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Physicians’ Decisions to Prescribe Antidepressant Therapy in Older Patients with Depression in a US Managed Care Plan

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Abstract

Background: Published studies indicate that depression in older adults is severely under-recognized and under-treated.

Objective: To characterize primary-care physicians’ decisions to prescribe antidepressants to older patients with depression.

Methods: Electronic medical record (EMR) notes from office visits of older patients (aged ≥65 years), treated in a central Massachusetts multi-specialty medical group practice, were screened every 2 weeks between August 2007 and July 2008 for mention of depression. Electronic surveys containing questions about depression severity and onset, and antidepressant treatment, were sent to physicians whose EMR notes indicated that they had treated an older patient with depression, until approximately 400 responses had been received. Physicians were asked about whether they prescribed antidepressants or made changes to antidepressant treatment and were asked about the extent to which they agreed with a set of pre-specified reasons for treatment recommendations. Physicians were also allowed to document any other reasons that influenced their decision. Patient characteristics and treatment were identified from administrative claims. Univariate analyses were used to describe patient characteristics and physician survey responses.

Results: Physicians responded to the survey and confirmed a depression diagnosis for 396 patients, for whom the average age was 77.1 years and 76.5% were female. Most patients had physician-reported depression onset after age 60 years (72.2%) and moderately severe depression (58.8%). Physicians reported that 62.9% of patients were already being treated with anti-depressants prior to their visit, 28.5% were recommended antidepressant initiation and 8.6% were not prescribed antidepressants. Selective serotonin reuptake inhibitors were most frequently prescribed. Maintaining prior therapy was recommended for 81.1% of treated patients and treatment modification for 18.9%. Almost all physicians (>92%) agreed that experience in use of prescription drugs, safety/tolerability and patient improvement influenced their decision to maintain prior therapy or recommend new therapy. 85.8% of physicians agreed that availability of efficacy data in the elderly influenced their decision to prescribe new therapy. 38.9% of patients who were recommended new therapy initiation did not fill an antidepressant prescription.

Conclusions: Despite previous reports of under-treatment of depression in the elderly, this study suggests that physicians are comfortable prescribing anti-depressants to the elderly, and the majority of older patients with depression were prescribed antidepressants. Rather than a physician’s prescribing decision, it may be patient factors, such as refusal to accept diagnosis/treatment and noncompliance, that may lead to under-treatment — approximately 40% of patients who were recommended new antidepressant therapy did not fill an antidepressant prescription.

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References

  1. Pratt LA, Brody DJ. Depression in the United States household population, 2005–2006. NCHS Data Brief 2008; 7 [online]. Available from URL: http://www.cdc.gov/nchs/data/databriefs/db07.htm [Accessed 2009 Feb 17]

  2. Kessler RC, Birnbaum H, Bromet E, et al. Age differences in major depression: results from the National Comorbidity Survey Replication (NCS R). Psychol Med 2010; 40: 225–37

    Article  PubMed  CAS  Google Scholar 

  3. Katon WJ, Lin E, Russo J, et al. Increased medical costs of a population-based sample of depressed elderly patients. Arch Gen Psychiatry 2003; 60: 897–903

    Article  PubMed  Google Scholar 

  4. Fischer LR, Wei F, Rolnick SJ, et al. Geriatric depression, antidepressant treatment, and healthcare utilization in a health maintenance organization. J Am Geriatr Soc 2002; 50: 307–12

    Article  PubMed  Google Scholar 

  5. Kivela SL, Pahkala K. Depressive disorder as a predictor of physical disability in old age. J Am Geriatr Soc 2001; 49: 290–6

    Article  PubMed  CAS  Google Scholar 

  6. Gallo JJ, Rebok GW, Tennsted S, et al. Advanced Cognitive Training for Independent and Vital Elderly (Active) Study Investigators. Linking depressive symptoms and functional disability in late life. Aging Ment Health 2003; 7: 469–80

    Article  PubMed  CAS  Google Scholar 

  7. Katona C, Livingston G. Safety and efficacy of antidepressants in older people: how well do antidepressants work in older people? A systematic review of number needed to treat. J Affect Disord 2002; 69: 47–52

    Article  PubMed  Google Scholar 

  8. Gorwood P, Weiller E, Lemming O, et al. Escitalopram prevents relapse in older patients with major depressive disorder. Am J Geriatr Psychiatry 2007; 15: 581–93

    Article  PubMed  Google Scholar 

  9. Mancini M, Gianni W, Rossi A, et al. Duloxetine in the management of elderly patients with major depressive disorder: an analysis of published data. Expert Opin Pharmacother 2009; 10: 847–60

    Article  PubMed  CAS  Google Scholar 

  10. Crawford MJ, Prince M, Menezes P, et al. The recognition and treatment of depression in older people in primary care. Int J Geriatr Psychiatry 1998; 13: 172–6

    Article  PubMed  CAS  Google Scholar 

  11. Volkers AC, Nuyen J, Verhaak PFM, et al. The problem of diagnosing major depression in elderly primary care patients. J Affect Disord 2004; 82: 259–63

    Article  PubMed  Google Scholar 

  12. Brown EL, McAvay G, Raue PJ, et al. Recognition of depression among elderly recipients of home care services. Psychiatr Serv 2003; 54: 208–13

    Article  PubMed  Google Scholar 

  13. Brown EL, Bruce ML, McAvay GJ, et al. Recognition of late-life depression in home care: accuracy of the outcome and assessment information set. J Am Geriatr Soc 2004; 52: 995–9

    Article  PubMed  Google Scholar 

  14. Bagley H, Cordingley L, Burns A, et al. Recognition of depression by staff in nursing and residential homes. J Clin Nurs 2000; 9: 445–50

    Article  PubMed  CAS  Google Scholar 

  15. Unutzer J, Katon W, Callahan CM, et al. Depression treatment in a sample of 1,801 depressed older adults in primary care. J Am Geriatr Soc 2003; 51: 505–14

    Article  PubMed  Google Scholar 

  16. Brown MN, Lapane KL, Luisi AF. The management of depression in older nursing home residents. J Am Geriatr Soc 2002; 50: 69–76

    Article  PubMed  Google Scholar 

  17. Unutzer J, Simon G, Belin TR, et al. Care for depression in HMO patients aged 65 and older. J Am Geriatr Soc 2000; 48(8): 871–8

    PubMed  CAS  Google Scholar 

  18. Sclar DA, Robison LM, Skaer TL, et al. What factors influence the prescribing of antidepressant pharmacotherapy? An assessment of national office-based encounters. Int J Psychiatry Med 1998; 28(4): 407–19

    Article  PubMed  CAS  Google Scholar 

  19. Sleath B, Shih YC. Sociological influences on antidepressant prescribing. Soc Sci Med 2003; 56(6): 1335–44

    Article  PubMed  Google Scholar 

  20. Nutting PA, Rost K, Dickinson M, et al. Barriers to initiating depression treatment in primary care practice. J Gen Intern Med 2002; 17: 103–11

    Article  PubMed  Google Scholar 

  21. Callahan CM, Nienaber NA, Hendrie HC, et al. Depression of elderly outpatients: primary care physicians’ attitudes and practice patterns. J Gen Intern Med 1992; 7(1): 26–31

    Article  PubMed  CAS  Google Scholar 

  22. Areán PA, Alvidrez J, Feldman M, et al. The role of provider attitudes in prescribing antidepressants to older adults: leverage points for effective provider education. Int J Psychiatry Med 2003; 33: 241–56

    Article  PubMed  Google Scholar 

  23. Orrell M, Collins E, Shergill S et al. Management of depression in the elderly by general practitioners I: use of antidepressants. Fam Pract 1995; 12: 5–11

    Article  PubMed  CAS  Google Scholar 

  24. Butler R, Collins E, Katona C, et al. How do general practitioners select antidepressants for depressed elderly people? Int J Geriatr Psychiatry 2000; 15: 610–3

    Article  PubMed  CAS  Google Scholar 

  25. Fitch K, Molnar FJ, Power B, et al. Antidepressant use in older people: family physicians’ knowledge, attitudes, and practices. Can Fam Physician 2005; 51: 80–1

    PubMed  Google Scholar 

  26. Gallo JJ, Ryan SD, Ford DE. Attitudes, knowledge, and behavior of family physicians regarding depression in late life. Arch Fam Med 1999; 8: 249–56

    Article  PubMed  CAS  Google Scholar 

  27. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40: 373–83

    Article  PubMed  CAS  Google Scholar 

  28. Romano PS, Roos LL, Jollis J. Adapting a clinical comorbidity index for use with ICD-9-CM administrative data. J Clin Epidemiol 1993; 46(10): 1075–9

    Article  PubMed  CAS  Google Scholar 

  29. Sambamoorthi U, Olfson M, Walkup JT, et al. Diffusion of new generation antidepressant treatment among elderly diagnosed with depression. Med Care 2003; 41: 180–94

    Article  PubMed  Google Scholar 

  30. Mulsant BH, Pollock BG, Nebes R, et al. A twelve-week, double-blind, randomized comparison of nortriptyline and paroxetine in older depressed inpatients and outpatients. Am J Geriatr Psychiatry 2001; 9: 406–14

    PubMed  CAS  Google Scholar 

  31. Bondareff W, Alpert M, Friedhoff AJ, et al. Comparison of sertraline and nortriptyline in the treatment of major depressive disorder in late life. Am J Psychiatry 2000; 157: 729–36

    Article  PubMed  CAS  Google Scholar 

  32. Navarro V, Gasto C, Torres X, et al. Citalopram versus nortriptyline in late life depression: a 12-week randomized single-blind study. Acta Psychiatr Scand 2001; 103: 435–40

    Article  PubMed  CAS  Google Scholar 

  33. Gallo JJ, Anthony JC, Muthen BO. Age differences in the symptoms of depression: a latent trait analysis. J Gerontology 1994; 49: 251–64

    Article  Google Scholar 

  34. Murray J, Banerjee S, Byng R, et al. Primary care professionals’ perceptions of depression in older people: a qualitative study. Soc Sci Med 2006; 63: 1363–73

    Article  PubMed  Google Scholar 

  35. Gallo JJ, Rabins PV. Depression without sadness: alternative presentations of depression in late life. Am Fam Physician 1999; 60: 820–6

    PubMed  CAS  Google Scholar 

  36. Prabhakaran P, Butler R. What are older peoples’ experiences of taking antidepressants? J Affect Disord 2002; 70: 319–22

    Article  PubMed  Google Scholar 

  37. Areán PA, Gum AM, Tang L, et al. Service use and outcomes among elderly persons with low incomes being treated for depression. Psychiatr Serv 2007; 58: 1057–64

    Article  PubMed  Google Scholar 

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Acknowledgements

Funding source and sponsor’s role: Funding for this research was provided by sanofi-aventis recherche & développement, Paris, France, to Analysis Group, Inc. Dr Bienfait-Beuzon provided input on study design and reviewed and approved the final version of the manuscript.

Conflicts of interest: Ms Ivanova, Dr Birnbaum and Ms Connolly are employees of Analysis Group, Inc. Dr Bienfait-Beuzon is an employee of sanofi-aventis recherche & développement, Paris, France. Dr Sheehy is an employee of Fallon Clinic, Inc., Worcester, MA, USA. Dr Emani was an employee of Fallon Clinic, Inc. at the time of the study but is now with Brigham & Women’s Hospital, Boston, MA, USA.

Author contributions: Study concept and design: Ms Ivanova, Dr Birnbaum, Dr Emani, Dr Sheehy and Dr Bienfait-Beuzon. Acquisition of subjects and/or data: Ms Ivanova, Dr Birnbaum, Dr Emani and Dr Sheehy. Analysis and interpretation of data: Ms Ivanova, Dr Birnbaum, Ms Connolly, Dr Emani, Dr Sheehy and Dr Bienfait-Beuzon. Preparation of manuscript (including drafting the article or revising it critically for important intellectual content and final approval of the version): Ms Ivanova, Dr Birnbaum, Ms Connolly, Dr Emani, Dr Sheehy and Dr Bienfait-Beuzon.

Other contributions: The authors thank Ellen Trencher and Judith Gilmore from Fallon Clinic, Inc. for their project coordination support in facilitating the project and conducting the survey.

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Authors and Affiliations

  1. Analysis Group, Inc., 10 Rockefeller Plaza, 15th Floor, New York, New York, 10020, USA

    Jasmina I. Ivanova MA (Manager)

  2. sanofi-aventis recherche & développement, Paris, France

    Catherine Bienfait-Beuzon

  3. Analysis Group, Inc., Boston, Massachusetts, USA

    Howard G. Birnbaum & Cristina Connolly

  4. Fallon Clinic, Inc., Worcester, Massachusetts, USA

    Srinivas Emani & Michael Sheehy

Authors
  1. Jasmina I. Ivanova MA
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  2. Catherine Bienfait-Beuzon
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  3. Howard G. Birnbaum
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  4. Cristina Connolly
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  5. Srinivas Emani
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  6. Michael Sheehy
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Correspondence to Jasmina I. Ivanova MA.

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Ivanova, J.I., Bienfait-Beuzon, C., Birnbaum, H.G. et al. Physicians’ Decisions to Prescribe Antidepressant Therapy in Older Patients with Depression in a US Managed Care Plan. Drugs Aging 28, 51–62 (2011). https://doi.org/10.2165/11539900-000000000-00000

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