‘I'd think more about safety rather than efficacy’: A Qualitative Study of Antidepressant Prescribing and Decision Making in Primary Care in England

BackgroundConcerns around inappropriate antidepressant prescribing continue to be raised. To prevent avoidable harm to patients, including adverse effects and withdrawal effects, it is important to understand potential overprescribing of antidepressants. This study aims to explore how primary care prescribers rationalise antidepressant prescribing and deprescribing decisions, and which contextual factors influence these decisions. MethodWe interviewed 16 primary care professionals, general practitioners (GPs) and mental health practitioners, across England. Semi-structured interviews consisted of discussing prescribing and deprescribing vignettes, followed by questions exploring participants approaches to antidepressant decision making. Reflexive thematic analysis was used to analyse the data. ResultsFour main themes emerged around antidepressant medicines optimisation: patient characteristics, illness factors, prescriber characteristics, and healthcare service factors. Patient characteristics encompassed aspects of the patient, their life and ideas that could contribute to prescribing choices. Illness factors included consideration of depression symptoms, associated symptom risks and previous treatment experiences. Prescriber characteristics involved expertise, guideline adherence, risk aversion and decision fatigue arising from prescribing. Healthcare service factors captured constraints of the services format and availability of alternative treatments.ConclusionOur findings suggest that prescribing decisions are impacted by a combination of psychosocial and environmental factors. Decision biases like risk aversion and decision fatigue can also impact prescribing practice. Health service constraints were perceived as limiting decision freedom through misaligned demand for and availability of non-pharmacological treatments, and insufficient decision support for deprescribing. Future research is required to establish patient and public perspectives and preferences for treatment.