Antidepressants – Who’s Prescribing What
Antidepressant medications are among the most commonly prescribed drugs in the United States – one of the top three, depending on who is counting — owing to a dramatic rise in antidepressant use in the last 10 to 15 years. A new health policy report finds, however, that this increase in antidepressant use is driven by nonpsychiatrist healthcare providers, often without a diagnosis of depression.
The report was recently published in Health Affairs. The authors analyzed data from the National Ambulatory Medical Care Surveys conducted by the Centers for Disease Control and Prevention, which summarize outpatient medical care practices, between 1996 and 2007. Overall, four out of five providers who prescribed antidepressants were not psychiatrists; most of them were primary care physicians. Antidepressants were prescribed in 9.3% of visits to primary care physicians, compared to 3.6% of visits to other nonpsychiatrist providers.
A worrisome finding, according to the authors, is that the proportion of antidepressants prescribed by nonpsychiatrists without a psychiatric diagnosis was 6.4% (increased from 2.5% in 1996). This proportion was highest among primary care physicians, accounting for 7.1% of antidepressant prescribing (up from 3.1%). Among other nonpsychiatrists, the proportion of antidepressants prescribed without a diagnosis was 5.8% (increased from 1.9%). Overall, the proportion of physician visits that resulted in an antidepressant prescription and a psychiatric diagnosis increased only slightly from 1.7% to 2.4%.
The most likely patients to receive antidepressants were non-Hispanic white women over the age of 50 with private health insurance or Medicare coverage. These women were also more likely to have chronic health conditions, including diabetes, high blood pressure, heart disease, excessive fatigue, headaches, nonspecific pain, or trouble sleeping.
A similar study reported that nearly 3 out of every 100 people in the United States received outpatient treatment for depression in 2007, increased from 2.3 people per 100 in 1998. Of these people, 75.3% were treated with an antidepressant, only slightly increased from 73.8% in 1998. At the same time, the proportion of people receiving psychotherapy decreased from 53.6% to 43.1%. Overall, data indicates that more than 10% of children, adolescents, and adults in the United States – roughly 27 million people — are receiving treatment with an antidepressant, with or without a diagnosis of depression.
One driving force of the increase in antidepressant use — other than excessive direct-to-consumer marketing — is the increased acceptance of antidepressant use among Americans. They stigma attached to mental health treatment is decreasing, particularly when it comes to less severe conditions. Many people view antidepressants as little more than enhancers of well-being. Also, some antidepressants are approved for nonpsychiatric conditions, including premenstrual dysphoric disorder, smoking cessation, diabetic neuropathic pain, chronic musculoskeletal pain, and fibromyalgia.
The authors of the current study do not intend to imply that antidepressant prescribing by nonpsychiatrist providers is inappropriate. But, the results do beg the question of who is prescribing what, and why? Antidepressants may not be effective for many of the conditions for which they are prescribed. Simply, more prescriber education and collaborative care might avoid unnecessary prescriptions and promote more appropriate treatments, like psychotherapy, exercise, and other lifestyle or behavioral changes.
Primary care physicians are in a tough spot today. They have too many patients and too little time to spend with them. Primary care physicians lack extensive training in specialized fields of medicine, and, without funding, reimbursement, or referral capabilities, are forced to do their best to take care of their patients, often with little support from other healthcare providers, insurance companies, or the patients themselves. A paradox related to the findings of these studies is that a large number of patients with mental health disorders still do not receive treatment for their conditions, because primary care physicians are not able to diagnoses their signs and symptoms. Improved awareness of appropriate prescribing on the part of physicians and patients and increased collaboration with more specialized healthcare providers will lead to better treatment outcomes for mental health disorders.
Marcus SC, & Olfson M (2010). National trends in the treatment for depression from 1998 to 2007. Archives of general psychiatry, 67 (12), 1265-73 PMID: 21135326
Mark TL (2010). For what diagnoses are psychotropic medications being prescribed?: a nationally representative survey of physicians. CNS drugs, 24 (4), 319-26 PMID: 20297856
Mojtabai, R., & Olfson, M. (2011). Proportion Of Antidepressants Prescribed Without A Psychiatric Diagnosis Is Growing Health Affairs, 30 (8), 1434-1442 DOI: 10.1377/hlthaff.2010.1024
Olfson M, & Marcus SC (2009). National patterns in antidepressant medication treatment. Archives of general psychiatry, 66 (8), 848-56 PMID: 19652124