Barriers
Patients perceived their negative expectations as a barrier to discontinuation. Patients with previous negative discontinuation experiences indicated that their negative experiences stopped them from attempting discontinuation again. For some, their negative experiences fuelled their negative expectations:
‘This belief … that things will get worse then.’
(P30, F, 24y)
‘I can’t come off it, because I tried it once, and I had really massive discontinuation phenomena.’
(P8, F, 39y)
Patients reported diffuse fears extending beyond recurrence or discontinuation symptoms, and perceived their fear of discontinuation as hindering discontinuation. The feeling of dependency constituted a further barrier:
‘I’m not sure how much good it does, but it sticks to me like pigeon shit … I can’t stop it.’
(P8, F, 39y)
External stressors and demands relating to patients’ personal or work life could also hinder discontinuation. Moreover, patients perceived a lack of support, whether social or professional, as a barrier. Finally, patients mentioned residual depressive symptoms, having comorbidities, and experiencing seasonal or weather-related fluctuations in mood as further factors hindering discontinuation.
Facilitators
Patients perceived their positive expectations and making positive experiences during discontinuation as facilitators:
‘I don’t think anything will come up again, I really do believe that things will be good.’
(P2, F, 54y)
‘I imagine it would motivate me to realise “Gee, you’ve already made it through so and so many weeks on a low dose and you’ve been doing fine.”’
(P19, F, 34y)
Patients indicated professional support as being central to successful discontinuation. Such professional support could be offered by physicians, psychotherapists, or qualified volunteers, such as recovery companions. Patients wanted professional support to involve a structured discontinuation framework, including regular check-ups. Having a contact person and receiving reassurance in case of uncertainties emerging during the discontinuation process was perceived as helpful. In addition, patients perceived social support as a facilitator. Forms of social support included a supportive work environment and exchange with friends, family, or other people affected:
‘What could facilitate the discontinuation process is if you do it in close supervision with a doctor and a therapist.’
(P15, F, 25y)
‘Support from my immediate environment, people who are close to me.’
(P5, non-binary, 27y)
Patients felt inadequately informed about discontinuation and requested specified treatment information early on. Patients noted a general lack of knowledge about appropriate antidepressant treatment among health professionals. They wanted more research to be conducted to generate and aggregate knowledge, so that health professionals can be trained accordingly:
‘Being well informed … that I get information that these [discontinuation symptoms] are normal and that they will probably stop at some point or that I can start [treatment] again.’
(P18, F, 39y)
‘If I expect anything from society, it’s that in the future all psychiatrists will be trained on how to taper antidepressants.’
(P25, M, 42y)
Stability in patients’ daily lives and their social environments could also help with discontinuation. Moreover, patients perceived a high sense of self-efficacy, trusting in their own capacity to cope with discontinuation, as aiding the process. Patients indicated having learned depression-related skills for managing their disease and expected these to positively affect discontinuation. Depression-related skills included mindfulness, self-care strategies, self-monitoring, and the ability to recognise signs of recurring depression and plan countermeasures. Such skills were generally attained in psychotherapy or psychoeducational groups and, for some patients, contributed to self-efficacy. A healthy lifestyle, especially engaging in physical activity and adhering to a healthy diet, was perceived as helpful. Some patients considered a healthy lifestyle as a strategy to ‘compensate’ for antidepressant use:
‘I definitely want to take more care of myself, which means meditating, taking more walks in the fresh air. Just the things that generally help with low mood or severe depression.’
(P28, F, 55y)
Patients described time for a slow tapering process despite day-to-day demands as a facilitator. This view was endorsed during participant checking, with the emphasis on a slow process with gradual, small, tapering steps. Some patients reported the internal belief ‘I am ready to discontinue’ and perceived it as facilitating discontinuation. This belief was accompanied by a high sense of self-efficacy and the anticipation that remission would remain stable after stopping antidepressants:
‘When you say, “OK, you can handle it and I don’t need them any more.”’
(P11, M, 29y)
All patients reported a discontinuation wish, albeit with varying intensity. Not all patients intended to realise this wish. For some patients, however, their strong desire to stop antidepressants was a facilitator:
‘I think that the whole thing [discontinuation] won’t be that easy for me. But … I want to make it and stop taking the medication anyway.’
(P12, M, 21y)
