Kaleidoscope.

The majority of people treated with antidepressants receive them in primary care, but there are limited data on medication maintenance or discontinuation in this setting. Nevertheless, much of the public discourse centres on primary care practices, with debate on ‘over-medicalisation of sadness in life’ and concern about the doubling of the prevalence of antidepressant prescriptions over the past couple of decades (in truth, much of the latter is due to longer treatment regimens, better aligning to national guidelines). Lewis et al undertook a pragmatic double-blinded randomised controlled trial across 150 UK general practices, recruiting 478 participants (the mean age was 54 years and three-quarters were women). All had a history of at least two depressive episodes and had taken antidepressants for at least 2 years but now felt well enough to consider stopping them. Only those on therapeutic doses of citalopram, sertraline, fluoxetine or mirtazapine were included, owing to the frequency of prescription of these antidepressants in primary care and their more limited discontinuation symptoms, to help mask blinding. Participants were either continued on treatment or put on a tapered discontinuation programme over several months via a pill placebo. Adherence to this across the following year was 70% and 52% in the respective groups. By the 52-week primary cut-off point, 39% of the maintenance group had relapsed, compared with 56% of the discontinuation cohort. By the end of the study, almost two-fifths of those in the discontinuation arm had been recommenced on medication. These data remind us that, unfortunately, relapse is common in depression whatever one does; clearly, they also show that many people can discontinue medication safely, but remaining on treatment enhances outcomes. The findings thus do not definitively guide the patient or clinician in ‘what to do’, but they help inform such discussions with best evidence on relative risks. It is particularly helpful to have such research in primary care, where the majority of such conversations will occur, and with non-specialised patient cohorts more reflective of ‘real world’ practice.