Liquid formulations set to transform antidepressant deprescribing in Australia
The Wilson Foundation is pleased to be partnering with a team of pharmacists that are leading a transformation in antidepressant deprescribing by developing easy-to-prepare, cost-effective oral liquid formulations for eleven of Australia’s most prescribed antidepressants.
These formulations will enable credentialed, community and compounding pharmacists, as well as GPs and other prescribing clinicians to support their communities in safely tapering medication by recommending professionally prepared liquid options as part of a supported, evidence-based hyperbolic tapering plan, as outlined in The Maudsley Deprescribing Guidelines and the RELEASE tapering plans.
Designed for ease and accessibility, the formulations can be compounded by any pharmacy using standard equipment and readily available ingredients.
Each formulation will undergo rigorous chemical, physical and microbial stability testing, with the aim of making them available to pharmacists through inclusion in the Australian Pharmaceutical Formulary and Handbook (APF).
This work will improve safety and accessibility for patients by providing professionally prepared liquid versions of their medications, eliminating the need to crush or disperse tablets at home.
Antidepressant use is rising worldwide, with 3.5 million Australians prescribed them each year [i]. Half are classified as long-term users, with an average treatment duration of four years[ii] - well beyond the recommended 6 to 12 months for a single episode of depression.
Extended use can lead to harmful side effects, especially in older adults.
Discontinuing antidepressants can be challenging due to:
Limited dose flexibility: Many antidepressants are not commercially available in strengths low enough to support the gradual dose reductions required for hyperbolic tapering. For instance, the lowest available strength of citalopram - the most commonly prescribed antidepressant in Australia - is a 10 mg tablet, which can make safe and effective tapering difficult.
Withdrawal symptoms: These can range from mild to severe and become more common the longer a person has been taking a medication[iii]. To help manage these symptoms and support safer withdrawal, the evidence-based hyperbolic tapering approach outlined in The Maudsley Deprescribing Guidelines can be utilised. This method involves progressively smaller dose reductions - particularly at lower doses - to allow the body time to adjust.
Dr Anna Seth, Tasmanian GP said:
“This is exciting research because existing options for gradual discontinuation of antidepressants are very limited creating a barrier for patients and the doctors who support them.
For patients where antidepressant cessation is appropriate, the ability to gradually taper doses using liquid formulations has the potential to greatly improve care by minimising the withdrawal symptoms that can make stopping these medications otherwise very challenging.
The cost of compounding these medications is prohibitive for many of my patients who are then stuck with either trying to crush and disperse tablets at home or stopping medications more abruptly and risking unpleasant withdrawal effects.”
Natalie Cooper, Project Lead, School of Pharmacy and Pharmacology, University of Tasmania said:
“With the lack of commercially available liquid antidepressant formulations in Australia, there are limited dosing options for people to withdraw from antidepressant medications.
Many people rely on inefficient and imprecise at-home methods of crushing and dispersing tablets, to lower their doses.
By creating easy-to-prepare, cost-effective liquid antidepressant formulations that any pharmacy can compound, we’re tackling a major barrier to antidepressant discontinuation.”
Joanne Gross, Tasmania Branch President, Pharmaceutical Society of Australia (PSA) said:
“PSA proudly supports the University of Tasmania’s antidepressant deprescribing project, bringing easy-to-prepare, standardised antidepressant oral liquid formulations to the Australian market.
Antidepressant deprescribing remains a challenge, particularly for long-term users experiencing withdrawal symptoms.
PSA looks forward to continuing to work with the University to make their findings accessible to all Australian pharmacists through the Australian Pharmaceutical Formulary and Handbook (APF), supporting flexible, individualised tapering regimens and improving patient outcomes.”
Anna King, lived experience of antidepressant withdrawal and Member of the RELEASE trial Lived Experience Advisory Group.
“I suffered severe and debilitating symptoms while withdrawing from antidepressants at a time when well informed tapering advice was unavailable, nor was there a reliable way to titrate my dose in tablet form.
The liquid formulations initiative provides a significant support to the application of the Maudsley Deprescribing Guidelines and the RELEASE toolkit by enabling patients to administer their required dosages accurately and consistently.
Together these tools will provide a safer, inexpensive and reliable way to mitigate the severity of withdrawal symptoms that can be associated with ceasing antidepressants”
Read more about the project including which antidepressants are included here.
Watch a 1 min video from Natalie Cooper, Project Lead, University of Tasmania here.
Watch a 7 min video from Dr Mark Horowitz, Co-Author of The Maudsley Deprescribing Guidelines here.
[i] Mental health prescriptions - Mental health. Australian Institute of Health and Welfare. https://www.aihw.gov.au/mental- health/topic-areas/mental-health-prescriptions (accessed Aug 25, 2024.
[ii] Atlas 2015. https://www.safetyandquality.gov.au/our-work/healthcare-variation/atlas-2015 (accessed Aug 25, 2024).
[iii] Antidepressants withdrawal effects and duration of use: a survey of patients enrolled in primary care psychotherapy services. Psychiatry Research, 18 April 2024. https://www.sciencedirect.com/science/article/pii/S0165178125001453