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

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

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

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

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

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

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

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

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

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

To examine antidepressant prescribing trends among office-based nonpsychiatrists, the authors analyzed data from the CDC’s National Ambulatory Medicare Care Surveys for the years 1996 to 2007. Physicians who participate in the survey provided information about patient visits during a randomly selected one-week period.

Physicians entered as many as three diagnoses for each visit included in the survey. Patients were put into two classifications — those having a mental disorder diagnoses on the basis of ICD-9-CM codes or those whose primary reason for a visit was for a “mental disorder.”

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

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

The proportion of visits that involved an antidepressant prescription more than doubled among nonpsychiatrists during the study period (4.1% to 8.8%, OR 2.2, P<0.001).

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

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

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

The findings’ implications include a need for better education of nonpsychiatrist physicians about appropriate antidepressant prescribing, formulary changes that encourage more appropriate use, and better communication between psychiatrists and nonpsychiatrists.

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

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

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