The value of antidepressant therapy was expressed by both the patients and the GPs interviewed. These views were held despite recognition of the dissonance between social and medical models of depression, and the apparent paradox of subscribing to a largely psychosocial view of cause and persistence while using medication as the main treatment. One frequently cited reason for the favouring of antidepressants was the inadequacy or unavailability of alternative treatments, but it was also clear that when such help was available patients were likely to reject social and psychological interventions in favour of long-term pharmacological solutions.
Barriers to discontinuation are significant. Feelings of pessimism, negative associations with ageing, deteriorating health, and fear of relapse all reinforce a patient's desire to continue using long-term antidepressants. Concerned not to distance their patients, GPs were inclined to perpetuate prescriptions. Neither patients nor GPs had concerns about side effects and this provides little apprehension in the initiation and maintenance of antidepressants. With few concerns about side-effects, relatively small financial costs, and a widespread belief in (at least partial) efficacy, a system was encountered where there is little pressure for change from the current practice of extensive prescription of long-term antidepressant medication to older patients.
Strengths and limitations of the study
The use of in-depth interviews and a multidisciplinary and reflective approach provided strength to the data collection and analysis. Obtaining an accurate patient narrative was difficult on occasions due to limited patient recall.
The purposive approach to sampling aimed to ensure that those who did respond were representative and shared similar characteristics to the typical population, but those who agreed to participate are inherently self-selecting.
Although the study only covered one geographical location in the UK, it did encompass several general practices in a socioeconomically diverse population. The study did not specifically address sex, ethnic, or class differences.
Comparison with existing literature
Previous research into antidepressant use has tended to focus on initiation and reports high levels of aversion and non-adherence.12–15
Contrary to this finding, this study suggests that at least those patients who are on long-term medication have little apprehension in taking antidepressants. As attitudes to antidepressants are not fixed and can change over time, it is possible that any initial apprehension is forgotten as antidepressants become an accepted treatment.16
Long-term users have been identified as reporting more positive effects with antidepressants.17
Similar accounts of dissonance between the medical and social model of depression have been recorded.6,7,18,19
Research examining late-life depression suggests that patients are more comfortable accepting depression and taking antidepressants for a ‘normal’ chronic condition rather than a social or psychiatric condition, hence the predilection to understand the condition in physical terms.18
Barriers to discontinuation, such as fear of withdrawal, discontinuation symptoms, and a lack of alternative treatments have been attested.5,20
Research has not previously focused on an older population, thus the influence of attitudes towards ageing have not been widely explored in the context of long-term antidepressant-taking behaviour.
Associations of depression with poor health expectations and ageing are commonly documented.21,22
GPs and patients perceive it an accepted part of ageing to become depressed.23
Late-life depression is viewed as ‘justifiable’ and understandable.9
Low expectations of treatment and therapeutic nihilism have been documented. This notion of nihilism mirrors the pessimism felt by many patients and their low expectations for recovery.
The fear of relapse and withdrawal from antidepressants, in particular SSRIs, are recognised as significant barriers to discontinuation.8
Similarly there is a large body of literature examining the challenges faced with the discontinuation of anxiolytics.24,25
Other barriers, such as those associated with ageing, have been explored here in more detail than previously. It is apparent that negative expectations and experiences of ageing can reinforce perceptions that antidepressants are long-term treatments, and that discontinuation is undesirable.
Implications for future research and clinical practice
This study's results suggest that GPs feel limited when considering alternative treatments for older patients experiencing depression. Older patient's themselves often feel that psychological and social treatments are unsuitable. More research might elicit older patients' views on different social and psychological treatments for the often social problems that contribute to depression.
These results emphasise the difficulties that are likely to be encountered in attempts to discontinue antidepressants that have already been prescribed for a substantial period. Therefore, preventive action is likely to be a more effective strategy for reducing inappropriate long-term prescribing in older patients. Prescribers need to consult with patients to plan an ‘exit strategy’ when considering antidepressant treatment and address patients' understanding about the long-term need for treatment.
In a recent meta-ethnography of patients' experiences of antidepressants, three time points were identified when it was suggested patients may benefit from a practitioner's intervention.26
The three time points (return to function; experience of adverse effects; latency period) would certainly be appropriate times to review and explore a patient's preferences and understanding of long-term antidepressants.
Despite experiencing considerable distress, many of the participants spoke positively about the future. Exploring experiences of depression and recovery and identifying future goals with patients may help to combat the low expectations experienced by many. Prescribers need to be aware that a patient's age need not be a barrier to plans for discontinuation.