Antidepressants increasingly prescribed for nonpsychiatric conditions

When patients visit their physicians for common health issues such as fatigue, headaches and premenstrual problems, they increasingly are getting a prescription for the same type of medication.

An antidepressant.

A study in the August issue of Health Affairs found that it is becoming more common for primary care doctors and other nonpsychiatrist physicians to prescribe antidepressants for conditions other than anxiety and major depressive disorder. The study found that between 1996 and 2007, the proportion of patient visits in which antidepressants were prescribed but no psychiatric diagnoses were noted increased from 59.5% to 72.7%.

Patients who received the drugs had complained of headaches, nonspecific pain, premenstrual tension and tiredness, among other problems.

The study shows that the uptick is being driven by a small percentage of physicians, however.

From 1996 to 2007, the percentage of patient visits to nonpsychiatrists that resulted in antidepressants for nonpsychiatric conditions increased from 2.5% to 6.4%. For visits to primary care physicians specifically, the percentage climbed from 3.1% to 7.1%, according to the study of more than 230,000 physician office visits by adults 18 and older.

Contributing to the rise is a growing awareness of mental illness among the public, who often ask doctors for antidepressants, experts say. There also is an increasing demand on primary care physicians to identify and treat mental issues due to a shortage of mental health professionals.

"We're trained to treat depression and anxiety, unless [the conditions are] particularly complicated, so it's not a big jump to have primary care physicians doing this," said Cranston, R.I., internist Yul Ejnes, MD, chair of the Board of Regents of the American College of Physicians.

The study's authors note some limitations to their data. One limitation was not accounting for visits in which physicians refilled antidepressant prescriptions for patients whose mental illness was well-managed.

Yet some mental health professionals are concerned that the study shows that antidepressants are being misused and overused.

Some speculate that doctors inadvertently are misusing the medications because of insufficient time to accurately identify mental illness, determine the condition's severity and develop the most appropriate treatment plan. Others say primary care physicians need more education on treating mental health conditions.

"In some ways, [prescribing an antidepressant] is the easiest thing to do," said David M. Reiss, MD, a San Diego psychiatrist. "It's not that physicians aren't trying to do a good job, but the [medication] is an easy way to give someone relief."

The issue, he said, is that prescribing antidepressants instead of a more appropriate treatment is "putting a Band-Aid on what might be a more serious and more complicated problem."

Though some research indicates that the drugs are more effective than placebos in treating conditions such as migraine headaches, there is insufficient evidence supporting their use for stress and fatigue, said lead study author Ramin Mojtabai, MD, MPH, PhD.

In some cases, patients are being unnecessarily exposed to the adverse effects of the medications, including an increased risk of diabetes, said Dr. Mojtabai, a psychiatrist and associate professor at Johns Hopkins Bloomberg School of Public Health in Baltimore.

Antidepressants on the rise

During the past two decades, the use of antidepressants in the United States has increased markedly, mental health experts say. Anxiety and depression medications, used by about 27 million Americans, are the third most-prescribed class of drug in the U.S., according to a 2010 National Health Statistics Report. Only analgesics and antihyperlipidemic agents are prescribed more.

Contributing to the rise in antidepressant prescriptions are direct-to-patient advertisements that suggest many common conditions, such as mild anxiety, stress and trouble sleeping, need to be treated medically, Dr. Reiss said. At the same time, celebrities such as actress Catherine Zeta-Jones have disclosed their mental health problems, and those disclosures have helped increase public awareness.

Talking about mental illness makes it less stigmatized, Dr. Ejnes said, adding that patients seem less self-conscious about discussing their mood disorders than they did in the past.

Though antidepressants often are recommended for major depressive disorder and anxiety, they should not be the first line of treatment for mild forms of these conditions, said William Narrow, MD, MPH, associate director in the division of research for the American Psychiatric Assn. Instead, he said physicians should first suggest that patients try getting more sleep and exercise, reduce stress, and limit alcohol consumption.

To help primary care doctors diagnose mental health conditions, Dr. Reiss recommends adding more in-depth questions about substance abuse and sleeping problems. He said physicians should ask patients about relationships with their families, inquire about substance abuse among relatives and discuss whether the patient ever was in an abusive relationship.

If an antidepressant is prescribed, Dr. Reiss encourages physicians to monitor patients closely. He suggests contacting the individual two to three days after issuing the medication to check how the patient is feeling.

Dr. Narrow recommends that primary care doctors become familiar with their local mental health professionals so they can refer patients with more complicated conditions to a specialist for treatment.

In areas where psychiatrists are sparse, family physician Lori Heim, MD, suggests using telemedicine to put primary care doctors in touch with mental health professionals.

"The mental health resources are limited [in my community]," said Dr. Heim, who practices in rural Vass, N.C., and is board chair of the American Academy of Family Physicians. "I hear that from other family physicians across the country, too. And, quite frankly, a lot of our patients want to be treated in their family doctor's office. They don't want to go talk to someone else."

New York psychiatrist T. Byram Karasu, MD, said education is key to ensuring that physicians know how to properly treat mental health conditions.

"There may be overuse of antidepressants or inappropriate use of the medications, but with [physician] training you can correct that," said Dr. Karasu, chair of the Dept. of Psychiatry and Behavioral Sciences at Albert Einstein College of Medicine in New York.