Most Psychiatric Drug Use Is Long-term With Few Safety Data

Nancy A. Melville

December 28, 2016

Approximately 1 in 6 adults in the United States report use of a psychiatric drug. Rates are significantly higher in adults older than 60 years, and long-term use is reported in the majority of cases – despite a lack of evidence of long-term safety in many instances, new research shows.

"The biggest surprise was the large extent of the long-term use ― 84.3% of all adults taking psychiatric drugs," first author Thomas J. Moore, a senior scientist of drug safety and policy at the Institute for Safe Medication Practices, in Alexandria, Virginia, told Medscape Medical News.

"This is a safety concern, because 8 of the 10 most widely used drugs have warnings about withdrawal/rebound symptoms, are DEA [US Drug Enforcement Agency] Schedule IV, or both," said Moore, who is also a professorial lecturer in the Department of Epidemiology and Biostatistics at the Milken Institute School of Public Health George Washington University, in Washington, DC.

The findings were published online December 12 in JAMA Internal Medicine.

Red Flag

Previous data from the Substance Abuse and Mental Health Services Administration indicate that in 2011, 11.5% of adults reported taking prescription medications for "problems with emotions, nerves or mental health." However, the data lacked details on types of medications and patient characteristics.

To take a closer look at the issue, Moore and his colleagues evaluated data from the 2013 Medical Expenditure Panel Survey, which included information on the use of antidepressants, antipsychotics and anxiolytics, sedatives, and hypnotics among people aged 18 to 85 years.

They found that among 242 million US adults, 16.7% reported filling one or more prescriptions for psychiatric drugs in 2013. Of those patients, 12% received antidepressants, 8.3% received anxiolytics, sedatives and/or hypnotics; and 1.6% received antipsychotics.

Of adults aged 18 to 39 years, 9.0% reported psychiatric drug use; of adults aged 60 to 85 years, 25.1% reported psychiatric drug use (odds ratio [OR], 3.4).

About twice as many women used psychiatric drugs (21.2%) than did men (11.9%; OR, 2.0).

Psychiatric drug use was considered long-term by the majority of adults across all three drug classes, with 84.3% reporting having filled three or more prescriptions in 2013 or indicating the initiation of the drug in 2011 or earlier.

Those with long-term use reported receiving a mean of 9.8 prescriptions for psychiatric drugs during 2013.

With respect to race, psychiatric drug use was highest among whites, with 20.8% reporting prescriptions, compared to 9.7% among blacks, 8.7% among Hispanics, and 4.8% among Asians.

Moore said the reasons for the higher rates among whites are unknown, but he speculated that it is not likely a matter of access to the medications.

"Given that all of the 10 leading drugs are all available as generics, I doubt that cost/access explains much of the difference," he said. "Another possible reason is cultural and gender attitudes towards medication for mild depression and sleep problems."

The 10 most commonly used psychiatric drugs were as follows:

  1. Sertraline (Zoloft, Pfizer) a selective serotonin reuptake inhibitor (SSRI)

  2. Citalopram (multiple brands), an SSRI

  3. Alprazolam (Xanax, Pharmacia/Upjohn), a benzodiazepine

  4. Zolpidem tartrate (multiple brands), a hypnotic

  5. Fluoxetine (multiple brands), an SSRI

  6. Trazodone (multiple brands), a serotonin antagonist reuptake inhibitor

  7. Clonazepam (Klonopin, Roche), a benzodiazepine

  8. Lorazepam (multiple brands), a benzodiazepine

  9. Escitalopram (Lexapro, Forest Laboratories), an SSRI

  10. Duloxetine (Cymbalta, Lilly), a serotonin-norepinephrine reuptake inhibitor

The high rates of long-term use of psychiatric drugs should raise a red flag for the need for more monitoring and awareness of potential risks, Moore added.

"Both patients and physicians need to periodically reevaluate the continued need for psychiatric drugs," he said.

As an example, he noted that depression tends to be a cyclical event and that in clinical trials, patients with depression who received placebo experienced a 50% improvement in symptoms of depression after 6 weeks.

Moreover, side effects associated with antidepressants can include sexual dysfunction, insomnia, and weight gain.

"In addition, patients need to understand that in many cases, stopping the drug may seem to make the problem come back," Moore added.

"But in fact, it could be withdrawal or rebound symptoms that will resolve with awareness and careful tapering of the dose when quitting."

In a report published in 2015, Moore and his colleagues described particularly alarming prescribing practices of the sleep drug zolpidem (multiple brands), which was ranked No. 1 on a Centers for Disease Control and Prevention (CDC) survey of psychiatric medications linked to emergency department visits.

Although the drug is recommended for short-term use, as many as 68% of patients used zolpidem long term, with patients receiving three or more prescriptions or refills and a mean of 229 days' supply.

The report showed that 22% of sustained zolpidem users were also sustained users of opioids. In 2013, the US Food and Drug Administration recommended that women and the elderly use the lower dose of 5 mg of generic zolpidem or 6.25 mg of the extended-release version of drug, yet only 5% of women and 10% of the elderly were dispensed the lower dose. A modest improvement was seen by 2014.

With respect to antidepressant use, the rates reported in the new survey (12.9%) suggest a steady increase from utilization reported in previous research. That research includes a 2014 study using data from six waves of the cross-sectional National Health and Nutrition Examination Survey, involving 35,379 adults.

That study reported an increase of overall prevalence of antidepressant use from 6.5% in 1999-2000 to 10.4% in 2009-2010 (P < .001). The rate of long-term use (defined as use for 24 months or longer) more than doubled, from 3.0% to 6.9% in the same period (P < .001).

The authors noted that the increasing trend in long-term antidepressant use was limited to those receiving care from general practitioners (adjusted odds ratio, 3.86; P < .001).

Upward Trend

First author Ramin Mojtabai, MD, PhD, MPH, a professor in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, said more data are needed to determine whether that trend is continuing.

"It is too early to be able to assess trends in more recent years," he told Medscape Medical News. "The fact that the trend was growing faster in patients who receive care from general medical providers may be simply an indication that these providers are becoming more comfortable prescribing antidepressants and other psychiatric medications on a long-term basis," he added.

Dr Mojtabai added that the new findings on antidepressants are consistent with trends shown in other research.

"There has been an upward trend in prescription and use of antidepressants, especially long-term use. Much of the increase happened in the 1990s with the introduction of Prozac [Eli Lilly]. The trend slowed down after the early 2000s but continues to grow at a slower pace," he said.

Dr Mojtabai and his team also reported on trends in sedative-hypnotic prescribing in a study published in July in the American Journal of Public Health. Findings from that study showed a significant increase in prescriptions for benzodiazepines, from 3.4% in 2005 to 4.7% in 2012, and for non–benzodiazepine receptor agonists, from 1.0% to 1.7% in the same period (for both, P < .01). There was a much higher prevalence of visits for continuing and new prescriptions of the drugs in psychiatry practices than in primary care or other specialty practices.

"Future research needs to examine the association of this practice pattern with long-term use of these medications and explore society-, physician-, and patient-level factors driving these trends," the investigators write.

"Our findings also highlight the need for renewed efforts to monitor the long-term prescribing of sedative-hypnotics to vulnerable patients — especially older adults. Part of these efforts could include disseminating information with guidance on safe prescribing practices for these medications through continuing education credits, classes or seminars, and information packets, or by reminders or alerts in electronic medical records warning about prescribing to particularly vulnerable groups."

The authors and Dr Mojtabai have disclosed no relevant financial relationships.

JAMA Psychiatry. Published online December 12, 2016. Abstract


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