Proportion Of Antidepressants Prescribed Without A Psychiatric Diagnosis Is Growing

Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
Health Affairs (Impact Factor: 4.64). 08/2011; 30(8):1434-42. DOI: 10.1377/hlthaff.2010.1024
Source: PubMed

ABSTRACT Over the past two decades, the use of antidepressant medications has grown to the point that they are now the third most commonly prescribed class of medications in the United States. Much of this growth has been driven by a substantial increase in antidepressant prescriptions by nonpsychiatrist providers without an accompanying psychiatric diagnosis. Our analysis found that between 1996 and 2007, the proportion of visits at which antidepressants were prescribed but no psychiatric diagnoses were noted increased from 59.5 percent to 72.7 percent. These results do not clearly indicate a rise in inappropriate antidepressant use, but they highlight the need to gain a deeper understanding of the factors driving this national trend and to develop effective policy responses. To the extent that antidepressants are being prescribed for uses not supported by clinical evidence, there may be a need to improve providers' prescribing practices, revamp drug formularies, or vigorously pursue implementation of broad reforms of the health care system that will increase communication between primary care providers and mental health specialists.

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    • "Some studies have shown that most patients (86-95%) diagnosed as depressed and treated by their GP with ADs met the DSM-IV depression criteria of a major depressive disorder (MDD) [16,17]. Others showed that the rate of off-label prescriptions varies between 20% and 60% of all prescribed ADs [18,19]. They are also prescribed in an inadequate manner, such as a too short duration of treatment [20] or in a sub-therapeutic dosage [3]. "
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    ABSTRACT: Background The frequency of antidepressant (ADs) prescription is high, with general practitioners (GPs) responsible for about 80% of the prescriptions. Some studies considered prescriptions meet DSM criteria, while others stress inadequate use. The importance of biological and psychosocial determinants of GP prescription behaviour remains little explored. We aimed to describe the importance of these biological and psychosocial determinants and their weight in the daily practice of GPs’. Methods During a week chosen at random, 28 GPs collected the AD prescriptions made within the previous six months, regardless of the reason for the patient contact. Bio psychosocial and AD treatment characteristics were recorded for all patients. In a random sample of 50 patients, patient characteristics were assessed via a structured face-to-face interview with the GP. Results The frequency of AD prescription was 8.90% [3.94 -17.02]. The GPs initiated 65.6% [60.1-70.8] of the prescriptions. The rate of AD prescription for non-psychiatric conditions was 18%. Patients had from 1 to 9 conditions, showing a high level of multi-morbidity. There was a strong influence of past medical history and contextual problems, such as work related problems. Conclusion AD prescription is related to complex contextual situations and multi-morbid patients. GPs use a bio psycho social approach, rather than a purely biological assessment. Awareness of these influences could improve prescription by GPs.
    BioPsychoSocial Medicine 07/2014; 8(1):17. DOI:10.1186/1751-0759-8-17
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    • "Individuals with depression have a threefold increase in comorbid chronic diseases, are less likely to seek and receive effective treatment for medical conditions, have lower rates of appropriate preventative health services and screening, and are less adherent to medical recommendations [13]. The majority of individuals with depression are treated by primary care providers who prescribe 80% of the antidepressant medications in the USA [14]. The burden of untreated depression at the primary care level is substantial as most depressions go unrecognized and untreated [15]. "
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    ABSTRACT: Depression is a frequent yet overlooked occurrence in primary health care clinics worldwide. Depression and related health screening instruments are available but are rarely used consistently. The availability of technologically based instruments in the assessments offers novel approaches for gathering, storing, and assessing data that includes self-reported symptom severity from the patients themselves as well as clinician recorded information. In a suburban primary health care clinic in Quito, Ecuador, we tested the feasibility and utility of computer tablet-based assessments to evaluate clinic attendees for depression symptoms with the goal of developing effective screening and monitoring tools in the primary care clinics. We assessed individuals using the 9-item Patient Health Questionnaire, the Quick Inventory of Depressive Symptoms-Self-Report, the 12-item General Health Questionnaire, the Clinical Global Impression Severity, and a DSM-IV checklist of symptoms. We found that 20% of individuals had a PHQ9 of 8 or greater. There was good correlation between the symptom severity assessments. We conclude that the tablet-based PHQ9 is an excellent and efficient method of screening for depression in attendees at primary health care clinics and that one in five people should be assessed further for depressive illness and possible intervention.
    02/2014; 2014:845397. DOI:10.1155/2014/845397
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    • "Over-diagnosis and over-treatment of depression are common in community and primary care settings in the US [66-68], and there is a real risk that depression screening could exacerbate this problem without contributing to better mental health. We hope that the USPSTF will re-evaluate evidence on depression screening, applying the three basic criteria that we have used in this review. "
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    ABSTRACT: The United States Preventive Services Task Force (USPSTF) recommends screening adults for depression in primary care settings when staff-assisted depression management programs are available. This recommendation, however, is based on evidence from depression management programs conducted with patients already identified as depressed, even though screening is intended to identify depressed patients not already recognized or treated. The objective of this systematic review was to evaluate whether there is evidence from randomized controlled trials (RCTs) that depression screening benefits patients in primary care, using an explicit definition of screening. We re-evaluated RCTs included in the 2009 USPSTF evidence review on depression screening, including only trials that compared depression outcomes between screened and non-screened patients and met the following three criteria: determined patient eligibility and randomized prior to screening; excluded patients already diagnosed with a recent episode of depression or already being treated for depression; and provided the same level of depression treatment services to patients identified as depressed in the screening and non-screening trial arms. We also reviewed studies included in a recent Cochrane systematic review, but not the USPSTF review; conducted a focused search to update the USPSTF review; and reviewed trial registries. Of the nine RCTs included in the USPSTF review, four fulfilled none of three criteria for a test of depression screening, four fulfilled one of three criteria, and one fulfilled two of three criteria. There were two additional RCTs included only in the Cochrane review, and each fulfilled one of three criteria. No eligible RCTs were found via the updated review. The USPSTF recommendation to screen adults for depression in primary care settings when staff-assisted depression management programs are available is not supported by evidence from any RCTs that are directly relevant to the recommendation. The USPSTF should re-evaluate this recommendation.Registration: PROSPERO (#CRD42013004276).
    BMC Medicine 01/2014; 12(1):13. DOI:10.1186/1741-7015-12-13 · 7.28 Impact Factor
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