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Randomized Controlled Trial
. 2024 Jun 3;7(6):e2418383.
doi: 10.1001/jamanetworkopen.2024.18383.

Internet and Telephone Support for Discontinuing Long-Term Antidepressants: The REDUCE Cluster Randomized Trial

Tony Kendrick  1 , Beth Stuart  2 , Hannah Bowers  1 , Mahboobeh Haji Sadeghi  3 , Helen Page  4 , Christopher Dowrick  4 , Michael Moore  1 , Mark Gabbay  4 , Geraldine M Leydon  1 , Guiqing Lily Yao  5 , Paul Little  1 , Gareth Griffiths  6 , Glyn Lewis  7 , Carl May  8 , Joanna Moncrieff  7 , Chris F Johnson  9 , Una Macleod  3 , Simon Gilbody  10 , Rachel Dewar-Haggart  1 , Samantha Williams  1 , Wendy O'Brien  1 , Riya Tiwari  1 , Catherine Woods  1 , Tasneem Patel  4 , Naila Khan  4 , Nadja van Ginneken  4 , Amy Din  1 , Claire Reidy  1 , Rebecca Lucier  1 , Bryan Palmer  11 , Taeko Becque  1 , Ellen van Leeuwen  12   13 , Shihua Zhu  1   14 , Adam W A Geraghty  1
Affiliations
Randomized Controlled Trial

Internet and Telephone Support for Discontinuing Long-Term Antidepressants: The REDUCE Cluster Randomized Trial

Tony Kendrick et al. JAMA Netw Open. .

Abstract

Importance: There is significant concern regarding increasing long-term antidepressant treatment for depression beyond an evidence-based duration.

Objective: To determine whether adding internet and telephone support to a family practitioner review to consider discontinuing long-term antidepressant treatment is safe and more effective than a practitioner review alone.

Design, setting, and participants: In this cluster randomized clinical trial, 131 UK family practices were randomized between December 1, 2018, and March 31, 2022, with remote computerized allocation and 12 months of follow-up. Participants and researchers were aware of allocation, but analysis was blind. Participants were adults who were receiving antidepressants for more than 1 year for a first episode of depression or more than 2 years for recurrent depression who were currently well enough to consider discontinuation and wished to do so and who were at low risk of relapse. Of 6725 patients mailed invitations, 330 (4.9%) were eligible and consented.

Interventions: Internet and telephone self-management support, codesigned and coproduced with patients and practitioners.

Main outcomes and measures: The primary (safety) outcome was depression at 6 months (prespecified complete-case analysis), testing for noninferiority of the intervention to under 2 points on the 9-item Patient Health Questionnaire (PHQ-9). Secondary outcomes (testing for superiority) were antidepressant discontinuation, anxiety, quality of life, antidepressant withdrawal symptoms, mental well-being, enablement, satisfaction, use of health care services, and adverse events. Analyses for the main outcomes were performed on a complete-case basis, and multiple imputation sensitivity analysis was performed on an intention-to-treat basis.

Results: Of 330 participants recruited (325 eligible for inclusion; 178 in intervention practices and 147 in control practices; mean [SD] age at baseline, 54.0 [14.9] years; 223 women [68.6%]), 276 (83.6%) were followed up at 6 months, and 240 (72.7%) at 12 months. The intervention proved noninferior; mean (SD) PHQ-9 scores at 6 months were slightly lower in the intervention arm than in the control arm in the complete-case analysis (4.0 [4.3] vs 5.0 [4.7]; adjusted difference, -1.1; 95% CI, -2.1 to -0.1; P = .03) but not significantly different in an intention-to-treat multiple imputation sensitivity analysis (adjusted difference, -0.9 (95% CI, -1.9 to 0.1; P = .08). By 6 months, antidepressants had been discontinued by 66 of 145 intervention arm participants (45.5%) who provided discontinuation data and 54 of 129 control arm participants (41.9%) (adjusted odds ratio, 1.02; 95% CI, 0.52-1.99; P = .96). In the intervention arm, antidepressant withdrawal symptoms were less severe, and mental well-being was better compared with the control arm; differences were small but significant. There were no significant differences in the other outcomes; 28 of 179 intervention arm participants (15.6%) and 22 of 151 control arm participants (14.6%) experienced adverse events.

Conclusions and relevance: In this cluster randomized clinical trial of adding internet and telephone support to a practitioner review for possible antidepressant discontinuation, depression was slightly better with support, but the rate of discontinuation of antidepressants did not significantly increase. Improvements in antidepressant withdrawal symptoms and mental well-being were also small. There were no significant harms. Family practitioner review for possible discontinuation of antidepressants appeared safe and effective for more than 40% of patients willing and well enough to discontinue.

Trial registration: ISRCTN registry Identifiers: ISRCTN15036829 (internal pilot trial) and ISRCTN12417565 (main trial).

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Kendrick reported receiving grants from the National Institute for Health and Care Research (NIHR); receiving personal fees from the Royal College of General Practitioners; and serving as a member of the National Institute for Health and Care Excellence (NICE) Guideline Committee for the Adult Depression guideline, which developed guidance on antidepressant withdrawal, outside the submitted work. Dr Bowers reported receiving personal fees from Outro Ltd outside the submitted work. Dr Dowrick reported receiving personal fees from the World Health Organization, iheed, Novartis, and World Organization of Family Doctors; and nonfinancial support from the Centre for Evidence-Based Medicine and the Department of General Practice, University of Melbourne outside the submitted work. Dr Yao reported receiving grants from UK Research and Innovation funding–National Natural Science Foundation of China Newton Fund initiative during the conduct of the study and serving as a core member of the NICE Public Health Advisory Committee between 2019 and 2023 with paid traveling expenditure to the meetings. Dr Griffiths reported receiving grants and personal fees from AstraZeneca and AbbVie and grants from Janssen-Cilag, AstraZeneca, Novartis, Astex, Roche, Heartflow, Celldex, BMS, BioNTech, Cancer Research UK, the British Lung Foundation, Unitaid, and GSK outside the submitted work. Dr Lewis reported receiving grants from Medical Research Council/UK Research and Innovation funding and the Wellcome Trust and travel and accommodation to attend European College of Neuropsychopharmacology 2024 outside the submitted work. Dr Moncrieff reported having a patent with royalties paid for books about psychiatric drugs. No other disclosures were reported.

Figures

Figure.
Figure.. CONSORT Diagram of Practice and Participant Flow Through the Trial
aCluster randomization by practice and minimized by large or small, urban or rural, and deprivation.
See this image and copyright information in PMC

References

    1. Alabaku O, Yang A, Tharmarajah S, Suda K, Vigod S, Tadrous M. Global trends in antidepressant, atypical antipsychotic, and benzodiazepine use: a cross-sectional analysis of 64 countries. PLoS One. 2023;18(4):e0284389. doi:10.1371/journal.pone.0284389 - DOI - PMC - PubMed
    1. Moore TJ, Mattison DR. Adult utilization of psychiatric drugs and differences by sex, age, and race. JAMA Intern Med. 2017;177(2):274-275. doi:10.1001/jamainternmed.2016.7507 - DOI - PubMed
    1. Rhee TG. Continuing versus new antidepressant use in older adults: US prescribing trends from 2006 to 2015. Eur Geriatr Med. 2018;9(4):551-555. doi:10.1007/s41999-018-0075-x - DOI - PMC - PubMed
    1. Taylor S, Annand F, Burkinshaw P, et al. . Dependence and Withdrawal Associated With Some Prescribed Medicines: An Evidence Review. Public Health England; 2019.
    1. Johnson CF, Macdonald HJ, Atkinson P, Buchanan AI, Downes N, Dougall N. Reviewing long-term antidepressants can reduce drug burden: a prospective observational cohort study. Br J Gen Pract. 2012;62(604):e773-e779. doi:10.3399/bjgp12X658304 - DOI - PMC - PubMed

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