A few years ago, a new primary care physician explained to me that among her many services she could also write my prescriptions for any drugs I might need, including , she said, antidepressants.
Her offer surprised me. I told her that if I were taking an antidepressant, I would to also need therapy care from a psychologist or psychiatrist. She explained that antidepressants are prescribed for everything from anxiety to weight control and that she was very confident in her ability to match the pill with the patient.
I thought about that conversation this week when I read a study about the increase in antidepressant prescribing by primary care physicians. According to the studying the August issue of Health Affairs, these medications are routinely prescribed by PCPs for uses that may not be supported by clinical evidence. "Many people view psychiatric medications as enhancers of personal and social well-being, providing benefits well beyond these medications clinically approved uses," the study says.
Analyzing office visit data from 1996-2007 compiled by the Centers for Disease Control and Prevention, the study found that more than 9% of PCP visits resulted in prescriptions for antidepressants, but in only 44% of those cases was there a diagnosis of depression or anxiety disorder.
The typical patient who gets a scrip for antidepressants is more than 50 years old and has a chronic condition – such as diabetes, hypertension, heart disease or asthma ?? that may contribute to symptoms of depression.
Big bucks are involved. Antidepressants are the third most commonly prescribed medication class in the U.S. with annual sales of about $10 billion.
That's money that health plans are spending on care that may not be necessary or could be treated with less expensive drugs. With billions of dollars in play, this prescribing trend has ramifications for public policy and health plan bottom lines.
In a telephone conversation, Ramin Mojtabai, a public health researcher at Johns Hopkins who co-authored the study, stressed that there is no evidence of inappropriate use. "We're just seeing more use of antidepressant among people who may have only vague symptoms like stress or maybe relationship problems."
My doctor was right when she clicked off a list of uses for antidepressants that didn't include, oddly enough, depression.
According to the study, antidepressants are increasingly associated with problems such as tiredness, smoking problems and headaches. Mojtabai noted that there's little evidence that antidepressants have any effect on these conditions or on milder episodes of depression or anxiety for that matter.
He said there's concern about physician followup. "We don't know if patients are referred to specialists or if they just continue to take the drugs because they are prescribed. Some patients may just stop taking the meds and encounter side effects."
Mojtabai pointed to a couple of reasons for the increase in PCP's prescribing antidepressants. A shortage of mental health professionals and a lack of insurance coverage top the list. And some people would rather ask their PCPs for these medications than seek the care of specialists, such as mental health practitioners.
In the study, Mojtabai and his co-author, Columbia University psychiatrist Mark Olfson, suggest that the new provider arrangements such as accountable care organizations will encourage more care coordination between primary care physicians and specialists, including psychologists and psychiatrists. That could help get antidepressant use back in line with clinical efficacy.
The study also makes two chief recommendations to help reduce the frequency of the prescribing of anti-depressants without a psychiatric diagnosis:
- Improve provider education on how to recognize mental disorders, the treatment limits of antidepressants and the long-term effects.
- Change drug formularies for antidepressants by creating cost-sharing tiers linked to diagnoses. Cost sharing would be less for patients who are prescribed the medications for recognized clinical conditions.
Mojtabai, who has studied the use of antidepressants for several years, says any policies should also look at how to make sure the drugs get to the people who really need them. "That's the paradox I've seen. Prescribing has increased but the people who really need antidepressants aren't getting them."
Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.
