Rise in antidepressant prescriptions questioned

Prescriptions for antidepressants given by nonpsychiatrists to patients without a specific psychiatric disorder increased more than 12% in 12 years, leading to the drug class becoming the third most commonly prescribed, a study found.

Research in the August Health Affairs reported that antidepressant prescriptions by doctors who didn't record a specific psychiatric disorder increased from 59.5% of all prescriptions by nonpsychiatrists in 1996 to 72.7% in 2007.

Researchers reviewed data on patients age 18 or older from the 1996-2007 Centers for Disease Control and Prevention's National Ambulatory Medical Care Surveys, a national sample of more than 233,000 office-based visits. In a pattern described as consistent with primary care physicians delivering basic mental health services, 45.8% of visits to nonpsychiatrist physicians were to primary care doctors, compared to 54.2% to other nonpsychiatrist physicians. But 8.7% of visits to a primary care doctor resulted in a psychiatric diagnosis compared to 1.6% of visits to other nonpsychiatrists (P<0.001).

Antidepressants were prescribed in 9.3% of primary care visits and 3.6% of visits to other nonpsychiatrists. Only 44% of primary care visits that resulted in a prescription for antidepressants included a psychiatric diagnosis, compared to 12.8% of visits to other nonpsychiatrists.

The proportion of antidepressants prescribed for patients without a psychiatric diagnosis increased from 2.5% of all visits to nonpsychiatrists to 6.4% between 1996 and 2007. For primary care visits, antidepressant prescribing grew from 3.1% to 7.1%. For other nonpsychiatrists besides primary care, visits without a psychiatric diagnosis grew from 1.9% to 5.8%. In contrast, antidepressants prescribed with a psychiatric diagnosis increased from 1.7% to 2.4%.

Patients who received antidepressants without a psychiatric diagnosis were more likely to be age 50 or older, and less likely to be men, members of a racial or ethnic minority, new patients, or paying for the visit themselves, researchers noted. These patients also tended to have diabetes, heart disease, or multiple medical conditions; have excessive fatigue and headaches; or report nonspecific pain or abnormal sensations.

Researchers said the growing use of antidepressants for broader conditions, such as boosting moods, relieving mild anxiety, or improving sleep, raises worrisome questions about whether the drugs are being inappropriately prescribed.

“We do not yet have proof that inappropriate use of antidepressants is increasing, but the change in prescribing trends is worrisome. The trends suggest that some primary care physicians overestimate the effectiveness of antidepressant medications in treating mild conditions, and that insufficient communication is occurring between primary care physicians and psychiatrists,” the authors wrote.

The study recommended:

• taking steps to better educate physicians on how to recognize mental disorders and what the evidence shows about the long-term benefits and limits of antidepressants;
• reforming insurers' drug formularies to help rein in inappropriate antidepressant prescribing; and
• reducing fragmented care to improve the delivery of mental health services and foster better collaboration among clinicians.

“Prescribing antidepressants without a psychiatric diagnosis is especially common in medical practices that prescribe the medications to a larger percentage of their patients,” the authors concluded. “Yet paradoxically, a large proportion of patients with common mental disorders do not receive needed treatment because their primary care providers do not detect their conditions.”

The study also suggested that patients discuss with their physicians whether antidepressants are the right treatment, and for physicians to seek alternative treatments.