Reviewing the long-term use of selective serotonin reuptake inhibitors in patients with depression

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Background

Patients with moderately severe depression who have not responded sufficiently to non-pharmacological interventions are often prescribed a SSRI as a first-line pharmacological option, e.g. citalopram, escitalopram, sertraline or fluoxetine.^{1, 2}

N.B. This audit focuses on the use of SSRIs, however, it can be easily applied to a range of other antidepressants, including mirtazapine, venlafaxine or tricyclic antidepressants (TCAs).

Antidepressants are not recommended indefinitely

The optimal duration for the pharmacological treatment of depression is likely to vary between patients, however, antidepressants should not be prescribed indefinitely. In general, patients should be encouraged to think of pharmacological interventions as a therapeutic trial with regular review of treatment. If pharmacological treatments are presented as a temporary measure, future discussions about withdrawing antidepressants are likely to be easier.

Recommendations for the management of patients taking SSRIs

Patients who are taking antidepressants should be regularly assessed, e.g. every three months, for the development of adverse effects and to determine if their current treatment is appropriate. In general, withdrawing antidepressants may be considered for patients who are coping well one year after recovery from a single episode of depression or at least three years after recovery from multiple episodes.² Recovery is defined as when the patient has returned to the same level of functioning that they had before the onset of depression.¹ Periodic discussions, i.e. at least every 12 months, about the possible duration of antidepressant treatment should be documented in the patient’s notes. Once a patient has made a full functional recovery it is appropriate to discuss potential timeframes and a regimen for antidepressant withdrawal. If patients are not currently comfortable with the idea of withdrawing from antidepressants, record the discussion in their notes and tell them that you will discuss the possibility again in the future. It is important that patients continue to receive social and psychological support while they are withdrawing from antidepressants.

Plan

Summary

This audit identifies patients who are taking a SSRI for the treatment of depression to determine if ongoing pharmacological treatment is appropriate.

Recommended audit standards

Ideally, all patients with depression who have been taking a SSRI for more than 12 months should have at least one documented discussion in the last 12 months about the intended duration of pharmacological treatment, i.e. whether SSRI withdrawal or continued treatment is appropriate. If there is no documented evidence of a discussion the patient should be flagged for review.

Data

Identifying eligible patients

You will need to have a system in place that allows you to identify patients with a diagnosis of depression who have been taking a SSRI for more than 12 months. Many practices will be able to do this by running a “query” through their PMS.

Sample size

The sample size is ideally all patients in the practice who are taking a SSRI for the treatment of depression, but if this number is too large, a sample size of 30 patients is sufficient for the purpose of the audit. However, it is recommended that all eligible patients are subsequently reviewed.

Review of treatment

Criteria for a positive result

A positive result is if a patient who has been taking a SSRI for at least 12 months for depression has a documented discussion in their notes about the intended duration of treatment and/or a documented plan for antidepressant withdrawal.

N.B. Patients taking SSRIs for indications other than depression should also be regularly assessed to determine if ongoing pharmacological treatment is appropriate. However, these patients are not included in this audit.

Identifying opportunities for Audit of Medical Practice

The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual performance and then to decide how to change practice.

Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.

Taking action

It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).

Problem solving process

• What is the problem or underlying problem(s)?
• Change it to an aim
• What are the solutions or options?
• What are the barriers?
• How can you overcome them?

Overcoming barriers to promote change

• Identifying barriers can provide a basis for change
• What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them in the practice setting
• Identify the barriers
• Develop a priority list
• Choose one or two achievable goals

Effective interventions

• No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to bring about lasting change
• Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behaviour

Review

Monitoring change and progress

It is important to review the action plan developed previously at regular intervals. It may be helpful to review the following questions:

• Is the process working?
• Are the goals for improvement being achieved?
• Are the goals still appropriate?
• Do you need to develop new tools to achieve the goals you have set?

Following the completion of the first cycle, it is recommended that the doctor completes the first part of the Audit of Medical Practice summary sheet (Appendix 1).

Undertaking a second cycle

In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance.

It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended that practices complete the remainder of the Audit of Medical Practice summary sheet.

Claiming credits for Te Whanake CPD programme requirements

Practice or clinical audits are useful tools for improving clinical practice and credits can be claimed towards the Patient Outcomes (Improving Patient Care and Health Outcomes) learning category of the Te Whanake CPD programme, on a two credit per learning hour basis. A minimum of 12 credits is required in the Patient Outcomes category over a triennium (three years).

Any data driven activity that assesses the outcomes and quality of general practice work can be used to gain credits in the Patient Outcomes learning category. Under the refreshed Te Whanake CPD programme, audits are not compulsory and the RNZCGP also no longer requires that clinical audits are approved prior to use. The college recommends the PDSA format for developing and checking the relevance of a clinical audit.

To claim points go to the RNZCGP website: www.rnzcgp.org.nz

If a clinical audit is completed as part of Te Whanake requirements, the RNZCGP continues to encourage that evidence of participation in the audit be attached to your recorded activity. Evidence can include:

1. A summary of the data collected
2. An Audit of Medical Practice (CQI) Activity summary sheet (Appendix 1 in this audit or available on the RNZCGP website).

N.B. Audits can also be completed by other health professionals working in primary care (particularly prescribers), if relevant. Check with your accrediting authority as to documentation requirements.