Risk Factors for Potential Antidepressant Overprescribing in Elderly Patients

Prescribing for non-psychiatric symptoms, greater clinical complexity, and prescribing without face-to-face contact can lead to antidepressant overprescribing in elderly patients, according to study results published in Pharmacology Research & Perspectives.

Investigators conducted a cohort study of new antidepressant prescriptions for elderly residents of Olmsted County, Minnesota, between 2005 and 2012. The medical records-linkage system of the Rochester Epidemiology Project was used to identify all residents age ≥65 who received an antidepressant prescription between January 1, 2005 and December 31, 2012 (n=4754). The study cohort was predominantly white (92.1%) and most participants were women (61.7%). Computerized indices from the Rochester Epidemiology Project were used to abstract sociodemographic data on patients. Potential antidepressant overprescribing was determined based on regulatory approval, level of evidence for drug efficacy identified from a standardized drug information database, and multidisciplinary expert review. Overprescribing criteria included antidepressant prescribing for non-psychiatric diagnoses or non-specific, sub-diagnostic psychiatric complaints, or with no listed indication.

During the study period, 3199 incident antidepressant prescriptions were written. The most commonly prescribed antidepressants were selective serotonin reuptake inhibitors (43.5%), trazodone/nefazodone (19.6%), tricyclic antidepressants (16.4%), and mirtazapine (12.3%). The majority of antidepressant prescriptions (56.9%) were for specific psychiatric indications, while 21.6% were for non-specific psychiatric symptoms and 21.5% were for general medical diagnoses. Potential antidepressant overprescribing occurred in nearly 23.6% of incident prescriptions. Selective serotonin reuptake inhibitors accounted for 74.4% of potential incidents, and mirtazapine accounted for an additional 19.3%.

Rates of potential overprescribing were greatest when antidepressants were prescribed for non-specific psychiatric indications (17.7%), followed by specific psychiatric indications (3.5%) and general medical indications (2.5%). Per logistic regression models that included all independent variables, nursing home residence (odds ratio [OR], 2.98; 95% CI, 1.29-6.93 vs community dwelling), having 11 or more medical conditions (OR, 3.31; 95% CI, 1.43-7.70 vs 0 to 3 medical conditions), and having 4 or more outpatient prescribers in the year preceding the index date (OR, 2.32; 95% CI, 1.15-4.67) were associated with potential antidepressant overprescribing. Potential overprescribing was also associated with a greater number of emergency room visits or hospitalizations in the year preceding index antidepressant prescription and being prescribed antidepressants via telephone, e‐mail, or patient portal. The risk for potential antidepressant overprescribing did not differ significantly by type of prescriber; for example, psychiatrist vs primary care provider.

These data highlight the risk factors for potential antidepressant overprescribing in elderly patients. Overprescribing typically involved newer antidepressants, a higher number of clinical diagnoses, and lack of face-to-face patient contact. Although the majority of incident antidepressant prescriptions were for appropriate indications, clinicians should be aware of these factors in order to minimize potential overprescribing.

Reference

Bobo WV, Grossardt BR, Lapid MI, et al. Frequency and predictors of the potential overprescribing of antidepressants in elderly residents of a geographically defined U.S. population. Pharmacol Res Perspect. 2019;23;7(1):e00461.