US antidepressant sales rise to $11B, due to primary care docs

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US antidepressants sales grow to $11 billion, due to those darned GPs, prescribing antidepressants for whatever ails you.

 

Nonpsychiatric Prescribing Fuels Rise in Antidepressant Use

 

By: Emily Hayes, "The Pink Sheet" 08/05/11

 

A rise in prescribing of antidepressants by doctors who are not psychiatrists, often for uses other than depression/anxiety, has helped build what is now a massive market, according to an 11-year health policy study just published in Health Affairs. Such prescribing could signal a need for formulary or other changes, the study authors conclude.

 

According to IMS Health, sales of antidepressants in the United States alone surpassed $11 billion in 2010.

 

Antidepressants are now the third most commonly prescribed drug class in this country, Ramin Mojtabai, M.D., Ph.D., of the Johns Hopkins Bloomberg School of Public Health, notes in the article. Appearing in the Aug. 3 issue of the policy journal, the article was coauthored by Columbia University psychiatrist Dr. Mark Olfson, whose research was funded by the Agency for Healthcare Policy and Research as well as Eli Lilly.

 

Four out of five physicians prescribing antidepressants are not psychiatrists, and antidepressants are commonly prescribed by primary care doctors, the authors noted (Health Aff. 2011;30:1434-42 [doi:10.1377/hlthaff.2010.1024]). In addition, they found the drugs are increasingly being given for nonpsychiatric uses.

 

Between 1996 and 2007, the percentage of doctor visits during which antidepressants were prescribed but no psychiatric diagnosis was noted increased from 59.5% to 72.7%, according to the study....

 

....Overall, the data show antidepressants were prescribed in 9.3% of visits to primary care doctors and 3.6% of visits to other nonpsychiatrists.

 

The authors noted that antidepressants have been demonstrated to be clinically effective for only a limited number of psychiatric conditions: major depressive disorder, chronic depression, some anxiety disorders, and a few other well-defined conditions.

 

But antidepressant use is becoming concentrated among people with less severe and poorly defined medical conditions, according to the study: "Associations between antidepressant prescriptions and problems such as tiredness, nonspecific pain, smoking problems, headaches, abnormal sensations and premenstrual tension suggest that antidepressants are being prescribed to treat these medical complaints."

Forays Into Additional Indications. During the study period, many antidepressant brands added additional, nonpsychiatric indications, so not all nonpsychiatric uses are off label. Those approvals have often launched with extensive advertising. Lilly’s Prozac (fluoxetine) was approved under the trade name Sarafem for premenstrual dysphoric disorder in 2000, Pfizer’s Zoloft (sertraline) added the PMDD claim in 2001, and GlaxoSmithKline’s Paxil CR (paroxetine) followed in 2003.

 

GlaxoSmithKline’s Wellbutrin (bupropion) was approved under the trade name Zyban as an aid to smoking cessation in 1997.

 

Pain and related indications have also been added for many of the branded products; while some approvals have come outside the study period, off-label use preceded the FDA imprimatur. Lilly’s Cymbalta (duloxetine) was approved for diabetic neuropathic pain in 2004 and chronic musculoskeletal pain in 2010. A fibromyalgia indication was cleared in 2008. Other antidepressants have been studied in fibromyalgia and are used off label.

 

Prescribing Trends Are ‘Worrisome.’ "We do not yet have proof that inappropriate use of antidepressants is increasing," the study authors say, "but the change in prescribing trends is worrisome."

 

They think the trends suggest that primary care physicians may overestimate the effectiveness of antidepressants in treating mild conditions, and that better communication is needed between primary care doctors and psychiatrists.

 

In the past, off-label prescribing of antidepressants has been tough to nail down, partly because patients may be prescribed a drug without a diagnosis code to protect privacy and avoid the stigma of a psychiatric disorder. Reimbursement patterns have also encouraged use of more general medical codes.

 

Identities of providers and patients in the National Ambulatory Medical Care Surveys are protected, however, and consequently providers had little motivation to deliberately withhold psychiatric diagnoses from researchers, the authors stated.

 

As part of the study, the researchers noted the presence of common conditions such as diabetes and heart disease, which have been linked to depression.

 

"Although such problems are often not the primary reason for a medical visit, a patient’s complaints about them may nevertheless prompt a provider to prescribe an antidepressant," the article stated.

 

Demographic data collected in the study suggest that those getting a prescription with no psychiatric diagnosis were more likely to be over 50, female, and covered by public health insurance. They were also more likely to have general indications of medical illness, such as diabetes or heart disease, and nonspecific pain or abnormal sensations.

 

The authors concluded that the underlying reasons for the trend in antidepressant prescribing are not clear, but may include patient demand and clinicians’ lack of awareness about appropriate prescribing.

 

"Many people view psychiatric medications as enhancers of personal and social well-being, providing benefits that are well beyond these medications’ clinically approved uses," they wrote.

 

Policy Implications. "With nonspecialists playing a growing role in the pharmacological treatment of common mental disorders, practice patterns of these providers are becoming increasingly relevant for mental health policy," the authors conclude.

 

In order to make policy recommendations, however, the authors believe a "deeper inquiry" is needed. But policy options could "range from clinical efforts to ensure patients receive the most appropriate treatments to the implementation of broad reforms of the health care system that will increase communication between primary care providers and mental health specialists."

 

Prescribers need to be educated about the evidence for long-term use of antidepressants in various conditions to cut down on inappropriate use and also to reach the large number of patients who do have psychiatric disorders and yet are not being treated with medication. While the study found that medical practices are increasingly prescribing antidepressants, "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."

 

Furthermore, the authors suggested, it may be possible to reform insurance formularies to include tiers of cost sharing based on the severity of the mental condition and whether evidence supports treatment with medication. Cost sharing could be lower for certain uses and higher when the drugs are used for conditions for which there is little to no evidence of efficacy.

 

However, in their view, research is needed to show whether the additional costs and complexity of such changes in formularies would outweigh the benefits.

 

Health reform efforts will produce some advantages to monitoring antidepressant use, both by reduction of the fragmentation of care and through adoption of electronic health records.

 

http://www.internalmedicinenews.com/news/mental-health/single-article/nonpsychiatric-prescribing-fuels-rise-in-antidepressant-use/8a560f9536.html

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Another version of the same story:

 

Americans' Use of Antidepressants On the Rise: Study

And more prescriptions are being written for people without a diagnosis of depression, researchers find

 

By Ellin Holohan

 

THURSDAY, Aug. 4 (HealthDay News) -- Americans are popping more antidepressants than ever before to deal with everyday stress, and non-psychiatrists are increasingly willing to prescribe the drugs to patients with no mental health diagnosis, a new study finds.

 

Antidepressants such as Prozac, Paxil and Lexapro are now the third most widely prescribed group of drugs in the United States, and many people may take them for minor complaints without being fully aware of potential risks, the researchers said.

 

"Both consumers and prescribers of antidepressants should be more knowledgeable about the indications (or symptoms) that antidepressants are better for," said Dr. Ramin Mojtabai, an associate professor of psychiatry at the Johns Hopkins Bloomberg School of Public Health in Baltimore. "Although these drugs do not have many acute side effects, there may be more long-term adverse effects."

 

The study authors said the increases don't necessarily mean that the drugs are being used inappropriately, but it's necessary to understand why antidepressant use is growing and, if necessary, to develop policies that ensure patients get the most effective treatment.

 

Using data from annual surveys by the U.S. Centers for Disease Control and Prevention, the researchers reviewed the records of 233,144 adult patients who made doctor visits between 1996 and 2007.

 

The study, published in the August issue of Health Affairs, found that the percentage of prescriptions for antidepressants written by non-psychiatrists more than doubled from about 4 percent to almost 9 percent over the 12-year period.

 

This included 9,454 antidepressant prescriptions for patients without a diagnosis of depression or other mental illness typically treated with the medication. For that group, the rate jumped from 2.5 percent at the start of the study period to 6.4 percent, the researchers said.

 

The study cautioned that a psychiatric diagnosis could have been made in some cases, but simply wasn't noted in the records studied.

 

By contrast, prescriptions for antidepressants for patients with diagnoses such as major or chronic depression increased by 44 percent, a much smaller increase.

 

About 4,000 patients who did have a mental health diagnosis received the drugs from non-psychiatrists in the study period.

 

The drugs prescribed to patients without a diagnosed mental health condition were more likely provided to white women between the ages of 35-64 and patients with public insurance and chronic medical conditions, such as diabetes and heart disease. The data also suggested that people complaining of nervousness, sleep problems, sexual dysfunction and an inability to quit smoking may be taking antidepressants, the study said.

 

Americans are turning to drugs to deal with everyday stress more frequently as the stigma of using antidepressants decreases, said Mojtabai, noting more than 10 percent of Americans now take antidepressants in any given year.

 

Direct marketing to consumers and reports of fewer side effects may help explain why patients and doctors are more open to antidepressants, he said.

 

But there may be consequences to that choice.

 

Some research has shown that withdrawal from antidepressants after many years "is not pleasant," said Mojtabai, who added that a possible link to diabetes has also been found. Not enough is known about how their use plays out in the long term, said Mojtabai.

 

"Pharmaceutical companies aren't interested in long-term effects because they don't need that for FDA approval," said Mojtabai, referring to the U.S. Food and Drug Administration, which approves drugs for use in the United States.

....

 

http://health.usnews.com/health-news/family-health/brain-and-behavior/articles/2011/08/04/americans-use-of-antidepressants-on-the-rise-study

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And another version:

 

Antidepressant Scripts Often Lack Diagnosis

By Charles Bankhead, Staff Writer, MedPage Today August 08, 2011

 

Almost three-quarters of the antidepressant prescriptions written by nonpsychiatrists had no documentation of psychiatric diagnoses, an analysis of recent prescribing trends showed.

 

Prescriptions without psychiatric diagnoses accounted for a majority of nonpsychiatrists' antidepressant prescriptions from 1996 to 2007, according to an article published online in Health Affairs.

 

And the proportion of prescriptions without documented psychiatric indications increased from about 60% to almost 73% over the study period.

 

The results do not necessarily demonstrate an increase in inappropriate prescribing but do indicate a need to find the reasons for the trend, Ramin Mojtabai, MD, of the Johns Hopkins School of Public Health in Baltimore, and Mark Olfson, MD, of Columbia University in New York City, wrote in the discussion of their findings.

 

"We do not yet have proof that inappropriate use of antidepressants is increasing, but the change in prescribing trends is worrisome," the wrote.

 

"In general medical practice, antidepressant use appears to be becoming concentrated among people with less severe and poorly defined mental health conditions," they added.

 

Antidepressant use has increased markedly over the past two decades, and antidepressants now rank as the third most commonly prescribed drug class in the U.S. (Arch Gen Psychiatry 2009;66:848-856, Natl Health Stat Report 2010;27:1-32).

 

Growth in antidepressant use has been fueled in large part by prescriptions written by nonpsychiatrists, who account for about four of every five antidepressant prescriptions written in the U.S., the authors wrote in their introduction.

 

Patients who receive mental health care in general medical practices tend to have less severe psychiatric conditions as compared with patients treated by mental health specialists, they continued. The increased use of antidepressants in primary care has created concern about inappropriate use.

 

"In fact, antidepressants have been demonstrated to be clinically effective for a limited number of psychiatric conditions ... and a few other well defined conditions," Mojtabai and Olfson wrote.

 

....

The final analysis involved 233,144 patient visits. During the study period, primary care physicians accounted for 45.8% of all visits to nonpsychiatrists and other nonpsychiatrist physicians for 54.2% of visits. Nonetheless, five times as many visits to primary care physicians included a psychiatric diagnosis (8.7% versus 1.6% for other nonpsychiatrists, P<0.001).

 

Primary care physicians prescribed antidepressants for 9.3% of patients' visits compared with 3.6% of visits to other nonpsychiatrist providers. When an antidepressant was prescribed, primary care physicians documented a psychiatric diagnosis in 44% of cases versus 12.8% of prescriptions written by other nonpsychiatrists.

 

....

The proportion of antidepressant prescriptions written without a supporting psychiatric diagnosis increased from 59.5% of visits in 1996 to 72.7% of visits in 2007.

 

The proportion of antidepressant prescriptions without a psychiatric diagnosis increased from 2.5% of all nonpsychiatrists' visits to 6.4% (OR 2.71, P<0.001). The proportion increased from 3.1% to 7.1% among primary care providers (OR 2.36, P<0.001) and from 1.9% to 5.8% among other nonpsychiatrist providers (OR 3.31, P<0.001).

 

Patients who received antidepressant prescriptions without a psychiatric diagnosis tended to be men, minorities, self-paying, and new to the practice. Additionally, the patients were more likely to have general medical conditions and chronic medical conditions, including diabetes, heart disease, and nonspecific pain.

 

....

"The widening misalignment between diagnosis and treatment suggests the need for a deeper inquiry," the authors wrote in conclusion. "Depending on the results of these investigations, various policy options might prove fruitful."

 

These policy options "range from clinical efforts to ensure that patients receive the most appropriate treatments to the implementation of broad reforms of the healthcare system that will increase communication between primary care providers and mental health specialists," they said.

 

....

 

Primary source: Health Affairs

 

Source reference:

Mojtabai R, Olfson M "Proportion of antidepressants prescribed without a psychiatric diagnosis is growing" Health Affairs 2011; DOI: 10.1377/hlthaff.2010.1024.

 

http://www.medpagetoday.com/Psychiatry/Depression/27950?utm_content=&utm_medium=email&utm_campaign=DailyHeadlines&utm_source=WC&userid=377937