The Research Question Background: Question: Increasing SSRI prescription is largely driven by use of maintenance therapy There is no evidence from RCTS for maintenance treatment in primary care patients Question: What is the effectiveness of maintenance SSRI treatment in preventing depression recurrence in primary care patients ?

What the Researchers Did Multicentre, placebo controlled, double blinded RCT Intervention: continuation of maintenance SSRI vs discontinuation (taper to placebo) Population: primary care treated patients currently taking fluoxetine for maintenance to prevent recurrence Primary outcome: occurrence of moderately severe depression over 18 months The patient population was patients taking fluoxetine, to reduce misclassification with discontinuation symptoms and to allow a standard and well masked taper. Most patients on long term maintenance were being prescribed fluoxetine, so this was a representative population. The response rate to the invitation to participate was 33% which is high for a study of this type The trial duration is longer than most studies in secondary care (most were only 12 months)

What the Researchers Found Maintenance treatment prevented a depression episode in 12.8% (23.3% vs 10.5%) p=0.005 NNT(18 mo)=8 7/8 patients experienced no benefit over 18 months 6% of patients had to restart because of intolerable discontinuation symptoms, despite tapering NNH=16 There was no harm in trialing discontinuation: no suggestion of poorer outcomes at 18 months in the taper arm (Patient relevant measures including mood, quality of life, overall psychological distress/symptoms, social and occupation functioning) The study sample had a long history of treatment and multiple episodes, so fit the current guideline recommendations The study duration was longer than those in secondary care, on which current recommendations are based (most existing trials were only 12 months duration)

What This Means for Clinical Practice The absolute benefit of SSRIs in preventing depression recurrence in primary care is much smaller than that previously estimated It seems reasonable to discuss these data with patients on maintenance treatment and offer a discontinuation trial to patients This provides good primary care data for shared decision making when considering initiation of maintenance treatment - the 33% response rate to the invitation to participate in the study was higih and indicates real patient interest in discontinuation