Date of Award

8-2020

Document Type

Campus Access Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Counseling

First Advisor

Lisa Cosgrove

Second Advisor

Boaz Levy

Third Advisor

Allen Shaughnessy

Abstract

Literature suggests that chronic and long-term prescriptions of antidepressant medication (ADM) in the United States and around the world continue to rise and many clinical guidelines recommend pharmacological maintenance treatment. Meta-analyses have found that for mild to moderate depression, ADM should not be the first line intervention because of concerns about the risk-benefit ratio. There are also concerns that long-term use of ADMs can lead to worsened outcomes. Given these findings, it is imperative that that treatment be guided by a blueprint of how to deprescribe medication after symptoms have remitted, patients have responded to treatment or in case of adverse effects or worsening symptoms. Deprescribing refers to actions involved in tapering, reducing, or stopping medications that are no longer indicated or are causing/have the potential to cause adverse effects. The consensus on discontinuing ADM is to taper the medication, but there is a lack of controlled data to guide this recommendation and no empirical evidence to inform deprescribing decisions. Facilitating patient-centered, evidence-based deprescribing strategies is thus a critical public health issue. The purpose of the present study was to explore psychiatrists’ experiences around deprescribing ADMs in their practice. This study aimed to answer 1) How do decisions about discontinuation of ADM get made by psychiatrists? That is, what informs psychiatrists’ practice of discontinuing ADM? 2) What are the conditions associated with discontinuing ADM and how do patient preferences factor in the decision-making process? 3) What facilitates and impedes successful deprescribing? Engaging in qualitative inquiry, a discourse analysis informed by social constructionist and Foucauldian approaches was used. Through the analysis I identified two main discursive constructions of depression that informed psychiatrists prescribing and deprescribing decision making: Depression is a Medical Illness and Depression is a Response to Challenging Life Circumstances. Facilitators and barriers to deprescribing practice were also identified. Findings are discussed in terms of the impact of discursive constructions of depression on prescribing and deprescribing practices and the need to support deprescribing practice is addressed by introducing a framework to assist prescribers in deprescribing ADMs. Systems level recommendations, recommendations for future research, and social justice implications are provided.

Comments

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