(216) Deprescribing of antidepressants: Development of indicators of high-risk and overprescribing using the RAND/UCLA Appropriateness Method

Background: Antidepressants have seen a substantial increase in use over recent decades, which is at least partly attributable to their increasing use for indications not well supported by clinical evidence (e.g., including milder forms of depression and insomnia) and excessive treatment durations. Of particular concern is their use in vulnerable older people, where comorbidity and comedication may increase the risk of serious adverse effects (e.g., fall injuries). However, critical review and deprescribing (where appropriate) of antidepressants does not routinely occur in clinical practice, partly because potential deprescribing indications are not recognized.

Objectives: The objectives of this study are to identify indicators of potential high-risk and overprescribing of antidepressants in order to support primary care clinicians in identifying situations, where deprescribing of antidepressants should be considered.

Methods: We used the RAND/UCLA Appropriateness Method (RAM), combining a structured literature review with a three-round expert consensus process, where results were discussed in moderated meetings in-between rounds. Each candidate indicator was scored on a 9-point Likert scale representing the necessity of a critical review of antidepressant use (1-3 = not necessary; 4-6 = uncertain; 7-9 = clearly necessary). Experts rated the indicators for the necessity of review (rather than necessity of deprescribing), since decisions to deprescribe require considerations of patient-specific balance of benefits/risks and patient preferences. Indicators with a median necessity rating ≥ 7 without disagreement after three rating rounds were accepted.

Results: The expert panel comprised two general practitioners, two clinical pharmacologists, three psychiatrists and three internists/geriatricians (total N=10). After three assessment rounds, there was consensus for 37 indicators of high-risk and 25 indicators of overprescribing. High-risk prescribing indicators included settings posing risks of drug-drug, drug-disease, and drug-age interactions or the occurrence of adverse drug reactions. Indicators with the highest ratings included those targeting the risk of QTc prolongation, delirium, gastrointestinal bleeding, and liver injury in those with specific additional risk factors. Overprescribing indicators target patients with long treatment durations for depression, anxiety, and insomnia as well as high doses for pain and insomnia.

Conclusions: The developed set of indicators may be used in drug utilization studies, as part of deprescribing interventions, and as outcome measures to evaluate their impact.