Guiding discontinuation of antidepressants by community pharmacists: A mixed-methods study

Abstract

Background Long-term AD use increases risks of harmful side effects, drug-drug interactions, and the feeling of dependence. Therefore, AD discontinuation may benefit some patients. The Dutch multidisciplinary guideline for reducing and stopping ADs provides recommendations based on expert opinions due to a lack of scientific evidence and is poorly implemented because of unclear responsibilities among healthcare providers (HCPs). This can leave patients uninformed, impacting their discontinuation process. In addition, pharmacists can play an important role in guiding patients for AD discontinuation. Their expertise in medication management allows them to identify patients for AD discontinuation, manage the process, and help with issues that may arise during discontinuation. Guidance and collaboration protocol were formulated based on literature combined with a context analysis conducted among HCPs and an interview study was conducted to investigate patients’ needs and wishes regarding guidance for AD discontinuation. This study tested an evidence-based guidance and collaboration protocol for AD discontinuation in daily pharmacy practice. Methods A mixed-methods proof-of-concept study was part of phase II of the Pharm Guide AD involving community pharmacists in the Amstelland region. Patients were selected in the pharmacies via the pharmacy information system (PIS) and flyers. Those meeting the inclusion criteria and deemed eligible for discontinuation after GPs assessment began the AD discontinuation. Data was collected from February 2024 to June 2024 through interviews and questionnaires with patients and pharmacists. Transcripts were analyzed using inductive thematic analysis, while quantitative data was analyzed using descriptive and logistic regression analysis. Assessments are made using the RE-AIM framework. This framework improves the measurement of outcomes at individual and organizational levels, focusing on five key dimensions: Reach, Effectiveness, Adoption, Implementation, and Maintenance. Results The results show that challenges are faced in patient recruitment due to various challenges, including patients’ preferences and pharmacist’s workload. Collaboration with GPs was effective during the preparation phase, although GPs had a limited role during the AD discontinuation. While patient selection demanded effort and time, tools like the STIZON monitor could streamline this process. Despite initial obstacles, pharmacists found the guidance protocol to be clear and effective. They played a crucial role in informing and guiding patients through the process, and patients valued them for their proactive support and effective communication. Patient feedback highlighted the need for better preparation and proactive follow-up during AD discontinuation. While pharmacists recommended the intervention for its effectiveness, challenges like time investment and compensation remain to be addressed for sustained implementation. However, the intervention holds potential for long-term reduction of AD use. Conclusion The challenges regarding AD discontinuation identified in previous studies, within the context analysis involving HCPs and patient interviews to investigate the needs and wishes regarding guidance, have been addressed through the development of the Pharm Guide AD protocols. By analyzing both patients’ and pharmacists’ perspectives, this study has shown various successes and challenges in implementing the Pharm Guide AD protocols for AD discontinuation in daily pharmacy practice. Further research is necessary to test these protocols, including comparative studies across various settings, randomized controlled trials, exploring post-discontinuation, and assessing the maintenance of the intervention could provide insights into its long-term sustainability.