Potentially Inappropriate Antidepressant Prescriptions Among Older Adults in Office-Based Outpatient Settings: National Trends from 2002 to 2012

  • Taeho Greg Rhee
  • Jon C. Schommer
  • Benjamin D. Capistrant
  • Ronald L. Hadsall
  • Donald L. Uden
Original Article


Using data from 2002 to 2012 National Ambulatory Medical Care Survey, we estimated that the prevalence of overall antidepressant prescriptions increased almost twofold from 5.2% in 2002 to 10.1% in 2012 in office-based outpatient visits made by older adults. In addition, older adults were exposed to the risk of potentially avoidable adverse drug events in approximately one in ten antidepressant-related visits, or 2.2 million visits annually. Amitriptyline and doxepin were the two most frequent disease-independent potentially inappropriate antidepressants. Racial/ethnic minorities, and Medicaid beneficiaries had higher odds of potentially inappropriate antidepressant prescriptions (P < 0.05). Efforts to minimize potentially inappropriate antidepressant prescriptions are needed.


Antidepressant Office-based care Older adults Beers Criteria Inappropriate use Prescribing pattern 



This study was funded to Dr. Rhee in part by St. Peter and Leiner Family Outcomes Research Fellowship, University of Minnesota College of Pharmacy.


Publicly available data were obtained from the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC). Analyses, interpretation, and conclusions are solely those of the authors and do not necessarily reflect the views of the Division of Health Interview Statistics or NCHS of the CDC.

Author Contributions

Dr. TGR conceived the study, acquired data, analyzed and interpreted the data, led the writing of the manuscript, and oversaw every aspect of the study. Drs. JCS, BDC, RLH, and DLU contributed to the interpretation of the data, and critically revised the manuscript.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they do not have a conflict of interest.

Ethical Approval

Using publicly available de-identified data, the research procedure for this study was exempted from the University of Minnesota Institutional Review Board.

Supplementary material

10488_2017_817_MOESM1_ESM.doc (118 kb)
Supplementary material 1 (DOC 117 KB)


  1. Alegria, M., Chatterji, P., Wells, K., Cao, Z., Chen, C. N., Takeuchi, D., … Meng, X. L. (2008). Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatric Services, 59(11), 1264–1272. doi: 10.1176/ Scholar
  2. American Geriatrics Society Beers Criteria Update Expert Panel. (2012). American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 60(4), 616–631. doi: 10.1111/j.1532-5415.2012.03923.x.CrossRefGoogle Scholar
  3. American Geriatrics Society Beers Criteria Update Expert Panel. (2015). American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. doi: 10.1111/jgs.13702.Google Scholar
  4. American Society of Health-System Pharmacists. (2015). American hospital formulary service (AHFS) drug information. Bethesda, MD: American Society of Health-System Pharmacists.Google Scholar
  5. Aparasu, R. R., Jano, E., & Bhatara, V. (2009). Concomitant antipsychotic prescribing in US outpatient settings. Research in Social & Administrative Pharmacy: RSAP, 5(3), 234–241. doi: 10.1016/j.sapharm.2008.08.005.CrossRefGoogle Scholar
  6. Beers, M. H. (1997). Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Archives of Internal Medicine, 157(14), 1531–1536.CrossRefPubMedGoogle Scholar
  7. Beers, M. H., Ouslander, J. G., Rollingher, I., Reuben, D. B., Brooks, J., & Beck, J. C. (1991). Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Archives of Internal Medicine, 151(9), 1825–1832.CrossRefPubMedGoogle Scholar
  8. Budnitz, D. S., Lovegrove, M. C., Shehab, N., & Richards, C. L. (2011). Emergency hospitalizations for adverse drug events in older Americans. The New England Journal of Medicine, 365(21), 2002–2012. doi: 10.1056/NEJMsa1103053.CrossRefPubMedGoogle Scholar
  9. Cahir, C., Bennett, K., Teljeur, C., & Fahey, T. (2014). Potentially inappropriate prescribing and adverse health outcomes in community dwelling older patients. British Journal of Clinical Pharmacology, 77(1), 201–210. doi: 10.1111/bcp.12161.CrossRefPubMedGoogle Scholar
  10. Centers for Medicare and Medicaid Services. (2015). Request for comments: Enhancements to the Star Ratings for 2017 and beyond. Baltimore: Centers for Medicare and Medicaid Services. Retrieved from
  11. Comer, J. S., Mojtabai, R., & Olfson, M. (2011). National trends in the antipsychotic treatment of psychiatric outpatients with anxiety disorders. The American Journal of Psychiatry, 168(10), 1057–1065. doi: 10.1176/appi.ajp.2011.11010087.CrossRefPubMedGoogle Scholar
  12. Curtis, L. H., Ostbye, T., Sendersky, V., Hutchison, S., Dans, P. E., Wright, A., … Schulman, K. A. (2004). Inappropriate prescribing for elderly Americans in a large outpatient population. Archives of Internal Medicine, 164(15), 15. doi: 10.1001/archinte.0.1621.CrossRefGoogle Scholar
  13. Daumit, G. L., Pratt, L. A., Crum, R. M., Powe, N. R., & Ford, D. E. (2002). Characteristics of primary care visits for individuals with severe mental illness in a national sample. General Hospital Psychiatry, 24(6), 391–395.CrossRefPubMedGoogle Scholar
  14. Fick, D. M., Cooper, J. W., Wade, W. E., Waller, J. L., Maclean, J. R., & Beers, M. H. (2003). Updating the Beers criteria for potentially inappropriate medication use in older adults: Results of a US consensus panel of experts. Archives of Internal Medicine, 163(22), 2716–2724. doi: 10.1001/archinte.163.22.2716.CrossRefPubMedGoogle Scholar
  15. Fick, D. M., Waller, J. L., Maclean, J. R., Heuvel, R. V., Tadlock, J. G., Gottlieb, M., & Cangialose, C. B. (2001). Potentially inappropriate medication use in a Medicare managed care population: Association with higher costs and utilization. Journal of Managed Care Pharmacy: JMCP, 7(5), 407–413.CrossRefGoogle Scholar
  16. Fillenbaum, G. G., Hanlon, J. T., Landerman, L. R., Artz, M. B., O’Connor, H., Dowd, B., … Schmader, K. E. (2004). Impact of inappropriate drug use on health services utilization among representative older community-dwelling residents. The American Journal of Geriatric Pharmacotherapy, 2(2), 92–101.CrossRefPubMedGoogle Scholar
  17. Finkelstein, E., Prabhu, M., & Chen, H. (2007). Increased prevalence of falls among elderly individuals with mental health and substance abuse conditions. The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 15(7), 611–619. doi: 10.1097/JGP.0b013e318033ed97.CrossRefGoogle Scholar
  18. Franic, D. M., & Jiang, J. Z. (2006). Potentially inappropriate drug use and health-related quality of life in the elderly. Pharmacotherapy, 26(6), 768–778. doi: 10.1592/phco.26.6.768.CrossRefPubMedGoogle Scholar
  19. Fu, A. Z., Jiang, J. Z., Reeves, J. H., Fincham, J. E., Liu, G. G., & Perri, M. 3rd (2007). Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly. Medical Care, 45(5), 472–476. doi: 10.1097/01.mlr.0000254571.05722.34.CrossRefPubMedGoogle Scholar
  20. Gonzalez, H. M., Vega, W. A., Williams, D. R., Tarraf, W., West, B. T., & Neighbors, H. W. (2010). Depression care in the United States: Too little for too few. Archives of General Psychiatry, 67(1), 37–46.CrossRefPubMedPubMedCentralGoogle Scholar
  21. Hanlon, J. T., Fillenbaum, G. G., Kuchibhatla, M., Artz, M. B., Boult, C., Gross, C. R., … Schmader, K. E. (2002). Impact of inappropriate drug use on mortality and functional status in representative community dwelling elders. Medical Care, 40(2), 166–176.CrossRefPubMedGoogle Scholar
  22. Harrison, D. L., Miller, M. J., Schmitt, M. R., & Touchet, B. K. (2010). Variations in the probability of depression screening at community-based physician practice visits. Primary Care Companion to the Journal of Clinical Psychiatry, 12(5). doi: 10.4088/PCC.09m00911blu.
  23. Hsiao, C. J., Cherry, D. K., Beatty, P. C., & Rechtsteiner, E. A. (2010). National Ambulatory Medical Care Survey: 2007 Summary. National Health Statistics Reports, 27 (pp. 1–32). Hyattsville, MD: National Center for Health Statistics.Google Scholar
  24. Jameson, J. P., & Blank, M. B. (2010). Diagnosis and treatment of depression and anxiety in rural and nonrural primary care: National survey results. Psychiatric Services, 61(6), 624–627. doi: 10.1176/ Scholar
  25. Klarin, I., Wimo, A., & Fastbom, J. (2005). The association of inappropriate drug use with hospitalisation and mortality: A population-based study of the very old. Drugs and Aging, 22(1), 69–82.CrossRefPubMedGoogle Scholar
  26. Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.Google Scholar
  27. Lagomasino, I. T., Stockdale, S. E., & Miranda, J. (2011). Racial-ethnic composition of provider practices and disparities in treatment of depression and anxiety, 2003–2007. Psychiatric Services, 62(9), 1019–1025. doi: 10.1176/ Scholar
  28. Larson, M. J., Miller, K., & Fleming, K. J. (2007). Treatment with antidepressant medications in private health plans. Administration and Policy in Mental Health, 34(2), 116–126. doi: 10.1007/s10488-006-0088-5.CrossRefPubMedGoogle Scholar
  29. Lau, D. T., Kasper, J. D., Potter, D. E., Lyles, A., & Bennett, R. G. (2005). Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Archives of Internal Medicine, 165(1), 68–74. doi: 10.1001/archinte.165.1.68.CrossRefPubMedGoogle Scholar
  30. Lindley, C. M., Tully, M. P., Paramsothy, V., & Tallis, R. C. (1992). Inappropriate medication is a major cause of adverse drug reactions in elderly patients. Age and Ageing, 21(4), 294–300.CrossRefPubMedGoogle Scholar
  31. Lindsey, P. L. (2009). Psychotropic medication use among older adults: What all nurses need to know. Journal of Gerontological Nursing, 35(9), 28–38.CrossRefPubMedPubMedCentralGoogle Scholar
  32. Mallet, L., Spinewine, A., & Huang, A. (2007). The challenge of managing drug interactions in elderly people. The Lancet, 370(9582), 185–191. doi: 10.1016/S0140-6736(07)61092-7.CrossRefGoogle Scholar
  33. Mamdani, M. M., Parikh, S. V., Austin, P. C., & Upshur, R. E. (2000). Use of antidepressants among elderly subjects: Trends and contributing factors. The American Journal of Psychiatry, 157(3), 360–367.CrossRefPubMedGoogle Scholar
  34. Mander, A., & Clayton, D. (2007). HOTDECK: Stata module to impute missing values using the hotdeck method. Newton: Boston College Department of Economics. Retrieved from
  35. Manseau, M., & Case, B. G. (2014). Racial-ethnic disparities in outpatient mental health visits to U.S. physicians, 1993–2008. Psychiatric Services, 65(1), 59–67. doi: 10.1176/ Scholar
  36. Maust, D. T., Oslin, D. W., & Marcus, S. C. (2014). Effect of age on the profile of psychotropic users: Results from the 2010 National Ambulatory Medical Care Survey. Journal of the American Geriatrics Society, 62(2), 358–364. doi: 10.1111/jgs.12640.CrossRefPubMedGoogle Scholar
  37. Mehrotra, A., Forrest, C. B., & Lin, C. Y. (2011). Dropping the baton: Specialty referrals in the United States. Milbank Quarterly, 89(1), 39–68. doi: 10.1111/j.1468-0009.2011.00619.x.CrossRefPubMedPubMedCentralGoogle Scholar
  38. Miller, G. E., Sarpong, E. M., Davidoff, A. J., Yang, E. Y., Brandt, N. J., & Fick, D. M. (2016). Determinants of potentially inappropriate medication use among community-dwelling older adults. Health Services Research. doi: 10.1111/1475-6773.12562.Google Scholar
  39. Mojtabai, R., & Olfson, M. (2010). National trends in psychotropic medication polypharmacy in office-based psychiatry. Archives of General Psychiatry, 67(1), 26–36. doi: 10.1001/archgenpsychiatry.2009.175.CrossRefPubMedGoogle Scholar
  40. Mojtabai, R., & Olfson, M. (2011). Proportion of antidepressants prescribed without a psychiatric diagnosis is growing. Health Affairs, 30(8), 1434–1442.CrossRefPubMedGoogle Scholar
  41. Mojtabai, R., & Olfson, M. (2014). National trends in long-term use of antidepressant medications: Results from the U.S. National Health and Nutrition Examination Survey. The Journal of Clinical Psychiatry, 75(2), 169–177. doi: 10.4088/JCP.13m08443.CrossRefPubMedGoogle Scholar
  42. Mort, J. R., & Aparasu, R. R. (2000). Prescribing potentially inappropriate psychotropic medications to the ambulatory elderly. Archives of Internal Medicine, 160(18), 2825–2831.CrossRefPubMedGoogle Scholar
  43. National Center for Health Statistics. (2015). Ambulatory health care data: Questionnaires, datasets, and related documentation. Retrieved from
  44. National Center for Health Statistics. (2011). Health, United States, 2010: With special feature on death and dying. Hyattsville, MD: National Center for Health Statistics.Google Scholar
  45. National Center for Health Statistics. (2012, 2016). About the Ambulatory Health Care Surveys. Retrieved from
  46. Olfson, M., Blanco, C., Wang, S., Laje, G., & Correll, C. U. (2014). National trends in the mental health care of children, adolescents, and adults by office-based physicians. JAMA Psychiatry, 71(1), 81–90. doi: 10.1001/jamapsychiatry.2013.3074.CrossRefPubMedGoogle Scholar
  47. Olfson, M., & Marcus, S. C. (2009). National patterns in antidepressant medication treatment. Archives of General Psychiatry, 66(8), 848–856. doi: 10.1001/archgenpsychiatry.2009.81.CrossRefPubMedGoogle Scholar
  48. Pagura, J., Katz, L. Y., Mojtabai, R., Druss, B. G., Cox, B., & Sareen, J. (2011). Antidepressant use in the absence of common mental disorders in the general population. The Journal of Clinical Psychiatry, 72(4), 494–501. doi: 10.4088/JCP.09m05776blu.CrossRefPubMedGoogle Scholar
  49. Raivio, M. M., Laurila, J. V., Strandberg, T. E., Tilvis, R. S., & Pitkala, K. H. (2006). Use of inappropriate medications and their prognostic significance among in-hospital and nursing home patients with and without dementia in Finland. Drugs and Aging, 23(4), 333–343.CrossRefPubMedGoogle Scholar
  50. Rhee, T. G., Capistrant, B. D., Schommer, J. C., Hadsall, R. S., & Uden, D. L. (2017). Effects of depression screening on diagnosing and treating mood disorders among older adults in office-based primary care outpatient settings: An instrumental variable analysis. Preventive Medicine, 100, 101–111. doi: 10.1016/j.ypmed.2017.04.015.CrossRefPubMedGoogle Scholar
  51. Sankaranarayanan, J., & Puumala, S. E. (2007). Antipsychotic use at adult ambulatory care visits by patients with mental health disorders in the United States, 1996–2003: National estimates and associated factors. Clinical Therapeutics, 29(4), 723–741. doi: 10.1016/j.clinthera.2007.04.017.CrossRefPubMedGoogle Scholar
  52. Schmader, K. E., Hanlon, J. T., Landsman, P. B., Samsa, G. P., Lewis, I. K., & Weinberger, M. (1997). Inappropriate prescribing and health outcomes in elderly veteran outpatients. The Annals of Pharmacotherapy, 31(5), 529–533.CrossRefPubMedGoogle Scholar
  53. Sclar, D. A., Robison, L. M., Schmidt, J. M., Bowen, K. A., Castillo, L. V., & Oganov, A. M. (2012). Diagnosis of depression and use of antidepressant pharmacotherapy among adults in the United States: Does a disparity persist by ethnicity/race? Clinical Drug Investigation, 32(2), 139–144. doi: 10.2165/11598950-000000000-00000.CrossRefPubMedGoogle Scholar
  54. Spinewine, A., Schmader, K. E., Barber, N., Hughes, C., Lapane, K. L., Swine, C., & Hanlon, J. T. (2007). Appropriate prescribing in elderly people: How well can it be measured and optimised? The Lancet, 370(9582), 173–184. doi: 10.1016/S0140-6736(07)61091-5.CrossRefGoogle Scholar
  55. StataCorp. (2013). Stata statistical software: Release 13. College Station, TX: StataCorp LP.Google Scholar
  56. Willcox, S. M., Himmelstein, D. U., & Woolhandler, S. (1994). Inappropriate drug prescribing for the community-dwelling elderly. JAMA: The Journal of the American Medical Association, 272(4), 292–296.CrossRefPubMedGoogle Scholar
  57. Wolters Kluwer Clinical Drug Information. (2015). Facts and comparisons. Retrieved from
  58. Zuckerman, I. H., Langenberg, P., Baumgarten, M., Orwig, D., Byrns, P. J., Simoni-Wastila, L., & Magaziner, J. (2006). Inappropriate drug use and risk of transition to nursing homes among community-dwelling older adults. Medical Care, 44(8), 722–730. doi: 10.1097/ Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  1. 1.Section of Geriatrics, Department of Internal Medicine, School of MedicineYale UniversityNew HavenUSA
  2. 2.Department of Pharmaceutical Care and Health SystemsUniversity of Minnesota College of PharmacyMinneapolisUSA
  3. 3.Division of Epidemiology and Community HealthUniversity of Minnesota School of Public HealthMinneapolisUSA

Personalised recommendations