Nonpsychiatrist providers may be overprescribing antidepressants

More doctors who are not psychiatrists are prescribing antidepressants, making these drugs the third most commonly prescribed group of medications in the United States, according to a study published in the August issue of Health Affairs.

Over a 12-year period, 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% of all visits in which nonpsychiatrist physicians prescribed antidepressants in 1996 to 72.7% in 2007.

Although antidepressants are clinically effective for major depressive disorder, chronic depression, and some anxiety disorders, researchers say the growing use of antidepressants by nonpsychiatrists for a broader range of 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, according to the Health Affairs article.

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

Patients who received antidepressants without a psychiatric diagnosis by nonpsychiatrist providers were more likely to be 50 years of age or older, compared to patients who received antidepressants and a psychiatric diagnosis. They were also less likely to be male, 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, to the extent that they are being prescribed for uses that are not supported by clinical evidence, the study’s recommendations include:

• 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;
• Reforming insurers’ drug formularies to help rein in inappropriate antidepressant prescribing;

• 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.