Health Affairs

Increase in Nonpsychiatrist Prescribing of Antidepressants Without a Psychiatric Diagnosis Helps Accelerate Use, Says Health Affairs Study

Researchers Say More Needs to Be Done to Educate Doctors and Consumers about Appropriate Use of Antidepressants

Bethesda, MD -- More doctors who aren't psychiatrists are offering antidepressants to patients, making these drugs the third most commonly prescribed group of medications in the United States, according to a study in the August issue of Health Affairs. A look at twelve-year trends shows that the percentage of visits in which antidepressants were prescribed to patients by doctors who didn't record a specific psychiatric disorder increased from 59.5 percent of all visits in which nonpsychiatrist physicians prescribed antidepressants in 1996 to 72.7 percent in 2007.

Although antidepressants are clinically effective for major depressive disorder, chronic depression, and some anxiety disorders, the researchers say the growing use of antidepressants by nonpsychiatrists for broader conditions raises worrisome questions about whether they are being inappropriately prescribed. Physicians are offering antidepressants to patients for use in boosting their moods, relieving mild anxiety, or improving sleep, the Health Affairs article notes.

"We don't know if those patients who are receiving antidepressants without a psychiatric diagnosis really are benefiting as much as those who do have a diagnosis," says lead author Ramin Mojtabai, an associate professor in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health. "Many of the patients who are receiving these medications are dealing with the stresses of life or physical illness, and there is no evidence that antidepressants are effective in these groups of patients," he says.

Mojtabai and Mark Olfson, a professor of clinical psychiatry at the College of Physicians and Surgeons of Columbia University, and a research psychiatrist at New York State Psychiatric Institute, examined data on patients age eighteen or older from the 1996-2007 Centers for Disease Control and Prevention's National Ambulatory Medical Care Surveys. In visits by patients to office-based physicians in which antidepressants were prescribed, the researchers found a significant increase in prescribing of antidepressants during the study period, chiefly for visits without a psychiatric diagnosis.

The proportion of antidepressants prescribed for patients without a psychiatric diagnosis increased from 2.5 percent of all visits to nonpsychiatrist providers to 6.4 percent between 1996 and 2007. For visits to primary care providers, antidepressant prescribing for nonpsychiatric disorders grew from 3.1 percent to 7.1 percent. For other nonpsychiatric providers, visits without a psychiatric diagnosis grew from 1.9 percent to 5.8 percent. In contrast, antidepressants prescribed with a psychiatric diagnosis increased only slightly over that period, from 1.7 percent to 2.4 percent.

Patients who received antidepressants without a psychiatric diagnosis by nonpsychiatrist providers were more likely to be fifty years of age or older, compared to patients who received antidepressants and a psychiatric diagnosis. They were also less likely to be males, members of a racial or ethnic minority groups, and new patients, and to be paying for the visit themselves. Patients whose nonpsychiatric providers prescribed antidepressants without noting a psychiatric disorder also tended to suffer from diabetes, heart disease, or multiple medical conditions; have excessive fatigue and headaches; and to complain of nonspecific pain or abnormal sensations.

The study didn't quantify whether antidepressants are being overprescribed. However, Mojtabai says, "to the extent that they are being prescribed for uses that are not supported by clinical evidence, we need to improve providers' prescribing practices." The study's recommendations include the following:

• 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. Such measures could also help providers identify the large number of patients who meet the clinical criteria for depressive or anxiety disorders but are not getting appropriate treatment.
  
  
• Reforming insurers' drug formularies to help rein in inappropriate antidepressant prescribing. Revised formularies could be designed so that patients whose providers prescribed antidepressants for recognized clinical indicators would have lower cost sharing than patients who received antidepressants for problems where there is little or no evidence of the medication's efficacy.
  
  
• Reducing fragmented care. The Affordable Care Act includes several provisions that will improve the delivery of mental health services and foster better collaboration among providers. If accountable care organizations are properly structured, for example, they might improve the quality of mental health in general medical settings and increase the involvement of mental health specialists in the primary care management of adult patients with major depressive disorder and other common mental disorders.

Mojtabai also says consumers should discuss with their physicians whether antidepressants are the right treatment for their problems. Although direct-to-consumer advertising contributes to patients demanding antidepressants for their problems, patients should also ask physicians to explain their diagnoses and whether there is evidence that the medicines prescribed are helpful. Also, he says, physicians should look for alternatives to some problems. For example, he says there are good ways to improve sleep that patients should try before assuming that medication is the best solution. "It may be beneficial for a patient and physician to discuss these other solutions before turning to antidepressants," he says.

Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears each month in print, with additional Web First papers published weekly at www.healthaffairs.org. You can also find the journal on Facebook and Twitter and download Narrative Matters on iTunes. Address inquiries to Sue Ducat at (301) 841-9962 or sducat@projecthope.org