Suboptimal use of antidepressants in the elderly: a population-based study in Nova Scotia

[Community pharmacists' and pharmacy technicians' attitudes and beliefs about depression in elderly]

OBJECTIVES

To analyze attitudes and beliefs of community pharmacists and pharmacy technicians about depression and treatment in older patients.

METHODS

A qualitative study was conducted with community pharmacists and pharmacy technicians. The first step of the study was to develop an interview guide to conduct semi-directive interviews. A thematic analysis was conducted based on the transcripts of the recording of audio interviews.

RESULTS

Eight pharmacists and 5 pharmacy technicians were included. The mean duration of semi-directive interviews was 14.8±4.6minutes. The main identified themes were as follows: 1/the depression: beliefs about depression and its risk factors in older patients; how to talk about depression with older patients at the counter; 2/the management of depression: how to talk about antidepressant with older patients at the counter, including treatment duration, dosage, efficacy and adverse effects of treatment, but also alternative therapies and advices; 3/barriers and facilitators of antidepressant adherence in older patients.

CONCLUSIONS

Barriers to conduct pharmaceutical care focusing on depression among older patients in community pharmacy have been identified: disease stigmatization, lack of privacy at the counter and lack of communication with the prescribing physician; but also a lack of knowledge concerning the specific therapeutic strategy for depression in the elderly. Thus, strengthening the pharmacy student teaching and the community pharmacist and pharmacy technician training regarding the posture to adopt and the therapeutic management of older patients with mental illness would be beneficial.

New antidepressant use in older adults: a Canadian population-based study (1997-2013)

OBJECTIVE

There has been much attention on appropriate prescribing in older adults in recent years. Recent guidelines favor the use of newer antidepressants over older agents based on their safety profile in this population. This study aimed to examine whether there has been a decline in older antidepressants and an increase in newer antidepressants used by older adults.

METHOD

A retrospective cross-sectional study using administrative databases examined the annual incidence of antidepressant use (per 1000) of community-dwelling adults ≥60 years old between 1997/1998 and 2012/2013 in Manitoba, Canada.

RESULTS

The population of Manitoba ≥60 years increased by 25.6% from 188,296 to 236,569 from 1997/1998 to 2012/2013. New antidepressant use peaked to 45.9 per 1000 in 1999/2000, and then decreased steadily to 30.5 per 1000 in 2012/2013 (p < 0.0001). Incident amitriptyline use was high but declined from 15.5 to 7.4 per 1000 (p < 0.001). An increase in incident trazodone, mirtazapine, and venlafaxine use was observed (p < 0.001).

CONCLUSIONS

There has been an overall decrease in the annual incidence of antidepressant users in older adults over the last 16 years, with a marked decline in new amitriptyline use and an increase in the incidence of newer agents.

Antidepressant adherence patterns in older patients: use of a clustering method on a prescription database

According to the World Health Organization, depression will become the second most important cause of disability worldwide by 2020. Our objective was to identify patterns of adherence to antidepressant treatments in older patients using several indicators of adherence and to characterize these patterns in terms of medication exposure. We conducted a retrospective cohort study using the French National Health Insurance reimbursement database. Incident antidepressant users aged more than 65 were included from July 1, 2010, to June 30, 2011, and followed up for 18 months. Antidepressant and other psychotropic drugs (opioids, benzodiazepines, antipsychotics, anti-epileptics) were recorded. Adherence to antidepressant treatment was assessed by several measures including proportion of days covered, discontinuation periods, persistence of treatment, and doses dispensed. Patients were classified according to their adherence patterns using a mixed clustering method. We identified five groups according to antidepressant adherence. One group (n = 7505, 26.9%) was fully adherent with regard to guidelines on antidepressant use. Two patterns of nonadherent users were identified: irregular but persistent users (n = 5131, 18.4%) and regular but nonpersistent users (n = 9037, 32.4%). Serotonin reuptake inhibitors were the most frequently dispensed antidepressant class (70.6%), followed by other antidepressants (43.3%, mainly serotonin-norepinephrine reuptake inhibitors and tianeptine) and tricyclic antidepressants (TCAs) (13.4%). Nonadherent users more frequently had a dispensing of TCA, opioid, and anti-epileptic medication than adherent users. Health policies to improve adherence to antidepressant treatment may require better training of physicians and pharmacists, insisting on the important role of the continuation period of antidepressant treatment.

Contemporary concepts in the pharmacotherapy of depression in older people

Late-life depression is common in older people. Its incidence increases significantly after age 70 to 85, as well as among those living in long-term care facilities. Depression contributes to excess morbidity and complicates management of comorbid conditions in older people. Diagnosis and management of depression often present clinicians with a challenge. Indeed, symptoms of depression in older people may not always be the same as those associated with depression in younger people. Additionally, age-related changes in pharmacokinetics and pharmacodynamics also impact selection, dosing, and monitoring of psychopharmacologic regimens. Optimizing management of depression and providing sound advice to older patients with depression requires knowledge and understanding of many clinical factors. The purpose of this review is to highlight salient issues in late-life depression, with a focus on the pharmacotherapy of depression.

Medication use and nonadherence to psychoactive medication for mental health problems by community-living Canadian seniors with depression

OBJECTIVES

To determine the relation between level of depression and psychoactive medication use and nonadherence in Canadian seniors, given that late-life depression is a common, serious mental health problem in Canada.

METHODS

Canadian Community Health Survey-Mental Health and Well-Being respondents aged 65 years and older (n = 7,736) comprised the study sample. Using the Composite International Diagnostic Interview to assess depressive symptoms, we created 4 depression levels to capture a spectrum of depressive disorders and (or) symptoms: major depression, comorbid major depression, depressive symptoms, and no depressive symptoms. Psychoactive medications assessed included sleep aids, anxiolytics, and mood stabilizers and (or) antidepressants (AD). Nonadherence was defined as either not taking medication as recommended or taking medication at a lower dosage than prescribed.

RESULTS

In total, 22.5% of respondents took psychoactive medication for a mental health problem in the previous 12 months. Psychoactive medication use was 46.8% for major depression, 43.1% for comorbid major depression, 34.0% for depressive symptoms, and 17.6% for no depressive symptoms. Rates of psychoactive medication use ranged from 46.5% of those with major depression, to 17.6% of those with no depressive symptoms. Overall, the rate of nonadherence to psychoactive medication was 31%; rates were highest among those with depressive symptoms (37.4%) and lowest among those with no depressive symptoms (27.4%). All 3 depressive categories were associated with greater odds of use and nonadherence.

CONCLUSION

All 3 depression categories were associated with increased use of and nonadherence to psychoactive medication; however, rates of AD and (or) mood stabilizer use for clinically significant depression were low.

Pharmacologic response to a diagnosis of late-life depression: A population study in Quebec

OBJECTIVE

To identify predictors of receiving psychoactive medication and receiving recommended first-line pharmacotherapy in individuals with newly diagnosed late-life depression.

METHODS

We undertook a retrospective database cohort study of 5258 beneficiaries of the Quebec provincial health insurance plan between 1999 and 2002. Subjects were aged 65 to 84 years and diagnosed with depression by primary care physicians or psychiatrists between October 2000 and March 2001; they had no depression diagnosis in the previous year. We defined receipt of psychoactive medication as having a pharmacy claim in the year following the depression diagnosis. We determined receipt of recommended first-line pharmacotherapy from the first psychoactive medication dispensed following diagnosis and defined it accordingly; we defined first-line pharmacotherapy according to the 2001 Canadian Psychiatric Association guidelines. We used multivariate generalized estimating equations models to identify the determinants of the 2 outcomes.

RESULTS

A total of 4421 (84.1%) patients received psychoactive medication following diagnosis; 2623 (59.3%) patients had not received antidepressants in the previous year. Of these, 1310 (49.9%) received recommended first-line pharmacotherapy. Independent predictors of receiving psychoactive medication were female sex, depression not otherwise specified (NOS), increasing comorbidity, and living in rural areas. Independent predictors of receiving recommended first-line pharmacotherapy were male sex, depression NOS, receiving medication in the month following diagnosis, and having the same physician diagnosing and treating the patient.

CONCLUSION

Male sex and continuity of care predicted that patients had the recommended medication dispensed.

Achieving long-term optimal outcomes in geriatric depression and anxiety

Depression and anxiety disorders are very common in the elderly. Data accumulated over the past 2 decades have shown that most older patients can tolerate and respond to acute treatment with serotonergic antidepressants, other psychotropic agents, or manual-based psychotherapy. However, outcomes under usual-care conditions remain poor. This review proposes that clinicians may significantly improve the long-term outcomes of their older patients with depression and anxiety by focusing on four key factors: (1) identification and treatment of comorbid conditions; (2) full remission of acute symptoms; (3) education of patients, families, and professional colleagues about the need for long-term treatment; and (4) prevention and management of medication side-effects.

Guideline for the management of late-life depression in primary care

OBJECTIVE

To develop a guideline for the primary care management of depression in later life based on best practice.

METHOD

Source material included relevant guidelines, literature reviews and consensus documents coupled with an updated literature review covering 1998-October, 2001. This material was summarised as a series of evidence-based statements and recommendations agreed by consensus.

RESULTS

Good quality evidence exists for the pharmacological and psychological treatment of depressive episode (major depression), although not specifically in primary care. There is some evidence of efficacy of antidepressants in late-life dysthymia and minor depression associated with poor functional status. In depressive episode, current evidence suggests acute treatment for at least six weeks and a continuation period of at least 12 months. Both tricyclic antidepressants and Selective Serotonin Re-uptake Inhibitors are effective in longterm prevention. There is less data on how to manage patients who do not respond in the acute treatment phase. More data is needed on sub-groups of patients with specific co-morbid medical conditions and those who are frail. Collaborative care is effective in older depressed primary care patients.

CONCLUSIONS

There are effective treatments for depression in primary care. More research is needed to address the optimum treatment of depression with medical co-morbidity and to elucidate the role of newer psychological interventions. Collaborative care between primary care and specialist services is a promising new avenue for management.

Antidepressant drugs in the elderly--role of the cytochrome P450 2D6

Depression, the most common mental health problem of the elderly, is often under-diagnosed and under-treated. As patients age, antidepressant pharmacologic treatment becomes more complicated due to an increased risk of adverse drug events. These risks are associated with age-related physiological changes and individual variability in drug metabolism related to several factors, the most frequent of which is polymedication as a result of coexisting chronic illnesses. Comedications induce drug interactions that depend on the patient's metabolic capacity linked to the genetically determined cytochrome P450 enzyme (CYP450) function. The effect of some isoenzyme polymorphism on the pharmacokinetics of many antidepressants and other psychotropic drugs is well characterized. The author approaches successively the notions of the cytochrome P450 (2D6), its role in the drug biotransformation, and the importance of knowing its substrates, inhibitors and inducers in order to predict drug interactions. The clinical significance of this notion, and the help that could be given by genotyping and phenotyping, are also explained. The author's experience on the relation between drug side effects and patient metabolic status, and on the antidepressant interactions with fluoxetine, fluvoxamine and citalopram, is given in order to rationalize and individualize antidepressant choice in elderly.

Antidepressant prescribing in nursing homes: is there a place for tricyclics?

OBJECTIVE

To deduce a model describing physicians' choice of antidepressants for treating elderly nursing home patients.

METHODS

Subjects were geriatric residents of 137 skilled nursing facilities who regularly received an antidepressant medication for at least one month (n = 3,440, 28% of all residents). Reasons for prescribing antidepressants and physicians' diagnoses of depression and dementia were identified by medical record audit. Residents were grouped by dementia and antidepressant target symptoms (depression, or one or more non-psychiatric symptoms, i.e. insomnia, pain, incontinence, itching).

RESULTS

Selective serotonin reuptake inhibitors (SSRIs) were prescribed preferentially over tricyclic antidepressants (TCAs) for treating depression in both demented and non-demented residents, but TCAs were nine times more likely to be prescribed for treating non-psychiatric target symptoms alone. When non-psychiatric target symptoms were present without depression or dementia, both amitriptyline and nortriptyline prescribing was increased, but amitriptyline appeared to be the antidepressant of choice. In all subgroups examined, its use was two to five times more prevalent when such symptoms were present. In patients with dementia, amitriptyline prescribing declined whether or not non-psychiatric target symptoms were present, but nortriptyline prescribing did not; nortriptyline was three times more likely than amitriptyline to be prescribed in the presence of dementia.

CONCLUSIONS

Physicians prescribe anticholinergic TCAs principally to treat common non-depressive symptoms in nursing home residents, preferring SSRIs for uncomplicated depression and depression with dementia. They tend to avoid prescribing anticholinergic TCAs other than nortriptyline when they recognize a patient as demented. The data suggest that physicians employ a decision model for antidepressant prescribing that simultaneously recognizes the utility of TCAs in treating non-psychiatric symptoms and the anticholinergic vulnerability of older, especially demented, patients. Whether or not this model leads to optimal patient management requires further study.

Evaluating the Impact of an Educational Program on Practice Patterns of Canadian Family Physicians Interested in Depression Treatment

BACKGROUND: Depression is frequently unrecognized and undertreated. Therefore, there is a need to increase the knowledge and skills of primary care physicians regarding the diagnosis and treatment of depression. The aim of this study was to provide, and evaluate the impact of, a brief educational program with a number of practice tools and resources in order to improve family physicians' knowledge, diagnosis, and treatment of depression. METHODS: Two educational programs (general and enhanced) were delivered to family physicians interested in depression treatment. The enhanced program focused on more practical clinical issues such as use of diagnostic and symptom assessment tools, recommended dosing of citalopram, how to initiate and discontinue treatment, and relapse prevention. Physicians' knowledge of depression was assessed pretraining and posttraining. Chart audits were conducted for 6 months. Primary endpoints were recognition of depression and pharmacologic management (initial dose, maximum dose, length of treatment, adverse events, and concomitant psychotropic drugs). Secondary endpoints were patient satisfaction with treatment, compliance, withdrawal from the study, treatment outcome, use of adjunctive psychotherapy, and number of office visits. RESULTS: There was a global increase in physicians' knowledge of depression in the short term. Physicians in the enhanced group were more likely to use a symptom-based diagnostic checklist, record the diagnosis of depression, and prescribe the recommended initial dose of citalopram, and they referred less frequently for adjunctive psychotherapy. No difference between educational intervention groups was found in patient satisfaction, compliance, and treatment outcome. CONCLUSIONS: A well-designed brief, simple, and low-cost educational program can increase family physicians' knowledge of depression, improve their diagnostic skills, and optimize their treatment of depression.

Program management of telemental health care services

Telemedicine is a new adjunct to the delivery of health care services that has been applied to a range of health care specialties, including mental health. When prospective telemedicine programs are planned, telemedicine is often envisaged as simply a question of introducing new technology. The development of a robust, sustainable telemental health program involves clinical, technical, and managerial considerations. The major barriers to making this happen are usually how practitioners and patients adapt successfully to the technology and not in the physical installation of telecommunications bandwidth and the associated hardware necessary for teleconsultation. This article outlines the requirements for establishing a viable telemental health service, one that is based on clinical need, practitioner acceptance, technical reliability, and revenue generation. It concludes that the major challenge associated with the implementation of telemental health does not lie in having the idea or in taking the idea to the project stage needed for proof of concept. The major challenge to the widespread adoption of telemental health is paying sufficient attention to the myriad of details needed to integrate models of remote health care delivery into the wider health care system.