Managing Antidepressant Discontinuation: A Systematic Review.

PURPOSE: We aimed to determine the effectiveness of interventions to manage antidepressant discontinuation, and the outcomes for patients. METHODS: We conducted a systematic review with narrative synthesis and meta-analysis of studies published to March 2017. Studies were eligible for inclusion if they were randomized controlled trials, quasi-experimental studies, or observational studies assessing interventions to facilitate discontinuation of antidepressants for depression in adults. Our primary outcomes were antidepressant discontinuation and discontinuation symptoms. Secondary outcomes were relapse/recurrence; quality of life; antidepressant reduction; and sexual, social, and occupational function. RESULTS: Of 15 included studies, 12 studies (8 randomized controlled trials, 2 single-arm trials, 2 retrospective cohort studies) were included in the synthesis. None were rated as having high risk for selection or detection bias. Two studies prompting primary care clinician discontinuation with antidepressant tapering guidance found 6% and 7% of patients discontinued, vs 8% for usual care. Six studies of psychological or psychiatric treatment plus tapering reported cessation rates of 40% to 95%. Two studies reported a higher risk of discontinuation symptoms with abrupt termination. At 2 years, risk of relapse/recurrence was lower with cognitive behavioral therapy plus taper vs clinical management plus taper (15% to 25% vs 35% to 80%: risk ratio = 0.34; 95% CI, 0.18-0.67; 2 studies). Relapse/recurrence rates were similar for mindfulness-based cognitive therapy with tapering and maintenance antidepressants (44% to 48% vs 47% to 60%; 2 studies). CONCLUSIONS: Cognitive behavioral therapy or mindfulness-based cognitive therapy can help patients discontinue antidepressants without increasing the risk of relapse/recurrence, but are resource intensive. More scalable interventions incorporating psychological support are needed.

Do care plans and annual reviews of physical health influence unplanned hospital utilisation for people with serious mental illness? Analysis of linked longitudinal primary and secondary healthcare records in England.

OBJECTIVE: To investigate whether two primary care activities that are framed as indicators of primary care quality (comprehensive care plans and annual reviews of physical health) influence unplanned utilisation of hospital services for people with serious mental illness (SMI). DESIGN, SETTING, PARTICIPANTS: Retrospective observational cohort study using linked primary care and hospital records (Hospital Episode Statistics) for 5158 patients diagnosed with SMI between April 2006 and March 2014, who attended 213 primary care practices in England that contribute to the Clinical Practice Research Datalink GOLD database. OUTCOMES AND ANALYSIS: Cox survival models were used to estimate the associations between two primary care quality indicators (care plans and annual reviews of physical health) and the hazards of three types of unplanned hospital utilisation: presentation to accident and emergency departments (A&E), admission for SMI and admission for ambulatory care sensitive conditions (ACSC). RESULTS: Risk of A&E presentation was 13% lower (HR 0.87, 95% CI 0.77 to 0.98) and risk of admission to hospital for ACSC was 23% lower (HR 0.77, 95% CI 0.60 to 0.99) for patients with a care plan documented in the previous year compared with those without a care plan. Risk of A&E presentation was 19% lower for those who had a care plan documented earlier but not updated in the previous year (HR: 0.81, 95% CI 0.67 to 0.97) compared with those without a care plan. Risks of hospital admission for SMI were not associated with care plans, and none of the outcomes were associated with annual reviews. CONCLUSIONS: Care plans documented in primary care for people with SMI are associated with reduced risk of A&E attendance and reduced risk of unplanned admission to hospital for physical health problems, but not with risk of admission for mental health problems. Annual reviews of physical health are not associated with risk of unplanned hospital utilisation.

Identifying primary care quality indicators for people with serious mental illness: a systematic review.

BACKGROUND: Serious mental illness (SMI) - which comprises long-term conditions such as schizophrenia, bipolar disorder, and other psychoses - has enormous costs for patients and society. In many countries, people with SMI are treated solely in primary care, and have particular needs for physical care. AIM: The objective of this study was to systematically review the literature to create a list of quality indicators relevant to patients with SMI that could be captured using routine data, and which could be used to monitor or incentivise better-quality primary care. DESIGN AND SETTING: A systematic literature review, combined with a search of quality indicator databases and guidelines. METHOD: The authors assessed whether indicators could be measured from routine data and the quality of the evidence. RESULTS: Out of 1847 papers and quality indicator databases identified, 27 were included, from which 59 quality indicators were identified, covering six domains. Of the 59 indicators, 52 could be assessed using routine data. The evidence base underpinning these indicators was relatively weak, and was primarily based on expert opinion rather than trial evidence. CONCLUSION: With appropriate adaptation for different contexts, and in line with the relative responsibilities of primary and secondary care, use of the quality indicators has the potential to improve care and to improve the physical and mental health of people with SMI. However, before the indicators can be used to monitor or incentivise primary care quality, more robust links need to be established, with improved patient outcomes.

Spiritual belief, social support, physical functioning and depression among older people in Bulgaria and Romania.

OBJECTIVES: An exploratory investigation is reported into the role of spirituality and religious practice in protecting against depression among older people living in rural villages in Bulgaria and Romania, two neighbouring countries with similar cultural, political and religious histories, but with differing levels of current religiosity. METHODS: In both countries, interviews were conducted with samples of 160 persons of 60 years and over in villages of similar socio-economic status. The Hospital Anxiety and Depression-D scale and the Royal Free Interview for Religious and Spiritual Beliefs were used to assess depression and spiritual belief and practice respectively. In addition social support, physical functioning and the presence of chronic diseases were assessed. One year later, follow-up interviews were conducted with 58 of the original sample in Bulgaria, in which additional measures of depression and of spiritual belief and practice were also included. RESULTS: The study demonstrates, as expected, significantly lower levels of spiritual belief in the Bulgarian sample (Bulgarian mean 29.7 (SD = 19.1), Romanian mean 47.6 (SD = 11.2), t = 10.2, p < 0.001), as well as significantly higher levels of depression (Bulgarian mean 12.0 (SD = 4.9), Romanian mean 7.3 (SD = 4.1), t = 9.3, p < 0.001), the latter attributable in large part to higher morbidity and disability rates, but less evidently to differences in strength of belief. However, analyses from both the cross-sectional study and the one-year follow-up of the Bulgarian sample do suggest that spiritual belief and practice may both influence and reflect physical and mental illness. CONCLUSIONS: Much of Eastern Europe displays high rates of depression among its older population and provides opportunities for investigation of the role of religious belief and practice in preventing and coping with depression. Further research is encouraged in populations of diverse religiosity.

Patients' and doctors' views on depression severity questionnaires incentivised in UK quality and outcomes framework: qualitative study.

OBJECTIVE: To gain understanding of general practitioners' and patients' opinions of the routine introduction of standardised measures of severity of depression through the UK general practice quality and outcomes framework. DESIGN: Semistructured qualitative interview study, with purposive sampling and constant comparative analysis. PARTICIPANTS: 34 general practitioners and 24 patients. SETTING: 38 general practices in three sites in England: Southampton, Liverpool, and Norfolk. RESULTS: Patients generally favoured the measures of severity for depression, whereas general practitioners were generally cautious about the validity and utility of such measures and sceptical about the motives behind their introduction. Both general practitioners and patients considered that assessments of severity should be seen as one aspect of holistic care. General practitioners considered their practical wisdom and clinical judgment ("phronesis") to be more important than objective assessments and were concerned that the assessments reduced the human element of the consultation. Patients were more positive about the questionnaires, seeing them as an efficient and structured supplement to medical judgment and as evidence that general practitioners were taking their problems seriously through a full assessment. General practitioners and patients were aware of the potential for manipulation of indicators: for economic reasons for doctors and for patients to avoid stigma or achieve desired outcomes. CONCLUSIONS: Despite general practitioners' caution about measures of severity for depression, these may benefit primary care consultations by increasing patients' confidence that general practitioners are correct in their diagnosis and are making systematic efforts to assess and manage their mental health problems. Further education of primary care staff may optimise the use and interpretation of depression questionnaires.