Majority of Psychotropic Meds Prescribed Without a Diagnosis

Deborah Brauser

September 12, 2013

Updated: Psychotropic medications are still being prescribed in large numbers to patients without a clinically diagnosed psychiatric disorder, new research suggests.

The study, which examined MarketScan claims data for 5.1 million patients who were prescribed at least 1 psychotropic medication, showed that 58.2% of the individuals had received no psychiatric diagnosis.

In addition, 69% of those between the ages of 50 and 64 years and 67% of those who did not receive any specialized mental health care were prescribed these medications without a diagnosis.

"The #1 takeaway is that a large majority of outpatients, proportionately larger among older outpatients, are being prescribed psychotropic medications in the absence of a clear indication for such use," lead investigator Ilse Wiechers, MD, Robert Wood Johnson Foundation Clinical Scholar at the Yale School of Medicine in New Haven, Connecticut, and who is affiliated with the US Department of Veterans Affairs, told Medscape Medical News.

"I think that this finding is concerning. But we can't say whether this is due to poor documentation, or inappropriate use of these medications, or underdiagnosis of mental health problems," said Dr. Wiechers, adding that more research is definitely needed.

The study was published online September 3 in Psychiatric Services.

Common Practice

"The idea for this study developed as I was seeing patients in my clinical work as a geriatric psychiatrist. They were often already taking several psychiatric medications, but nowhere was it documented that they had any mental illness," said Dr. Wiechers.

"And oftentimes the patients themselves couldn't tell me why they were taking these medications," she said, adding that some evidence has shown that this practice is not uncommon, especially with antidepressants.

Dr. Ilse Wiechers

However, there has been little in the literature that has looked at other classes of psychotropic medications, Dr. Wiechers noted.

For this study, the researchers examined data from MarketScan, a private insurance claims database, for 5,132,789 adult patients (64% women) who filled a prescription for at least 1 psychotropic during 2009.

The patient data were also divided into 3 age subgroups: 18-39 years (37%), 40-49 years (23%), and 50-64 years (40%). The psychotropic prescriptions were divided into 6 classes: antidepressants, antipsychotics, benzodiazepines, stimulants, anticonvulsant mood stabilizers, and lithium.

A patient was classified as having used mental health specialty care if they submitted a claim for services during the preceding year at a mental health or substance use specialty clinic or visits with a treatment specialist, or for psychotherapeutic services.

Age Increases Risk

Results showed that the patients between the ages of 50 and 64 years were 2.9 times more likely to be prescribed a psychotropic without psychiatric diagnosis than those in the 18- to 39-year age group (odds ratio, 2.87; P < .001). And those in the 40- to 49-year age group were 1.8 times more likely to receive this type of prescription than those in the younger group (P < .001).

"Diagnoses signifying potential medical indications for use and severity of comorbid medical conditions were only weakly related to absence of a psychiatric diagnosis and did not alter these age trends," write the investigators.

The most likely drug classes to be prescribed without psychiatric diagnosis were anxiolytics (61%), mood stabilizers (58%), and antidepressants (52%). The least likely drugs were lithium, stimulants, and antipsychotics (12%, 26%, and 31%, respectively).

"It is unclear why these…medications were so closely linked to diagnosis," the researchers write.

"One possibility is that [they] have more narrowly defined clinical indications for use and lower rates of off-label prescribing than the other classes studied," they add.

Only 14% of the individuals who used mental health care services received a prescription without diagnosis.

The fact that 67% of the total prescriptions without diagnosis were to patients not receiving any specialized mental health care likely means that the medications were prescribed in primary care, general medical, and surgical settings, write the researchers.

Still, Dr. Wiechers noted that "we don't yet have the evidence" to recommend a change in prescribing practices.

"What we can say is that based on looking at a national sample of individuals covered by commercial health insurance, many are prescribed psychotropic medications without a documented, clear indication for use," she said.

"Cause for Concern"

"I thought this was a good study that is supporting what has been found in previous research," Ramin Mojtabai, MD, PhD, MPH, associate professor in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, told Medscape Medical News.

However, "it has strengths in that it has used a broader range of medications than many of the prior studies have used," he added.

Dr. Ramin Mojtabai

Dr. Mojtabai, who was not involved with this research, published a study along with colleagues in the Journal of Clinical Psychiatry in 2011 that showed that antidepressant use without a mental illness diagnosis is common in the general population.

He noted that he admires the current study's large sample size, which allowed the investigators to assess trends by different ages. "They also did a good job of addressing for general medical indications for psychotropic medication use."

Although he agreed with Dr. Wiechers that the study cannot say for certain why there was such a high number of prescriptions without diagnosis, he also agreed that the findings were concerning and deserve more research.

"This was based on billing records. And reimbursement records may not reflect the diagnosis or the clinician's assessment of the clinical status of the patient at the time," said Dr. Mojtabai.

"It's also possible that a number of these patients had been prescribed medications for a long-standing mental health problem. So when you look at the period of only 1 year, the refills for the medications may not reflect the diagnosis that initiated the use the medications many years ago."

Nevertheless, "even with these caveats, there are still some concerning trends," he noted, such as the differences between those who visited a mental health care setting and those who visited primary care settings, as well as the age gradients that were shown.

"So these trends cannot really be explained away simply by the nature of the data," he said.

The study was funded by several organizations, the full list of which is published in the original article. One of the study authors reports having received research support from Janssen Pharmaceutica, AstraZeneca, and Wyeth Pharmaceuticals, having been a consultant to Otsuka, and having been a testifying expert in a case involving Janssen. Dr. Wiechers and the other study author have disclosed no relevant financial relationships.

Psychiatr Serv. Published online September 3, 2013. Abstract

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