers in Australian general practice.

Costs to the Medicare Benefits Schedule for general practitioner consultations: A time-series analysis.

The COVID-19 pandemic was a catalyst for the introduction of additional telehealth funding (telehealth item numbers) for general practitioner (GP) consultations through the Medicare Benefits Schedule (MBS) in Australia. This study evaluated the impact of telehealth funding on costs to the MBS for GP consultations from January 2017 to December 2021. An interrupted time series analysis assessed MBS costs (initial and monthly growth) for GP consultations (in-person, videoconference, telephone) before and after additional telehealth item numbers were introduced. From January 2017 to February 2020, total MBS costs for GP consultations were, on average, $545 million per month compared to $592 million per month from March 2020 to December 2021. There was an initial cost increase of approximately $39 million in the first month after additional telehealth funding was introduced (p = 0.0001). Afterwards, there was no significant change in monthly costs (p = 0.539). The introduction of additional MBS telehealth funding increased overall MBS costs for GP consultations. This increased cost for GP telehealth services could save costs to society if it translates into improved continuity of care, decreased hospitalisations, reduced productivity losses and improved patient outcomes. Future policy reform should incorporate a cost-benefit analysis to determine if increased MBS costs for GP consultations are a good investment.

Doctors, drugs of dependence and discipline: a retrospective review of disciplinary decisions in New Zealand, 1997-2016.

AIM: To describe disciplinary cases for inappropriate prescribing of drugs of dependence by doctors in New Zealand, 1997-2016. METHODS: A retrospective analysis of disciplinary decisions to describe characteristics of cases (setting, drugs, outcome) and doctors (sex, specialty, years since qualification). RESULTS: There were 25 disciplinary decisions involving 24 doctors. Disciplined doctors were mostly male (19;76%), working in general practice (19;76%), and older (mean 24 years in practice). Pharmacists were the most common source of notification to the authorities (6;24%); medical colleagues reported only four (16%). The alleged misconduct often involved behaviour in addition to inappropriate prescribing. In all cases the doctor was found guilty of professional misconduct. Penalties were severe: six doctors were removed from practice, 11 were suspended, and of the remainder all but one had restrictions on practice imposed. In many decisions there was no patient harm documented. CONCLUSION: Disciplinary cases for inappropriate prescribing of drugs of dependence by doctors in New Zealand are not common, but the consequences can be dire. The role of discipline in doctors with drug dependence is unclear.