Antidepressants Prescribed Without Psychiatric Diagnosis
Aug 4, 2011 — Antidepressants may be increasingly prescribed by non-psychiatrists to treat medical disorders in the absence of a psychiatric diagnosis.
The proportion of non-psychiatrist doctor visits where antidepressants were prescribed without a documented psychiatric diagnosis increased from 59.5% to 72.7% between 1996 and 2007, according to a new study in Health Affairs.
Experts not affiliated with the study are quick to caution that there are many possible, and plausible, explanations for what seems to be an uptick, and that depression remains largely underdiagnosed and undertreated in the U.S.
In the study, researchers analyzed antidepressant prescriptions written for adults aged 18 and older from 1996 to 2007 during office-based doctors’ visits. In 1996, 2.5% of all visits to non-psychiatrists resulted in an antidepressant prescription. In 2007, that increased to 6.4%. Antidepressant prescriptions from primary care doctors for nonpsychiatric disorders increased from 3.1% to 7.1% during the study period. Many of these patients were listed as having general medical conditions such as diabetes, heart disease, or nonspecific pain symptoms.
Are Non-Psychiatrists Doling Out Antidepressants?
By contrast, antidepressants prescribed by non-psychiatrist doctors for psychiatric diagnoses only increased from 1.7% to 2.4% from 1996 to 2007, the study showed.
“We need to better understand the causes for increased prescription of antidepressants without a psychiatric diagnosis in the general medical settings,” study author Ramin Mojtabai, MD, PhD, MPH, an associate professor in department of mental health at Johns Hopkins Bloomberg School of Public Health in Baltimore, says in an email.
“What we are observing is that Americans are increasingly viewing psychiatric medications as a solution for a wide range of social and interpersonal problems and for dealing with daily stress [and] general medical providers appear to be going along with this trend,” he says.
Although the findings suggest that these medications may be overly prescribed, depression and anxiety disorders are still underdiagnosed and undertreated, he says. “The irony is that many patients with major depression or anxiety disorders who could potentially benefit from treatment with antidepressant medications do not receive these treatments,” Mojtabai says.
The solution, he says, involves both clinician and patient education regarding the appropriate treatment with antidepressants.
Mojtabai’s co-author, Mark Olfson, MD, a professor of clinical psychiatry at the College of Physicians and Surgeons of Columbia University and a research psychiatrist at New York State Psychiatric Institute, both in New York City, says that the new findings “raise concerns about inappropriate use of antidepressants.”
But the data only provide a snapshot, he says. “It is possible that these individuals have a history of depression or other mental health issues that led to the prescription but may not be documented in this visit,” he says.
The findings may also speak to our fragmented health care system, Olfson says. “If you are in a situation where you receive medicine from one doctor and see another doctor for counseling, make sure the two are communicating,” he says. “The more coordinated the care, the more focused and effective the treatment will be. Medications and counseling are more powerful together than either one alone.”
Peter D. Kramer, MD, a psychiatrist at Brown University in Providence, R.I., and the author of several books, including Listening to Prozac, says that the study asks more questions than it answers.
“This is a chart review so the question is, ‘Are the findings documenting inappropriate prescribing or inappropriate charting?’” he says.
“Most people are treated outside of specialty, and there have been very extensive efforts to educate the primary care community about depression, and it’s hard to say whether this study shows the success of this effort or the failure,” he says.
Victor Reus, MD, professor of psychiatry at the University of California at San Francisco School of Medicine, says that there may be more going on here than meets the eye. For example, doctors often get reimbursed at lower rates for treating psychiatric conditions, so they may be more likely to use another code in the files. There are also still stigmas attached to psychiatric illnesses, which could play a role in the lack of diagnoses evident in some of these records.
“Some people may have had the diagnosis made by a psychiatrist and there was a relationship with a general practitioner who prescribed antidepressants,” he says. In these cases, the psychiatric diagnosis may be listed in a different set of records for the same person.
What’s more, “there are ample efficacy data to show that if you have depression that is secondary to stroke or heart attack, you are just as likely to achieve benefit from antidepressants as if you had an autonomous depression without a secondary medical illness,” he says.
The bottom line? “There are so many plausible explanations for what is going on,” he says.
Alan Manevitz, MD, a clinical psychiatrist at Lenox Hill Hospital in New York City, agrees with Reus.
“Some general practitioners may also be becoming more skilled at picking up softer signs of depression and intervening earlier, especially in people with co-existing medical problems that are linked to depression like heart attack or stroke,” he says.