Proportion of antidepressants prescribed without a psychiatric diagnosis is growing

Psychopharmacologic Management in Integrated Care: Challenges for Residency Education

The integration of psychiatric care in primary care is becoming a reality. Psychiatric training programs are facing multiple challenges to accommodate this transition. We here present the perspectives of Group for the Advancement of Psychiatry Committee on Psychopharmacology. The members of the group respond to the concerns raised by a resident currently confronting this changing landscape. By discussing the training, clinical, and communicating challenges of integrated care, they shed light on many of the questions being tackled by residency training programs. This commentary on the timely discussion about integrated care seeks to provide insight on the future of training in psychiatry by outlining the core questions of this change.

Social differences associated with the use of psychotropic drugs among men and women aged 65 to 74 years living in the community: the International Mobility in Aging Study (IMIAS)

Background

Elderly persons make greater use of psychotropic drugs, but there are few international studies on social differences in the use of these medications. The aim of this study is to examine social differences in the use of psychotropic drugs among persons aged 65–74 years in the International Mobility in Aging Study (IMIAS).

Methods

The sample consisted of 1,995 participants in the IMIAS 2012 baseline study in Saint-Hyacinthe (Canada), Kingston (Canada), Tirana (Albania), Manizales (Colombia), and Natal (Brazil). During home visits, all medication taken by the participants in the previous 15 days was recorded. We then used the Anatomical Therapeutic Chemical classification system to code psychotropic drugs as anxiolytics, sedatives, hypnotics (ASH); antidepressants (ADP); or analgesics, antiepileptics, or antiparkinsonians (AEP). Prevalence ratios for psychotropic drug use according to sex, education, income, and occupation were estimated by fitting a Poisson regression and controlling for demographic and health covariates.

Results

Psychotropic drug use was higher among Canadian participants than among those living outside Canada. Prevalence of AEP drug use was higher for women than men in the Canadian and Latin American sites. In Tirana, antidepressant drugs were rarely used. Socioeconomic differences varied among sites. In the Canadian cities, low socioeconomic standing was associated with higher frequency of psychotropic drug use. In the Latin American cities, elderly people with high education and income levels showed a higher level of antidepressant drug use, while people with manual occupations had a higher use of AEP drugs. In Tirana, ASH drug use was higher among those with low income.

Conclusion

An inverse association was observed between socioeconomic standing and psychotropic drug use in Canada, while the opposite was true in Latin America. Albania was notable for an absence of antidepressant use and greater use of ASH drugs among low-income groups.

SSRI use and risk of fractures among perimenopausal women without mental disorders

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) were recently approved by the FDA to treat vasomotor symptoms associated with menopause. No prior study has directly examined whether fracture risk is increased among perimenopausal women who initiate SSRIs or among a population of women without mental disorders more generally.

METHODS

Female patients without mental illness, aged 40-64 years, who initiated SSRIs were compared with a cohort who initiated H2 antagonists (H2As) or proton-pump inhibitors (PPIs) in 1998-2010, using data from a claims database. Standardised mortality ratio weighting was applied using the propensity score odds of treatment to adapt the distribution of characteristics among patients starting H2A/PPIs to the distribution among SSRI initiators. Poisson regression estimated risk differences and Cox proportional hazards regression the RR of fractures among new users of SSRIs versus H2A/PPIs. Primary analyses allowed for a 6-month lag period (ie, exposure begins 6 months after initiation) to account for a hypothesised delay in the onset of any clinically meaningful effect of SSRIs on bone mineral density.

RESULTS

Fracture rates were higher among the 137,031 SSRI initiators compared with the 236,294 H2A/PPI initiators, with HRs (SSRI vs H2A/PPI) over 1, 2 and 5 years of 1.76 (95% CI 1.33 to 2.32), 1.73 (95% CI 1.33 to 2.24) and 1.67 (95% CI 1.30 to 2.14), respectively.

CONCLUSIONS

SSRIs appear to increase fracture risk among middle-aged women without psychiatric disorders, an effect sustained over time, suggesting that shorter duration of treatment may decrease fracture risk. Future efforts should examine whether this association pertains at lower doses.

Long term sertraline effects on neural structures in depressed and nondepressed adult female nonhuman primates

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are widely prescribed for mood and other disorders. However, their neural effects are difficult to study due to patient compliance and drug history variability, and rarely studied in those prescribed SSRIs for non-mood disorders. Here we evaluated SSRI effects on neural volumetrics in depressed and nondepressed monkeys.

METHODS

42 socially-housed cynomolgus monkeys were randomized to treatment balanced on pretreatment depressive behavior and body weight. Monkeys were trained for oral administration of placebo or 20 mg/kg sertraline HCl daily for 18 months and depressive and anxious behavior recorded. Volumes of neural regions of interest in depression were measured in magnetic resonance images and analyzed by 2 (depressed, nondepressed)×2 (placebo, sertraline) ANOVA.

RESULTS

Sertraline reduced anxiety (p=0.04) but not depressive behavior (p=0.43). Left Brodmann's Area (BA) 32 was smaller in depressed than nondepressed monkeys (main effect of depression: p<0.05). Sertraline and depression status interacted to affect volumes of left Anterior Cingulate Cortex (ACC), left BA24, right hippocampus (HC), and right anterior HC (sertraline×depression interactions: all p's<0.05). In the Placebo group, depressed monkeys had smaller right anterior HC and left ACC than nondepressed monkeys. In nondepressed monkeys, sertraline reduced right HC volume, especially right anterior HC volume. In depressed monkeys sertraline increased left ACC volume. In nondepressed monkeys, sertraline reduced left BA24 volumes resulting in smaller BA24 volumes in nondepressed than sertraline-treated depressed monkeys.

CONCLUSIONS

These observations suggest that SSRIs may differentially affect neural structures in depressed and nondepressed individuals.

What factors influence long-term antidepressant use in primary care? Findings from the Australian diamond cohort study

BACKGROUND

Antidepressants are one of the most commonly prescribed drugs in primary care. The rise in use is mostly due to an increasing number of long-term users of antidepressants (LTU AD). Little is known about the factors driving increased long-term use. We examined the socio-demographic, clinical factors and health service use characteristics associated with LTU AD to extend our understanding of the factors that may be driving the increase in antidepressant use.

METHODS

Cross-sectional analysis of 789 participants with probable depression (CES-D≥16) recruited from 30 randomly selected Australian general practices to take part in a ten-year cohort study about depression were surveyed about their antidepressant use.

RESULTS

165 (21.0%) participants reported <2 years of antidepressant use and 145 (18.4%) reported ≥2 years of antidepressant use. After adjusting for depression severity, LTU AD was associated with: single (OR 1.56, 95%CI 1.05-2.32) or recurrent episode of depression (3.44, 2.06-5.74); using SSRIs (3.85, 2.03-7.33), sedatives (2.04, 1.29-3.22), or antipsychotics (4.51, 1.67-12.17); functional limitations due to long-term illness (2.81, 1.55-5.08), poor/fair self-rated health (1.57, 1.14-2.15), inability to work (2.49, 1.37-4.53), benefits as main source of income (2.15, 1.33-3.49), GP visits longer than 20min (1.79, 1.17-2.73); rating GP visits as moderately to extremely helpful (2.71, 1.79-4.11), and more self-help practices (1.16, 1.09-1.23).

LIMITATIONS

All measures were self-report. Sample may not be representative of culturally different or adolescent populations. Cross-sectional design raises possibility of "confounding by indication".

CONCLUSIONS

Long-term antidepressant use is relatively common in primary care. It occurs within the context of complex mental, physical and social morbidities. Whilst most long-term use is associated with a history of recurrent depression there remains a significant opportunity for treatment re-evaluation and timely discontinuation.

Major depression diagnoses among patients with systemic sclerosis: baseline and one-month followup

OBJECTIVE

Depression is common in many rheumatic diseases and is associated with poor prognosis. No studies of patients with any rheumatic diseases, however, have assessed the stability of major depressive disorder (MDD) diagnoses over time. The objective of the present study was to assess the stability of MDD diagnoses among patients with systemic sclerosis (SSc; scleroderma), a rare autoimmune rheumatic disease, across 2 assessments approximately 1 month apart.

METHODS

SSc patients were recruited from 7 Canadian Scleroderma Research Group Registry sites (April 2009 to June 2012). Current (30-day) MDD was assessed with the Composite International Diagnostic Interview at baseline and approximately 1 month later.

RESULTS

Among 309 patients with baseline assessments who received followup assessments an average of 34 days later, prevalence of 30-day MDD was 4% (95% confidence interval [95% CI] 2%-7%; n = 12) at baseline and 5% (95% CI 3%-8%; n = 16) at followup. Only 3 of 12 patients (25% [95% CI 9%-53%]) with MDD at baseline had MDD 1 month later.

CONCLUSION

Most patients with SSc who meet criteria for MDD appear to experience mild, time-limited episodes of low mood that often resolve on their own without specific treatment. Consistent with international guidelines on depression management in nonpsychiatric settings, "watchful waiting" or "active monitoring" is a good strategy for SSc patients with mild depression to avoid unnecessary treatment among those whose symptoms may be transient and may resolve without medical intervention.

Trends in psychological distress, depressive episodes and mental health treatment-seeking in the United States: 2001-2012

BACKGROUND

There has been an increase in the use of mental health services in a number of industrialized countries over the past two decades with little impact on mental health status of the populations. Few studies, however, have examined recent trends in mental health status in the US.

METHODS

Using data from three large general annual population surveys in the US-the National Health Interview Survey, Behavioral Risk Factor Surveillance System, and National Survey on Drug Use and Health-we examined temporal trends in non-specific psychological distress, depressive episodes and mental health treatment seeking over the 2001-2012 period.

RESULTS

Prevalence of past-month significant psychological distress and past-year depressive symptoms changed little over time. However, a larger percentage of participants reported poor mental health for ≥15 days or 30 days in the past month in 2011-2012 (8.7% and 5.7%, respectively) than in 2001-2002 (6.6% and 4.6%). A larger percentage of participants in the later period also reported receiving mental health treatments.

LIMITATIONS

Possible changes in mental health status may have been missed due to the limited scope of assessments or the small magnitude of changes. Potential reciprocal influences between service use and mental health status could not be investigated because of cross-sectional data.

CONCLUSIONS

Despite increasing use of mental health treatments in the US in the first decade of this century, there is no evidence of decrease in prevalence of psychological distress or depression. Poor match between need for treatment and actual treatments received in usual care settings may partly explain the findings.

Mental health nurses responding to suffering in the 21st century occidental world: accompanying people in their search for meaning

Much of contemporary health and mental health practice pays little attention to suffering, and when it does, invariably suffering is conflated with pain. Within such views, the health care practitioner ought to be concerned with removing or stopping the suffering as, for many parts of the occidental world at least, suffering is regarded as antagonistic to the pursuit of happiness. However, it has been recognized since ancient times that the experience of suffering can give rise to growth. This view sees suffering as an inevitable aspect of the human condition and experience; as something that might need to be endured, minimized, relieved, explored for meaning and maybe even learned from. The former conceptualization of suffering leaves little, if any, room for the sufferer to be to be proud of his suffering and to consider it ennobling rather than degrading, and such views are highly congruent with the increased pathologizing of 'everyday life' and with that, the inexorable proliferation of pharmacological 'treatment'. Accordingly, we assert that there is a clear need for Psychiatric/Mental Health nurses to re-think their views of suffering and consider how they might help the person discover meaning in the experience; how they might accompany the individual on his/her suffering journey. We therefore identify a range of approaches and interventions that Psychiatric/Mental Health nurses can use when attempting to help those experiencing mental health-related suffering.

How do GP practices and patient characteristics influence the prescription of antidepressants? A cross-sectional study

BACKGROUND

Under-prescription of antidepressants (ADs) among people meeting the criteria for major depressive episodes and excessive prescription in less symptomatic patients have been reported. The reasons influencing general practitioners' (GPs) prescription of ADs remain little explored. This study aimed at assessing the influence of GP and patient characteristics on AD prescription.

METHODS

This cross-sectional study was based on a sample of 816 GPs working within the main health care insurance system in the Seine-Maritime district of France during 2010. Only GPs meeting the criteria for full-time GP practice were included. The ratio of AD prescription to overall prescription volume, a relative measure of AD prescription level, was calculated for each GP, using the defined daily dose (DDD) concept. Associations of this AD prescription ratio with GPs' age, gender, practice location, number of years of practice, number of days of sickness certificates prescribed, number of home visits and consultations, number and mean age of registered patients, mean patient income, and number of patients with a chronic condition were assessed using univariate and multivariate analysis.

RESULTS

The high prescribers were middle-aged (40-59) urban GPs, with a moderate number of consultations and fewer low-income and chronic patients. GPs' workload (e.g., volume of prescribed drug reimbursement and number of consultations) had no influence on the AD prescription ratio. GPs with more patients with risk factors for depression prescribed fewer ADs, however, which could suggest the medications were under-prescribed among the at-risk population.

CONCLUSIONS

Our study described a profile of the typical higher AD prescriber that did not include heavy workload. In future work, a more detailed assessment of all biopsychosocial components of the consultation and other influences on GP behavior such as prior training would be useful to explain AD prescription in GP's practice.

Prescription and indication trends of antidepressant drugs in the Netherlands between 1996 and 2012: a dynamic population-based study

PURPOSE

Antidepressant drug use increases worldwide. It is pivotal to closely monitor the use of antidepressants and to determine in what subpopulations the rise is most substantial. In a Dutch primary care database, we aimed to investigate the (sex- and age-specific) prevalence and incidence of antidepressant prescription and to monitor the indication of incident prescriptions over a 17-year period (1996-2012).

METHODS

This study, embedded in the Integrated Primary Care Information database, included all patients aged 10 years or older. Per calendar year, prevalence and incidence of antidepressant drug prescription were calculated by drug class (tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and others), sex, and age. The indication of incident prescriptions (e.g., depression, anxiety, sleep disorders, and neuropathic pain) was determined based on the International Classification of Primary Care codes.

RESULTS

In total, 1.49 million patients were included. For all antidepressants together, the prevalence increased over time. However, incident prescription of specific SSRIs decreased from 2000 onward. During the study period, incidence and prevalence were higher in older and female patients. The increase in prevalence and the decrease in incidence were more pronounced in females than that in males. Furthermore, antidepressants were increasingly prescribed for indications such as neuropathic pain and sleep disorders.

CONCLUSIONS

In Dutch primary care, prevalent prescription of antidepressants continued to increase, but incident prescription of particular SSRIs decreased from 2000 onward. In later years, antidepressants were less frequently prescribed for depression-related indications in incident users.

Antidepressant use and lifetime history of mental disorders in a community sample: results from the Baltimore Epidemiologic Catchment Area Study

OBJECTIVE

Past studies have shown that many individuals who use antidepressants have no current or lifetime history of mental disorders. However, recent studies suggest that the one-time retrospective evaluation of mental disorders commonly used in such studies may substantially underestimate the true lifetime prevalence of mental disorders. We examined the prevalence of mental disorders, assessed prospectively over multiple interviews, among individuals currently using antidepressants in a community sample.

METHOD

Using data from the Baltimore Epidemiologic Catchment Area (ECA) Study Wave 1 (1981) through Wave 4 (2004-2005) (N = 1,071), we assessed lifetime prevalence of common mood and anxiety disorders according to DSM-III and DSM-III-R criteria, based on 4 interviews, among participants who reported current antidepressant use. Furthermore, we examined factors associated with current antidepressant use.

RESULTS

Thirteen percent of participants at Wave 4 reported currently using antidepressant medications. Among antidepressant users, 69% never met criteria for major depressive disorder (MDD); and 38% never met criteria for MDD, obsessive-compulsive disorder, panic disorder, social phobia, or generalized anxiety disorder in their lifetime. Female gender, Caucasian ethnicity, recent or current physical problems (eg, loss of bladder control, hypertension, and back pain), and recent mental health facility visits were associated with antidepressant use in addition to mental disorders.

CONCLUSIONS

Many individuals who are prescribed and use antidepressant medications may not have met criteria for mental disorders. Our data indicate that antidepressants are commonly used in the absence of clear evidence-based indications.

Measuring the bright side of being blue: a new tool for assessing analytical rumination in depression

Background

Diagnosis and management of depression occurs frequently in the primary care setting. Current diagnostic and management of treatment practices across clinical populations focus on eliminating signs and symptoms of depression. However, there is debate that some interventions may pathologize normal, adaptive responses to stressors. Analytical rumination (AR) is an example of an adaptive response of depression that is characterized by enhanced cognitive function to help an individual focus on, analyze, and solve problems. To date, research on AR has been hampered by the lack of theoretically-derived and psychometrically sound instruments. This study developed and tested a clinically meaningful measure of AR.

Methods

Using expert panels and an extensive literature review, we developed a conceptual framework for AR and 22 candidate items. Items were field tested to 579 young adults; 140 of whom completed the items at a second time point. We used Rasch measurement methods to construct and test the item set; and traditional psychometric analyses to compare items to existing rating scales.

Results

Data were high quality (<1% missing; high reliability: Cronbach's alpha  = 0.92, test-retest intraclass correlations >0.81; evidence for divergent validity). Evidence of misfit for 2 items suggested that a 20-item scale with 4-point response categories best captured the concept of AR, fitting the Rasch model (χ² = 95.26; df  = 76, p = 0.07), with high reliability (r_p = 0.86), ordered response scale structure, and no item bias (gender, age, time).

Conclusion

Our study provides evidence for a 20-item Analytical Rumination Questionnaire (ARQ) that can be used to quantify AR in adults who experience symptoms of depression. The ARQ is psychometrically robust and a clinically useful tool for the assessment and improvement of depression in the primary care setting. Future work is needed to establish the validity of this measure in people with major depression.

A prescription for unemployment? Recessions and the demand for mental health drugs

We estimate the relationship between mental health drug prescriptions and the level of labor market activity in the USA. Based on monthly data from the National Ambulatory Medical Care Survey of physicians and aggregated by US census regions, we find that the number of mental health drug prescriptions (those aimed at alleviating depression and anxiety) rises by about 10% when employment falls by 1% and when unemployment rises by 100 basis points, but only for patients in the Northeast region. This paper is one of the first to look at compensatory health behavior in response to the business cycle.

The diagnostic accuracy of the Patient Health Questionnaire-2 (PHQ-2), Patient Health Questionnaire-8 (PHQ-8), and Patient Health Questionnaire-9 (PHQ-9) for detecting major depression: protocol for a systematic review and individual patient data meta-analyses

BACKGROUND

Major depressive disorder (MDD) may be present in 10%-20% of patients in medical settings. Routine depression screening is sometimes recommended to improve depression management. However, studies of the diagnostic accuracy of depression screening tools have typically used data-driven, exploratory methods to select optimal cutoffs. Often, these studies report results from a small range of cutoff points around whatever cutoff score is most accurate in that given study. When published data are combined in meta-analyses, estimates of accuracy for different cutoff points may be based on data from different studies, rather than data from all studies for each possible cutoff point. As a result, traditional meta-analyses may generate exaggerated estimates of accuracy. Individual patient data (IPD) meta-analyses can address this problem by synthesizing data from all studies for each cutoff score to obtain diagnostic accuracy estimates. The nine-item Patient Health Questionnaire-9 (PHQ-9) and the shorter PHQ-2 and PHQ-8 are commonly recommended for depression screening. Thus, the primary objectives of our IPD meta-analyses are to determine the diagnostic accuracy of the PHQ-9, PHQ-8, and PHQ-2 to detect MDD among adults across all potentially relevant cutoff scores. Secondary analyses involve assessing accuracy accounting for patient factors that may influence accuracy (age, sex, medical comorbidity).

METHODS/DESIGN

Data sources will include MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, and Web of Science. We will include studies that included a Diagnostic and Statistical Manual or International Classification of Diseases diagnosis of MDD based on a validated structured or semi-structured clinical interview administered within 2 weeks of the administration of the PHQ. Two reviewers will independently screen titles and abstracts, perform full article review, and extract study data. Disagreements will be resolved by consensus. Risk of bias will be assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Bivariate random-effects meta-analysis will be conducted for the full range of plausible cutoff values.

DISCUSSION

The proposed IPD meta-analyses will allow us to obtain estimates of the diagnostic accuracy of the PHQ-9, PHQ-8, and PHQ-2.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014010673.

An electronic health record driven algorithm to identify incident antidepressant medication users

OBJECTIVE

We validated an algorithm designed to identify new or prevalent users of antidepressant medications via population-based drug prescription records.

PATIENTS AND METHODS

We obtained population-based drug prescription records for the entire Olmsted County, Minnesota, population from 2011 to 2012 (N=149,629) using the existing electronic medical records linkage infrastructure of the Rochester Epidemiology Project (REP). We selected electronically a random sample of 200 new antidepressant users stratified by age and sex. The algorithm required the exclusion of antidepressant use in the 6 months preceding the date of the first qualifying antidepressant prescription (index date). Medical records were manually reviewed and adjudicated to calculate the positive predictive value (PPV). We also manually reviewed the records of a random sample of 200 antihistamine users who did not meet the case definition of new antidepressant user to estimate the negative predictive value (NPV).

RESULTS

161 of the 198 subjects electronically identified as new antidepressant users were confirmed by manual record review (PPV 81.3%). Restricting the definition of new users to subjects who were prescribed typical starting doses of each agent for treating major depression in non-geriatric adults resulted in an increase in the PPV (90.9%). Extending the time windows with no antidepressant use preceding the index date resulted in only modest increases in PPV. The manual abstraction of medical records of 200 antihistamine users yielded an NPV of 98.5%.

CONCLUSIONS

Our study confirms that REP prescription records can be used to identify prevalent and incident users of antidepressants in the Olmsted County, Minnesota, population.

Why do general practitioners prescribe antidepressants to their patients? A pilot study

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.

Patterns of psychotropic medicine use in pregnancy in the United States from 2006 to 2011 among women with private insurance

Background

Psychiatric disorders are equally common during pregnancy as among non-pregnant women, and many of these conditions are treated with psychotropic medicines. Relatively little is known about patterns of use of many these agents during pregnancy, and specifically of how rates may have shifted during the last decade. We aimed to quantify the rate of pregnancy related exposures to categories of psychotropic medicines stratified according to the primary indication for use (antidepressants, antipsychotics, anxiolytics, and psychostimulants), trimester of pregnancy, trends over time and region, and indication for use.

Methods

We conducted a retrospective cohort study of pregnancies among women in the Truven Health MarketScan database (source population 70 million Americans), which captures person-specific clinical use and includes detailed information on filled prescriptions, hospitalizations and outpatient visits for all privately insured employees and their dependents. We classified psychotropic medicines of interest using ATC level 3 accordingly: antipsychotics (N05A); anxiolytics (N05B); antidepressants (N06A); psychostimulants, agents used for ADHD and cognitive enhancement (N06B). We also examined temporal and regional trends in use.

Results

We included 343,299 women who had a live birth between Jan 1, 2006 and Dec 31, 2011, of whom 10.3% were dispensed one or more psychotropic medicines during pregnancy. This rate varied from 6% to 15% between states. The rate of use of psychotropic medicines was relatively stable between 2006 and 2011. The most commonly used psychotropic medicines were selective serotonin reuptake inhibitors (5.1%) and benzodiazepine or benzodiazepine-like medicines (3.9%). Among psychotropic users, the most commonly associated psychiatric diagnosis was depression (25.0%), followed by anxiety disorders (24.4%). Approximately 1.6% of women used more than one category of psychotropic medicine in pregnancy, most commonly an antidepressant and an anxiolytic medicine (1.2%).

Conclusions

Given this relatively high rate of use, the lack of evidence that the most frequently used medications improve birth outcomes and the safety concerns associated with both early and late pregnancy use for many frequently-used medications, there is a need for further study of factors driving psychotropic medication use during pregnancy.

Selective serotonin reuptake inhibitor use and increased risk of cataract surgery: a population-based, case-control study

PURPOSE

To investigate whether selective serotonin reuptake inhibitor use is associated with an increased risk of cataract surgery.

DESIGN

Population-based case-control study.

METHODS

setting: Olmsted County, Minnesota. patient population: Eligible patients were county residents in the Rochester Epidemiology Project. Cases included 6024 county residents aged 50+ years who underwent first-eye cataract surgery between January 1, 2004 and December 31, 2011. Controls included 6024 residents who never had cataract surgery and were matched to cases by age, sex, and date of surgery. Logistic regression models were used to compute odds ratios for differences in selective serotonin reuptake inhibitor use between cases and controls, and to adjust for confounding variables. observation procedure: Rochester Epidemiology Project databases were used to assess cataract surgery and selective serotonin reuptake inhibitor treatment. main outcome measure: Selective serotonin reuptake inhibitor use.

RESULTS

In the cataract surgery cohort of 6024 residents, 1024 (17%) were selective serotonin reuptake inhibitor users compared to 788 (13%) in the matched cohort of 6024 residents never having cataract surgery (P < .001). Selective serotonin reuptake inhibitor use of 1 or more years was associated with an increased risk of cataract surgery (odds ratio [OR] = 1.36; 95% confidence interval [CI], 1.23-1.51; P < .001). The associations were similar in women (OR = 1.37; 95% CI, 1.22-1.55; P < .001) and men (OR = 1.34; 95% CI, 1.12-1.61; P = .002). The risk of cataract surgery was highest with citalopram use (OR = 1.53; 95% CI, 1.33-1.77; P < .001).

CONCLUSION

Selective serotonin reuptake inhibitor use of 1 or more years in people aged 50+ years is associated with an increased risk of cataract surgery.

National prevalence of receipt of antidepressant prescriptions by persons without a psychiatric diagnosis

OBJECTIVE

The study addressed recent concerns regarding increasing prescription of antidepressant drugs to patients with no recorded psychiatric diagnosis.

METHODS

Records from ten large integrated health systems in the Mental Health Research Network were used to examine diagnoses received by 1,011,946 health plan members who filled at least one antidepressant prescription in 2010.

RESULTS

Among individuals filling antidepressant prescriptions, psychiatric diagnoses recorded during the year were depressive disorders (48%), anxiety disorders (27%), bipolar disorders (3%), and attention deficit disorders (3%). The proportion of those filling prescriptions who had no psychiatric diagnosis was 39%, which fell to 27% after the analysis excluded prescriptions for antidepressants often prescribed for nonpsychiatric indications (tricyclic antidepressants, trazodone, and bupropion).

CONCLUSIONS

Prescription of antidepressants to patients without an appropriate diagnosis appears to be less common than previously reported.

Increased risk among older veterans of prescribing psychotropic medication in the absence of psychiatric diagnoses

OBJECTIVE

This study uses Veterans Health Administration (VHA) pharmacy and encounter claims to evaluate the use of psychotropic medications without a psychiatric diagnosis across age groups.

METHODS

National VHA administrative data for fiscal year 2010 (FY2010) were used to identify all veterans who filled a prescription for at least one psychotropic medication from VHA (N = 1.85 million). Bivariate and multivariate analyses were used to compare the proportion of these veterans without any psychiatric diagnosis, across age groups, adjusting for possible medical indications. Analyses were repeated for six different classes of psychotropic medications and comparing mental health utilizers and non-mental health utilizers. Comparisons were made to prescribing of HIV and diabetes medications without an indicated diagnosis.

RESULTS

Of all VHA patients prescribed a psychotropic medication in FY2010, 30% had no psychiatric diagnosis, with highest proportions among veterans ages 65-85. This practice was most frequent among nonmental health utilizers and far more prevalent for psychotropic medications than for HIV or diabetes medications. Logistic regression analysis found that age greater than 65 was the strongest predictor of being prescribed a psychotropic without a psychiatric diagnosis. Adjustment for possible medical use of psychotropics and overall medical comorbidity did not substantially alter these trends.

CONCLUSION

Older veterans, especially those not using specialty mental healthcare, are more likely to be prescribed psychotropic medications in the absence of a psychiatric diagnosis, perhaps representing unnecessary use, under-diagnosis of mental illness, or incomplete documentation.

Utilization patterns of antidepressants between 1991 and 2011 in a population-based cohort of middle-aged and elderly

BACKGROUND

In middle-aged and older patients in whom antidepressant use increased in last decades, patterns of use might be of concern The objective of this study was to investigate the patterns of prevalence, incidence and duration of antidepressant use in an ageing population.

METHODS

All participants (aged>45 years) from the population-based Rotterdam Study were followed from January 1st 1991 until death, loss to follow-up, or end of the study period (December 31st 2011). Antidepressant drug dispensing, based on pharmacy records, were subdivided into Tricyclic Antidepressants (TCAs), Selective Serotonin Reuptake Inhibitors (SSRIs) and other antidepressants. One-year prevalence, 5-year incidence and duration of antidepressant use were calculated.

RESULTS

Yearly prevalence of antidepressant use increased from 3.9% in 1991 to 8.3% of the population in 2011. The increase in SSRI use was 5.8-fold, whereas use of other antidepressants doubled and TCA use remained stable over time. Incidence of all antidepressants decreased from 23.9 to 14.2 per 1000 person-years between 1992 and 2011. The duration of a first treatment episode increased over time.

CONCLUSION

Despite the prevalence of antidepressant use increased over time, incidence did not, which is most likely explained by a longer treatment duration and recurrent episodes.

The mistreatment of major depressive disorder

OBJECTIVE

To examine the effects of classification on treatment in major depressive disorder (MDD).

METHOD

This is a narrative review.

RESULTS

MDD is a highly heterogeneous category, leading to problems in classification and in specificity of treatment. Current models classify all depressions within a single category. However, the construct of MDD obscures important differences between severe disorders that require pharmacotherapy, and mild-to-moderate disorders that can respond to psychotherapy or remit spontaneously. Patients with mild-to-moderate MDD are being treated with routine or overly aggressive pharmacotherapy.

CONCLUSIONS

The current classification fails to address the heterogeneity of depression, leading to mistreatment.

Tablet-based screening of depressive symptoms in quito, ecuador: efficiency in primary care

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.

There are no randomized controlled trials that support the United States Preventive Services Task Force Guideline on screening for depression in primary care: a systematic review

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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. Please see related article: http://www.biomedcentral.com/1741-7015/12/14 REGISTRATION: PROSPERO (#CRD42013004276).

The nurse's role in primary care antidepressant medication adherence

Depression remains one of the most common conditions seen in primary care settings. Antidepressant medications (ADMs) are considered standard treatment for moderate to severe depression, and in some instances, for minor depression. When ADM adherence is low, patients are at risk for treatment failure and poor quality of life. Nurses may be key in ensuring the success of ADM therapy; however, little is known about the interventions nurses use or the consequent patient outcomes. The objectives of this article were to identify studies in which nurses managed ADM adherence and to collect evidence about the efficacy of these interventions. A systematic literature review of clinical trial studies was conducted, which specifically included the role of the nurse. Nurse interventions identified were: patient care management, medication monitoring, depression education, and referrals to specialty providers. Nurses use a range of interventions to manage ADM adherence. In most studies, these approaches, including collaborative care, were efficacious.

Clinician-identified depression in community settings: concordance with structured-interview diagnoses

BACKGROUND

Relatively little is known about the prevalence and correlates of overdiagnosis of depression in community settings. This study examined the extent to which individuals with clinician-identified depression in the community meet the criteria for DSM-IV major depressive episodes (MDE) and characteristics of these individuals.

METHODS

In a sample of 5,639 participants with clinician-identified depression drawn from the 2009-2010 United States National Survey of Drug Use and Health, the proportion of participants who met the 12-month MDE criteria, ascertained by a structured interview, and variations in MDE diagnosis across different groups of participants were examined. Mental health profiles and service use of participants who met the MDE criteria were compared to those who did not meet these criteria.

RESULTS

Only 38.4% of participants with 12-month clinician-identified depression met the 12-month MDE criteria. Older adults were less likely than younger adults to meet the criteria - only 14.3% of those 65 years old or older met the criteria, whereas participants with more education and those with poorer overall health were more likely to meet the criteria. Participants who did not meet the 12-month MDE criteria reported less distress and impairment in role functioning and used fewer services. A majority of both groups, however, were prescribed and used psychiatric medications.

CONCLUSIONS

Depression overdiagnosis and overtreatment is common in community settings in the USA. There is a need for improved targeting of diagnosis and treatments of depression and other mental disorders in these settings.

Trend in SSRI-SNRI antidepressants prescription over a 6-year period and predictors of poor adherence

PURPOSE

To describe antidepressant (AD) use in the Emilia-Romagna Region (Italy) and to evaluate adherence to treatment with selective serotonin receptor inhibitors or selective noradrenaline receptor inhibitors (SSRI-SNRI).

METHODS

Reimbursed prescriptions of AD were retrieved from the Emilia-Romagna Regional Health Authority Database. The overall AD consumption from the 2006-2011 period was expressed in terms of prevalence and amount of use. Adherence to treatment was assessed in a cohort of patients who received SSRI-SNRI, and was followed throughout a 6-month period from the start of each treatment episode. Adherence was considered according to three parameters: duration of treatment ≥ 120 days, prescription coverage ≥ 80 %, and gaps between prescriptions < 3 months. Determinants of non-adherent regimen, including sociodemographic and clinical variables, were identified by multivariate logistic regression by calculating adjusted Odds Ratio (adjOR) and the relevant 95 % confidence interval (95CI).

RESULTS

From 2006 to 2011, the prevalence of use of AD increased by 5 % (from 86 to 90 per 1,000 inhabitants) and the amount of antidepressant consumption increased by 20 % (from 43 to 51 defined daily dose per thousand inhabitants per day [DDD/TID]), with a 14 % rise in the intensity of drug use (from 182 to 208 DDD per patient). Out of 347,615 SSRI-SNRI treatment episodes, only 23.8 % were adherent. Comorbidity (adjOR:0.69; 95CI:0.67-0.72) and recurrence of AD treatment in the previous year (0.91; 0.89-0.92) were associated with better adherence. Moreover, patients treated with duloxetine (0.58; 0.55-0.60), escitalopram (0.64; 0.62-0.66) or sertraline (0.65; 0.64-0.67) showed better adherence in comparison with paroxetine.

CONCLUSIONS

Clinical variables resulting in improved adherence seem to identify patients with more severe disorders and who actually need a pharmacological approach, whereas differences in adherence among ADs could in part be caused by channeling and sponsorship bias. Initiatives addressed at improving cooperation between primary care and psychiatrists could decrease AD prescription for cases of sub-threshold or mild depression that easily drop out because of rapid symptom relief or side effects.

Age and sex patterns of drug prescribing in a defined American population

OBJECTIVE

To describe the age and sex patterns of drug prescribing in Olmsted County, Minnesota.

PATIENTS AND METHODS

Population-based drug prescription records for the Olmsted County population in 2009 were obtained using the Rochester Epidemiology Project medical records linkage system (n=142,377). Drug prescriptions were classified using RxNorm codes and were grouped using the National Drug File-Reference Terminology.

RESULTS

Overall, 68.1% of the population (n=96,953) received a prescription from at least 1 drug group, 51.6% (n=73,501) received prescriptions from 2 or more groups, and 21.2% (n=30,218) received prescriptions from 5 or more groups. The most commonly prescribed drug groups in the entire population were penicillins and β-lactam antimicrobials (17%; n=23,734), antidepressants (13%; n=18,028), opioid analgesics (12%; n=16,954), antilipemic agents (11%; n=16,082), and vaccines/toxoids (11%; n=15,918). However, prescribing patterns differed by age and sex. Vaccines/toxoids, penicillins and β-lactam antimicrobials, and antiasthmatic drugs were most commonly prescribed in persons younger than 19 years. Antidepressants and opioid analgesics were most commonly prescribed in young and middle-aged adults. Cardiovascular drugs were most commonly prescribed in older adults. Women received more prescriptions than men for several drug groups, in particular for antidepressants. For several drug groups, use increased with advancing age.

CONCLUSION

This study provides valuable baseline information for future studies of drug utilization and drug-related outcomes in this population.

Antidepressant use and glycemic control

RATIONALE

Past research on the association of antidepressant medication use with glycemic control abnormalities has produced mixed results.

OBJECTIVE

To examine the association of antidepressant use with glycemic control abnormalities and screen-positive diabetes in a representative population sample of US adults without a diagnosis of diabetes.

METHODS

Using data from adult participants of the National Health and Nutrition Examination Survey (NHANES, 2005-2010), the association of antidepressant use with continuous measures of HbA1c, fasting blood sugar, 2-h oral glucose tolerance test, insulin sensitivity and screen-positive diabetes according to HbA1c, fasting blood sugar and 2-h oral glucose tolerance test were assessed.

RESULTS

Antidepressant use was not associated with increased levels of HbA1c, fasting blood sugar, 2-h oral glucose tolerance test, reduced insulin sensitivity or increased prevalence of screen-positive diabetes. Results were mostly consistent across sociodemographic groups and across different lengths of exposure, different classes of antidepressants and levels of body mass index.

CONCLUSIONS

In this representative population sample, antidepressant use was not associated with an increased risk of abnormalities in glycemic control or undetected diabetes. Positive findings from past research may be attributable to detection bias, in that individuals prescribed antidepressants may be more likely to be tested and diagnosed with diabetes.

Evidence of prescription of antidepressants for non-psychiatric conditions in primary care: an analysis of guidelines and systematic reviews

BACKGROUND

Antidepressants (ADs) are commonly prescribed in primary care and are mostly indicated for depression. According to the literature, they are now more frequently prescribed for health conditions other than psychiatric ones. Due to their many indications in a wide range of medical fields, assessing the appropriateness of AD prescription seems to be a challenge for GPs. The aim of this study was to review evidence from guidelines for antidepressant prescription for non-psychiatric conditions in Primary Care (PC) settings.

METHODS

Data were retrieved from French, English and US guideline databases. Guidelines or reviews were eligible if keywords regarding 44 non-psychiatric conditions related to GPs' prescription of ADs were encountered. After excluding psychiatric and non-primary care conditions, the guidelines were checked for keywords related to AD use. The latest updated version of the guidelines was kept. Recent data was searched in the Cochrane Database of Systematic Reviews and in PubMed for updated reviews and randomized control trials (RCTs).

RESULTS

Seventy-eight documents were retrieved and were used to assess the level of evidence of a potential benefit to prescribing an AD. For 15 conditions, there was a consensus that prescribing an AD was beneficial. For 5 others, ADs were seen as potentially beneficial. No proof of benefit was found for 15 conditions and proof of no benefit was found for the last 9. There were higher levels of evidence for pain conditions, (neuropathic pain, diabetic painful neuropathy, central neuropathic pain, migraine, tension-type headaches, and fibromyalgia) incontinence and irritable bowel syndrome. There were difficulties in summarizing the data, due to a lack of information on the level of evidence, and due to variations in efficacy between and among the various classes of ADs.

CONCLUSIONS

Prescription of ADs was found to be beneficial for many non-psychiatric health conditions regularly encountered in PC settings. On the whole, the guidelines were heterogeneous, seemingly due to a lack of trials assessing the role of ADs in treatment strategies.

The failure of the antidepressant drug discovery process is systemic

Current antidepressants are crude compared with the ideal and patents on most have expired. There are therefore strong clinical and commercial pressures for new drugs to replace them. The prospects for this are, however, now markedly reduced as several major pharmaceutical companies have abandoned work in this area whilst many others have sharply decreased their research investment. These changes and the lack of progress over such a long period are indicative of a catastrophic systems failure which, it is argued, has been caused in large part by a logical flaw at the animal modelling stage. This tautology has served to lock the current antidepressant drug discovery process into an iterative loop capable only of producing further variations of that which has gone before. Drugs produced by this approach have proved to be only poorly effective in the context of the clinically depressed population as a whole. Hence, the inevitable failure of the current antidepressant drug discovery process has left little behind that can be salvaged. Therefore, it is suggested that this be urgently reformulated on more rational grounds using more appropriate species in new animal models based upon a thorough understanding of the behavioural expressions of depression in the clinic.

Antidepressant use and new-onset diabetes: a systematic review and meta-analysis

Antidepressant use has been linked to new-onset diabetes. However, the existing literature on this relationship has yielded inconsistent findings. The primary objective of this study was to systematically synthesize the literature on the relationship between antidepressant use and new-onset diabetes using meta-analysis. A systematic literature search was conducted to identify relevant studies in seven electronic databases. Two independent reviewers identified the final list of studies to be included in the meta-analysis using a priori selection criteria. Results for the primary outcome of interest, that is, odds and hazards of developing new-onset diabetes, were pooled using a random-effects model. Egger's regression test and the Trim and Fill method were utilized to detect the presence of any potential publication bias. Sensitivity analysis was conducted using the leave-one-out method as well as individual categories of antidepressant drugs. Eight studies met the inclusion criteria. Random effects models revealed that adults with any use of antidepressants were more likely to develop new-onset diabetes compared with those without any use of antidepressants [odd ratios = 1.50, 95% confidence interval (CI), 1.08-2.10; hazards ratio = 1.19, 95% CI, 1.08-1.32]. Sensitivity analyses revealed fair robustness; selective serotonin reuptake inhibitors and tricyclic antidepressants were more likely to be associated with the development of new-onset diabetes. Results from the Egger's regression test and Trim and Fill method revealed no evidence of publication bias. Among adults, antidepressant use was associated with higher chances of new-onset diabetes. However, because a cause-and-effect relationship cannot be established by observational studies, future randomized controlled studies are needed to confirm this association.

Psychotropic medication claims among religious clergy

This study examined psychotropic medication claims in a sample of Protestant clergy. It estimated the proportion of clergy in the sample who had a claim for psychotropic medication (i.e., anti-depressants and anxiolytics) in 2005 and examined associations between sociodemographic characteristics, occupational distress and having a claim. Protestant clergy (n = 749) from nine denominations completed a mail survey and provided access to their pharmaceutical records. Logistic regression models assessed the effect of sociodemographic characteristics and occupational distress on having a claim. The descriptive analysis revealed that 16 % (95 % Confidence interval [CI] 13.3 %-18.5 %) of the clergy in the sample had a claim for psychotropic medication in 2005 and that, among clergy who experienced frequent occupational distress, 28 % (95 % CI 17.5 %-37.5 %) had a claim. The regression analysis found that older clergy, female clergy, and those who experienced frequent occupational distress were more likely to have a claim. Due to recent demographic changes in the clergy population, including the increasing mean age of new clergy and the growing number of female clergy, the proportion of clergy having claims for psychotropic medication may increase in the coming years. To the best of our knowledge, this is the first study to examine the use of psychotropic medication among clergy.

Treating depression with antidepressants: drug-placebo efficacy debates limit broader considerations

The core issue regarding antidepressants for many clinicians is whether they perform significantly better than placebos. However, this article suggests eight additional concerns beyond drug efficacy alone to consider regarding antidepressants including: (1) formulating only a one-dimensional, biological view of depression; (2) defining the client's role as passive in treatment; (3) economic corruption of the research and reporting; (4) false or misleading consumer advertising; (5) conflicting data that confuse practitioners and consumers alike; (6) over- and under-prescription of medications; (7) drug side-effects; and (8) harm to the environment. The enhanced effects of psychotherapy utilizing hypnosis offer a means of avoiding most, if not all, of the problems associated with the use of antidepressants as a primary form of treatment.

Psychiatric and medical comorbidities, associated pain, and health care utilization of patients prescribed buprenorphine

This study describes the comorbidities and health care utilization of individuals treated with buprenorphine using the 2007-2009 MarketScan Research Databases. Buprenorphine recipients had a high prevalence of comorbidities associated with chronic pain, including back problems (42%), connective tissue disease (24-27%), and nontraumatic joint disorders (20-23%). Approximately 69% of recipients filled prescriptions for opioid agonist medications in the 6 months before buprenorphine initiation. Buprenorphine recipients were frequently diagnosed with anxiety (23-42%) and mood disorders (39-51%) and filled prescriptions for antidepressants (47-56%) and benzodiazepines (47-56%) at high rates. Surprisingly, only 53-54% of patients filling a prescription for buprenorphine had a coded opioid abuse/dependence diagnosis. Research is needed to better understand buprenorphine's effectiveness in the context of prescription drug abuse and the best way to coordinate services to address the patient's comorbid addiction, pain, and psychiatric illnesses.

Weight gain and glucose dysregulation with second-generation antipsychotics and antidepressants: a review for primary care physicians

Second-generation antipsychotics (SGAPs) and second-generation antidepressants (SGADs) have multiple US Food and Drug Administration-approved indications and are frequently prescribed by primary care physicians. We review the relative potential of these drugs to cause weight gain and glucose dysregulation, and offer clinical guidance to minimize and manage this risk. Among SGAPs, clozapine and olanzapine have a high risk for causing weight gain and glucose dysregulation; iloperidone, paliperidone, quetiapine, and risperidone have a medium risk; and aripiprazole, asenapine, lurasidone, and ziprasidone have a low risk. Young, drug-naïve patients are particularly vulnerable to weight gain associated with SGAPs. With the exception of clozapine, SGAPs have modest differences in their efficacy; however, their side effect profiles may influence selection. Using SGAPs with high metabolic liability conservatively and limiting their off-label use are important means to minimize risk. Patients should be screened before initiating any SGAP (or any antipsychotic medication) and monitored subsequently following standard guidelines, such as those provided by the American Diabetes Association. Healthy lifestyle counseling should be offered to all patients. Patients showing evidence of significant weight gain should be switched to an SGAP with a lower metabolic liability. Metformin may have some utility in young patients with limited exposure to antipsychotic drugs if lifestyle interventions fail and switching the SGAP is not an option. This option should be tried sooner than later for the best possible result. For SGADs, paroxetine and mirtazapine are associated with weight gain, and bupropion may cause modest weight loss. Other SGADs are mostly weight neutral, but individual variations may occur. Depression is associated with weight change and is a risk factor for glucose dysregulation. Treatment of depression improves glucose metabolism. We recommend that all patients taking SGADs be screened using anthropometric measures and metabolic assessment at baseline. Monitoring should be guided individually based on weight gain and other risk factors.

Use of psychotropic medication in children and adolescents with autism spectrum disorders

OBJECTIVES

The goal of this study was to examine rates of psychotropic medication use and identify associated child and family characteristics among children and adolescents with autism spectrum disorder (ASD) enrolled in an autism registry maintained by the Autism Treatment Network (ATN).

METHODS

The sample, derived from the ATN registry, consists of 2853 children aged 2 to 17 years with diagnoses of ASD supported by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and the Autism Diagnostic Observation Schedule with available data on medication use. As part of initial enrollment in the registry, parents completed questionnaires on current psychotropic medication use, psychiatric and medical conditions, and demographics.

RESULTS

Of the 2853 children, 763 (27%) were taking ≥ 1 psychotropic medication; 15% were prescribed 1 medication, 7.4% received 2 medications, and 4.5% received ≥ 3. Among children aged 3 to 5 years, 11% were taking ≥ 1 psychotropic medication; among 6- to 11-year-old children, 46%; and 66% of adolescents aged 12 to 17 years were taking at ≥ 1 psychotropic medication. A parent report of comorbid diagnosis of attention-deficit/hyperactivity disorder, bipolar disorder, obsessive-compulsive disorder, depression, or anxiety was associated with a high rate of use, with 80% receiving ≥ 1 psychotropic medication. Only 15% of children with no comorbid psychiatric disorder were taking psychotropic medication. Psychotropic medication use was also related to sleep and gastrointestinal problems.

CONCLUSIONS

The prescription of psychotropic medications in this registry sample is highly related to comorbid psychiatric disorder. Other factors associated with use include medical comorbidities, race, ethnicity, and older age.

Managing the classification of psychiatric diagnoses: a systematics perspective

For almost a century, the American Psychiatric Association has improved psychiatric practice via its diagnostic manual series. However, the increasing number of diagnoses has created predicaments for clinicians and society. This report suggests explanations for this "inflation" and, using systematics, proposes the following five linked strategies for improving our diagnostic schema. First, criteria based on purposes underlying diagnosis should form the basis for including and excluding psychiatric diagnoses. Second, the major categories (or classes) should be reduced from 17 to one half to one third that number. Third, many psychiatric diagnoses should be removed from their current status as independent diagnoses (or subclasses) and relegated to a more specific taxonomic stratum (e.g., infraclass). Fourth, promising information for new or modified taxons would compose a fourth stratum (or parvclass). Fifth, comorbidity would become a more useful concept if defined as major, intermediate, and minor comorbidity, occurring at class, subclass, and infraclass levels.

Strategies to improve the management of depression in primary care

Effective management of depression in the primary care setting requires a systematic, population-based approach, which entails systematic case finding and diagnosis, patient engagement and education, use of evidence-based treatments, including medications and/or psychotherapy, close follow-up to ensure patients are improving, and a commitment to adjust treatments or consult with mental health specialists until depression is significantly improved. Programs in which primary care providers and mental health specialists collaborate effectively using principles of measurement-based stepped care and treatment to target can substantially improve patients' health and functioning while reducing overall health care costs.

Prevalence of antidepressant prescription or use in patients with acute coronary syndrome: a systematic review

BACKGROUND AND OBJECTIVES

Depression is common among acute coronary syndrome (ACS) patients and is associated with poor prognosis. Cardiac side effects of older antidepressants were well-known, but newer antidepressants are generally thought of as safe to use in patients with heart disease. The objective was to assess rates of antidepressant use or prescription to patients within a year of an ACS.

METHODS

PubMed, PsycINFO, and CINAHL databases searched through May 29, 2009; manual searching of 33 journals from May 2009 to September 2010. Articles in any language were included if they reported point or period prevalence of antidepressant use or prescription in the 12 months prior or subsequent to an ACS for ≥100 patients. Two investigators independently selected studies for inclusion/exclusion and extracted methodological characteristics and outcomes from included studies (study setting, inclusion/exclusion criteria, sample size, prevalence of antidepressant prescription/use, method of assessing antidepressant prescription/use, time period of assessment).

RESULTS

A total of 24 articles were included. The majority were from North America and Europe, and most utilized chart review or self-report to assess antidepressant use or prescription. Although there was substantial heterogeneity in results, overall, rates of antidepressant use or prescription increased from less than 5% prior to 1995 to 10-15% after 2000. In general, studies from North America reported substantially higher rates than studies from Europe, approximately 5% higher among studies that used chart or self-report data.

CONCLUSIONS

Antidepressant use or prescription has increased considerably, and by 2005 approximately 10% to 15% of ACS patients were prescribed or using one of these drugs.