FormalPara Key Points

Psychotropic drugs are used by more than one in three subjects aged 65 years and over in a 1-year period.

Consumption is higher for women than for men, and rises with increasing age in both genders.

A majority of psychotropic drug consumers have received at least one PIM prescription.

1 Introduction

Psychotropic drug consumption in France is the highest in Europe, whether considered in volume, in delivered defined daily doses (DDDs), in expense per capita, or in prevalence [1–4]. For instance, the 12-month prevalence rate of psychotropic drug consumption in the French general population is around 20 % [2–4], compared to only 6 % in Germany [2], and such consumption increases with age [3, 4]. Psychotropic drug consumption is thus very high in French older adults [3, 4], and this turns out to be an issue as the elderly are especially vulnerable to adverse drug events because of a higher risk of comorbid conditions, multiple drug prescriptions, and impaired physical and cognitive functions [5]. These drugs, particularly those listed as inappropriate medications for elderly adults [6], have many potential iatrogenic effects, which may lead to poorer health, for example falls [7–10], confusion or excessive sedation, and to higher use of healthcare resources, notably emergency room visits and hospitalization [11]. In the current context of the aging of the population and of cost-containment policies, it is therefore important to study the use of psychotropic drugs in elderly people in order to reduce adverse health outcomes and their associated costs, particularly since a significant proportion of them may be preventable.

While psychotropic drug consumption in the elderly has been well investigated in the USA [12, 13], little research has been done in this area in Europe, notably in France, despite high psychotropic drug consumption and potentially high inappropriate use in the French elderly population [14, 15]. To our knowledge, the only studies that have been published concern the overall French population without a specific focus on the elderly [2–4], and, moreover, several of these are restricted to a limited number of psychotropic drug classes [16].

Based on the reimbursement claims of a French private health insurance plan (MGEN), the study presented here aimed to establish epidemiological data for the use of psychotropic drugs among older people in France and its characteristics, notably according to age, gender, and drug therapeutic class. Particular attention was paid to more qualitative aspects such as the prescriber’s medical specialty, the treatment duration, and the rate of inappropriate prescribing in this population using a list of potentially inappropriate medications (PIMs) adapted to the French medical practice: the Laroche criteria [17].

2 Methods

2.1 Sample

The MGEN is a private organization providing statutory health insurance in France to education, culture, research, and sport professionals, both when in work and after retirement. It also offers voluntary complementary health insurance coverage. In 2011, we randomly selected a sample of 34,630 beneficiaries, who were representative of the total population of more than three million affiliates of the MGEN. The sampling strata used were age, gender, and type of coverage. Among these, we selected for this study the 5840 affiliates aged 65 years or more on 31 December 2011 who had their statutory health insurance managed by the MGEN, for whom complete information on reimbursement for prescribed drugs was available.

2.2 Data Collected

For each participant, data were derived from the MGEN database. Sociodemographic data retrieved included gender, date of birth, and region of residence. Regions were regrouped by European constituency boundaries [18]. Reimbursement data included all reimbursement claims for medical consultations and examinations, and medication prescriptions occurring between 1 January and 31 December 2011. Data collected for each reimbursement claim for a consultation or an examination included the date of medical care delivery and the practitioner’s medical specialty. Data collected for each reimbursement claim for medication, corresponding to each individual drug prescribed, included the commercial name of the drug, the presentation identification code (CIP), the relevant ATC (anatomical therapeutic chemical), and EphMRA (European Pharmaceutical Market Research Association) therapeutic classes, the medical speciality of the prescribing practitioner, the date the prescription was filled, and the number of boxes dispensed. The information collected only related to care administered or medication prescribed outside hospitalization (i.e., in outpatient departments, clinics, health centres, dispensaries, or private offices/surgeries).

2.3 Psychotropic Drugs

For this study, psychotropic drugs were defined using five main therapeutic classes based on the EphMRA classification with some marginal modifications. These were antipsychotics, hypnotics, anxiolytics, antidepressants, and mood stabilizers. Antipsychotics were defined as all drugs from the N5A class with the exception of Xenazine® (tetrabenazine). Vesadol® (buzepine), and Prazinil® (carpipramine) were also included in this class. Hypnotics were defined as the N5B class with the exception of Calcibronat® (calcium bromo-galactogluconate), Hypnomidate® (etomidate), Etomidate Lipuro®, Narcozep® (flunitrazepam), Galirene® (calcium bromide), and Pentothal® (thiopental)—subdivided into nonherbal hypnotics (N5B1, N5B2, and N5B3), and herbal hypnotics (N5B5). Anxiolytics included all N5C class drugs, together with Librax® (chlordiazepoxide). Antidepressants consisted of the N6A2, N6A4, N6A5, and N6A9 class drugs. Mood stabilizers corresponded to the N6A3 class drugs.

2.4 Treatment Duration

Treatment durations were calculated using the WHO’s DDDs [19]. The DDD is the daily dose recommended for each drug in its principal indication. The drug composition for each presentation was recovered using the presentation identification code [20]. For each prescription, the amount of DDDs dispensed was obtained by multiplying the number of boxes by the number of units per box and by the unitary dose, and dividing it by the corresponding DDD for the drug in question. We made the assumption that each given DDD was equivalent to one day of treatment.

$$ {\text{No}} . {\text{ of DDDs}}\;{\text{dispensed}} = \frac{{{\text{No}} .\;{\text{of}}\;{\text{boxes}} \times {\text{No}} .\;{\text{of}}\,{\text{units}} \times {\text{Unitary}}\;{\text{dose}}}}{\text{DDD}} $$

2.5 Potentially Inappropriate Medications (PIMs)

To evaluate if a given prescription was potentially inappropriate, we used the Laroche criteria published in 2007, which is a PIM list adapted to French prescribing habits by expert consensus [17]. Only criteria independent of posology and diagnosis were retained for our study. For criteria 33, we considered that use was concomitant when at least two treatment time periods overlapped, assuming that a period of treatment began at the delivery date and lasted the number of days corresponding to the amount of DDDs dispensed.

2.6 Data Analysis

The statistical analysis was performed using Stata™/SE 13. The Chi square test was used to evaluate differences in distributions of categorical variables, Student’s t test to compare means of continuous variables, and Cuzick’s test to detect a trend across age groups. We also used logistic regressions. A p value less than 0.05 was considered as statistically significant, and all quoted confidence intervals (CIs) were calculated at the 95 % confidence level.

3 Results

3.1 Sample Description

The sociodemographic characteristics of the sample are presented in Table 1. A majority of subjects were female (65.6 %). The men included in the sample were significantly younger than the women (p < 0.001). The geographic distribution also differed between genders, with notably a larger proportion of women living in the Paris area (p = 0.016).

Table 1 Sociodemographic characteristics of the sample
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3.2 Twelve-Month Prevalence Rate of Psychotropic Drug Consumption

Of the 5840 subjects included, 2213 had filed at least one reimbursement claim for a psychotropic drug during the year 2011 (Table 2), corresponding to an annual prevalence rate of 37.9 % (CI 36.6–39.1) with 428 (7.3 %) having only one claim. It is worth noting that, even if herbal medicines were excluded, this did not change the prevalence of any psychotropic drug use (37.6 %; CI 36.3–38.8).

Table 2 Prevalence rate of psychotropic drug consumption according to sociodemographic and healthcare consumption characteristics
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The most frequently used psychotropic drug class was anxiolytics (23.5 %; CI 22.4–24.6). The prevalence of hypnotics use was 15.9 % (for both herbal and non-herbal hypnotics, CI 15.0–16.8; 15.1 % for non-herbal only, CI 14.2–16.0), followed by antidepressants (15.4 %; CI 14.5–16.3). The least used were antipsychotics (2.5 %; CI 2.1–2.9]) and mood stabilizers (0.8 %; CI 0.6–1.1). The use of psychotropic drugs was found to increase with age, irrespective of drug class. Moreover, the rate of psychotropic drug consumption turned out to be significantly higher in women for all therapeutic classes except antipsychotics, yielding an overall prevalence rate for men of 28.6 % (CI 26.7–30.6) and of 42.7 % for women (CI 41.2–44.3).

3.3 Prescribers’ Speciality

Most psychotropic drugs (81.8 %; CI 81.4–82.3) were prescribed by general practitioners (GPs), psychiatrists being responsible for only 7.7 % of drug prescribing (CI 7.4–8.1). This pattern of prescription was observed for all therapeutic classes. The psychotropic drugs least often prescribed by GPs were mood stabilizers (57.0 %; CI 52.3–61.7), which were more frequently prescribed by psychiatrists (21.6 %) or practitioners practising in medical institutions (14.9 %). On the other hand, hypnotics were most often prescribed by GPs (87.0 %; CI 86.0–87.9).

3.4 Medical Consultations

Almost all psychotropic drug users (98.6 %) had visited at least one physician during the year 2011, irrespective of medical specialty and of drug class. When the type of professional consulted was examined, we found that only 6.2 % of psychotropic drug users had consulted a psychiatrist at least once in the year 2011. However, this rate varied a lot with age, decreasing from 12.7 % in the youngest age group (65–69 years) to about 4.0 % among those aged 80 years old and over.

3.5 Treatment Duration

Considering only psychotropic drug users, the mean annual DDD ratio was 83 (median 38) for antipsychotics, 134 (median 84) for hypnotics, 82 (median 47) for anxiolytics, 198 (median 146) for antidepressants, and 124 (median 102) for mood stabilizers. Overall, the average length of treatment prescribed was 193 days per user (median 111). Significant differences were found between genders, the length of treatment for men (170 DDDs) being shorter than for women (201 DDDs, p < 0.001). The number of DDDs delivered did not significantly increase with age, the oldest subjects (over 84 years) receiving about 181 DDDs of psychotropic drugs during the year (median 121) compared with 201 DDDs (median 102) for the youngest ones (65–69 years).

3.6 Twelve-Month Prevalence Rate of PIM Prescriptions

More than half of psychotropic drug users (64.5 %) had received at least one PIM prescription (Table 3). If concomitant use of two or more psychotropic drugs of the same therapeutic class is considered as inappropriate too, which concerned 38.5 % of users, this proportion rises to 77.3 %. The most frequently encountered forms of inappropriate use related to criterion 10 corresponding to long acting benzodiazepine use (53.9 %).

Table 3 Prevalence rates of potentially inappropriate prescriptions of psychotropic drugs
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Multiple logistic regression analysis (Table 4) identified a higher odds ratio (OR) for PIM prescription in patients having had more than three psychotropic medications prescribed (OR 4.35; CI 3.40–5.57). In addition, a trend towards a lower odds ratio for PIM prescription was observed with increasing age, although this was not statistically significant in all age groups. Finally, no differences by gender, region, or type of health professional consulted were observed.

Table 4 Prevalence rates of potentially inappropriate prescriptions of psychotropic drugs according to sociodemographic and healthcare consumption characteristics among psychotropic drug users and associated odds ratios (N = 2213)
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4 Discussion

Our results show that in 2011, more than one out of three health insurance affiliates aged 65 years and over received a prescription of psychotropic drugs, principally anxiolytics, hypnotics, or antidepressants, although one in five users received only one prescription in the year. These psychotropic drug users had taken medication on average for 6 months in the year, and more than half of them had received at least one prescription of psychotropic drugs considered not appropriate for the elderly. GPs were found to have delivered most of these prescriptions (82 %). In contrast, only 7.7 % of drug prescribing was attributable to psychiatrists; and with increasing age, consultation with mental health specialists decreased while psychotropic drug consumption increased. Finally, the number of psychotropic prescriptions was associated with a higher odds ratio of PIM prescription.

Previous studies have already shown that France has a higher level of psychotropic drug consumption in adults than other European countries [1–3]. In this study, we estimated the annual rate of psychotropic drug use to be 38 % in subjects aged 65 years or more. In the non-institutionalized general population, an overall 12-month prevalence rate of 19 % for six European countries was found in the ESEMeD survey for this age group [2, 3], and a comparable rate was found in 2003 for the USA [12].

Our study reported patterns of consumption very similar to other studies. For example, women in general consume more psychotropic medication than men [2, 3, 12], and in Europe, anxiolytics/hypnotics represent the most frequently used psychotropic drug class in elderly persons, followed by antidepressants [2–4]. In France, Lecadet et al., considering people aged 70 years and over, reported results similar to ours, with a consumption rate of about 33 % for men and 54 % for women in the year 2000 [4], which yielded a 40 % overall prevalence rate. Our results, however, differ from the ESEMeD survey, which collected data from face-to-face interviews carried out in general population. This survey found a consumption rate over the year 2000 that was half that reported in the present study and in Lecadet et al. in general population [4], which are both based on reimbursement claims, being only 23 % for the 65 years and over age group [3]. This may suggest some under-reporting of psychotropic drug use by consumers.

Interestingly, our study shows that more than half (77 %) of psychotropic drug consumers aged 65 and over had received at least one PIM prescription, which represents more than one in four elderly people (29 %), and the scope of the problem is certainly underestimated since prescriptions that do not fit the PIM criteria are not necessarily documented, for example with respect to drug interactions with other medication, co-morbidities and patient’s characteristics. On the one hand, this finding is coherent with previous studies on the prevalence of PIM use in older adults in France: for example, when considering long-acting benzodiazepines, rates vary from 5 to 18 % in community settings to 17–23 % in acute care hospitals [21–24]. In particular, Bongue et al. [22] reported a rate of 18 % in subjects aged 75 years and over using reimbursement claims data and the same set of PIM criteria [17]. On the other hand, compared to other countries, our findings seem to indicate that PIM use is more frequent in France. Although not restricted to psychotropic drugs, the rates observed in the general aging population of other countries are often similar or lower than those found in our study, although restricted to psychotropic drugs, for example, 24 % in the USA in 1987 [25] and 21 % in 1996 [26], 20 % in the early 2000s by Fialová et al. for eight European countries [27], ranging from 6 % in Denmark to 41 % in the Czech Republic, 17–20 % for 1997–2001 in The Netherlands [28], and 13 % in Finland in 1997 [29]. It should, however, be borne in mind that comparisons are often difficult as the PIM criteria used [30], the inclusion criteria (i.e., age and setting), and the methods of data collection may differ from one study to another.

Concerning the relationship between psychotropic drug prescription and age, some American studies have previously reported that psychotropic drug prescription in the absence of any psychiatric diagnosis is more frequent in elderly subjects than in younger ones [13, 31]. Our results also show an increasing trend in psychotropic drug use with age within older people, even though other studies have shown that the prevalence of psychiatric disorders does not increase with age [32]. On the other hand, in this population, whereas psychotropic drug consumption increases with age, consultation with mental specialists in psychotropic drug users clearly decreases as well as their likelihood of having PIM prescriptions. As regards gender, psychotropic drug consumption was clearly more frequent in women. No such difference was observed for PIMs, although it has been reported in another study population [33].

Our results have, however, to be interpreted in light of the potential limitations of the study. Firstly, our sample is representative of the MGEN population aged 65 years and over, but not necessarily representative of the French aging population. Indeed, the MGEN covers less than a tenth of the French general population, namely members working in France within the national education system or in certain ministries and research institutes. For this reason, the MGEN population is mostly composed of middle class individuals and their relatives. Secondly, the analysis was based on reimbursement claims, but this does not necessarily imply that reimbursed drugs have actually been taken. For example, in France, drugs are delivered in blister packs, which can contain more tablets than prescribed by the practitioner, and all may not have been used. Moreover, a treatment could have been discontinued for intolerance or for perceived lack of efficiency. Some previous studies have shown that compliance to treatment is poor, especially for people suffering for depressive symptoms [34, 35]. On the other hand, certain drugs that may have been prescribed or used do not appear in the MGEN database if they are either not eligible for reimbursement or given during hospitalization. In addition, claims data are generated for accounting purposes, which explains the presence of very few individual characteristics. Additional variables, such as educational level [36], would have been interesting to investigate. Finally, the Laroche criteria related to posology were not taken into consideration since no dosage information was available in the database.

5 Conclusion

Many psychotropic drug prescriptions to older people may not be justified, or even be dangerous, considering the high proportion of inappropriate drugs prescribed. Considering the extent to which psychotropic drugs are prescribed to elderly subjects in France, efforts should be made notably to warn consumers and doctors about the risks associated with them and to encourage a more rational use of these drugs. Actions to address this have been proposed in 2007 by a panel of French professionals and institutions.