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.
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
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
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.
- National Institute for health and care excellence. First-choice antidepressant use in adults with depression or
generalised anxiety disorder. 2015. Available from: www.nice.org.uk/advice/ktt8 (Accessed Aug, 2017)
- Malhi GS, Bassett D, Boyce P, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice
guidelines for mood disorders. Aust N Z J Psychiatry 2015;49:1087–206. http://dx.doi.org/10.1177/0004867415617657
- National Institute for Health and Care Excellence C. Generalised anxiety disorder and panic disorder in adults:
management. 2011. Available from: www.nice.org.uk/guidance/cg113 (Accessed August, 2017)
- Maurer DM. Screening for depression. Am Fam Physician 2012;85:139–44.
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.
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
- 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
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
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 Continuing Professional Development (CPD)
This audit has been endorsed by the RNZCGP for CPD purposes for General Practitioners and can be claimed towards the Patient Outcomes (Improving Patient Care and Health Outcomes) learning category of the Te Whanake CPD programme, on a credit per learning hour basis. General practitioners are encouraged to discuss the outcomes of the audit with their peer group or practice; this may also be recorded as a reflection if suitable.
To claim points go to the RNZCGP website: www.rnzcgp.org.nz
The RNZCGP encourages that evidence of participation in the audit be attached to your recorded activity. Evidence can include:
- A summary of the data collected
- An Audit of Medical Practice (CQI) Activity summary sheet (included as Appendix 1).