Why are psychotropic drugs prescribed to out-patients? A methodological study

Measurement of drug utilization in Sweden: methodological and clinical implications

The available sources of information on drug utilization in the Swedish population at large are reviewed. They comprise whole-sale statistics, drug deliveries to hospitals and prescription data. Drug consumption is preferably expressed in defined daily doses (DDD) per capita, where DDD is the average recommended dose on the major indication of the drug. Under ideal circumstances--drugs used continuously on one indication--the number of DDDs per population ought to agree with morbidity data. This turned out to be the case with antidiabetic drugs. The pitfalls with this unit of measurement include major discrepancies between recommended and prescribed doses, and the use of the drug on vastly different indications (such as neurosis and psychosis in the case of neuroleptics). Nevertheless, the DDD methodology may serve as a therapeutic audit in attempts to follow and influence therapeutic habits of health personnel in hospitals and primary health care. Wholesale data combined with individual-based prescription data are particularly useful in this regard.

Antidepressant treatment in general practice--an interview study

OBJECTIVE

To elucidate potential problems concerning the use of antidepressants (AD) in general practice.

DESIGN

Cross-sectional, descriptive interview study.

SETTING

General practices, Odense, Denmark.

SUBJECTS

Random sample consisting of 98 AD users from 12 general practices.

MAIN OUTCOME MEASURES

Indication for AD treatment, justification of the treatment, duration of AD treatment, daily dose of AD, side effects, Hamilton depression rating, WONCA score.

RESULTS

The primary indication for AD treatment was depression (72 patients), partly regular depression (therapeutic/prophylactic treatment) (n = 39), partly depressive tendencies (n = 32) (1 unknown). Median treatment duration was 3 years; 25% had been in treatment for more than 10 years. The general practitioners judged the treatment problematic/unacceptable in 23 cases, largely because of uncertain indication or because other or no treatment was considered better for the patient. The daily doses of AD were generally low. Side effects were modest. The patients often had a relatively high depression score and poor status according to the WONCA-scale.

CONCLUSIONS

The use of low doses, long duration of treatment, and uncertainty about the relevance of the treatment are important features of the use of AD by general practitioners. There seems to be a discrepancy between the use of AD in general practice and the scientifically-based recommendations.

The prescription of psychotropic drugs in primary health care

We followed the prescription of psychotropic drugs by primary health care physicians over a 3-year period. The material consisted of 1000 randomly selected adult primary health care patients. At least one psychotropic drug was prescribed to one third (n = 307) of the sample during the follow-up period. The most commonly used drug category was that of benzodiazepines, which was prescribed to 24% of the sample. An antidepressive was prescribed to 8%, a neuroleptic to 2% and "other psychotropic drugs" to 10% of the sample. The most important predictor for prescribing psychotropic drugs was recognition of mental problems at the initial survey, but age and marital status also had an association with the prescription. No gender difference was found after controlling for mental problems. Psychotropic medication was also prescribed to 13% of the patients who had no sign of mental disorder.

Concurrent use of more than one major psychotropic drug (polypsychopharmacy) in out-patients--a prescription database study

1. In order to assess the prevalence of concurrent use of more than one major psychotropic drug (polypsychopharmacy) in out-patients, a prescription database study was conducted in the Odense area for a period of 2 years. 2. During the index period 5.12% of the inhabitants purchased major psychotropic drugs. Of these, 14% had a period of polypsychopharmacy recorded. The age-specific prevalence of users increased with age, the prevalence for over 90 years of age was 18%. Sixty-seven per cent of the psychotropic drug users were women. 3. For neuroleptic and antidepressant users, about 20% were subject to polypsychopharmacy, for lithium 61%. The most prevalent combination was neuroleptics-neuroleptics. In none of the 10 most prevalent combinations were the mean daily doses significantly lower on polypsychopharmacy compared with single drug regimens, in two they were higher. 4. Polypsychopharmacy with psychotropic drugs was frequent in out-patients. In polypsychopharmacy daily doses were not lowered in order to limit side effects.

Neuroleptic drug utilization in out-patients--a prescription database study

1 A prescription database study was conducted to describe the out-patient utilization of neuroleptics in the Odense area (207,000 inhabitants) during a period of 1 year. 2 Neuroleptic drug use is widespread, the period prevalence being 2.45% of the population. 3 The prevalence increases with increasing age. Fifteen percent of the population aged 90 years or more received neuroleptic drugs in spite of the many warnings against side effects in the elderly. 4 Estimated daily doses of neuroleptics were considerably lower than the Defined Daily Dose, probably as a reflection of many neuroleptics being prescribed to non-psychotic patients, in whom lower doses are used. 5 For perphenazine, a comparison of estimated daily doses from this study with doses from patients whose treatment had been adjusted by plasma concentration monitoring showed that generally much lower doses were used by patients included in this study.

Antipsychotic drug prescription in general practice in Italy

Prescribing patterns of neuroleptic drugs in a population of about 3,700,000 inhabitants were analysed using all individual prescriptions delivered by the Italian National Health Service during 4 years (1986-1989). Data contained in a regional prescription database were analysed using an outpatient drug monitoring system (VIDEOFAR). The proportion of subjects receiving neuroleptics was about 1.3% of the entire population. During 1989, 20.2% of 52,716 observed subjects received multiple neuroleptic therapy. Haloperidol, the most frequently prescribed antipsychotic, was dispensed to 21.3% of the individuals as the only neuroleptic treatment. Consumption sharply increased with age and about 60% of patients receiving a prescription were women. Nonetheless, among the heavy users in the younger ages, the male-to-female ratio is significantly greater than one. Although the principal indications for neuroleptics are subacute or chronic clinical conditions, a surprisingly high proportion of subjects (ranging from 48% to 76% depending on the type of neuroleptic) received only one single prescription during 1989.

Zuclopenthixol, melperone and haloperidol/levomepromazine in the elderly. Meta-analysis of two double-blind trials at 15 nursing homes in Norway

A meta-analysis was carried out of the data from two double-blind, multi-centre studies with identical methodology which compared the effectiveness of treatment of elderly patients with zuclopenthixol and with other antipsychotic drugs. In one study, patients were treated for 4 weeks with either zuclopenthixol or melperone; in the other, with either zuclopenthixol or a combination of haloperidol and levomepromazine. The meta-analysis evaluated the results of 96 patients, 49 in the zuclopenthixol group and 47 in the comparison group. Doses, which were adjusted to individual patient's needs, were low as shown by the percentages of defined daily doses for each of the study drugs. The results indicated that all three treatment alternatives were effective in the treatment of elderly patients with symptoms of agitation and hostility/aggressiveness. There was a trend, however, for zuclopenthixol to have a more rapid onset of effect. Zuclopenthixol also has the advantage for both patients and nursing staff that dosage is once daily. Only few and mild side-effects were reported with the three drug regimens.

Benzodiazepine dependence: detoxification under standardized conditions

In an analysis of the withdrawal syndrome of 12 patients dependent on benzodiazepines (BZD), important factors such as underlying psychiatric disease, precipitating life events, complaints leading to BZD use, and also positive and negative psychological and social consequences, duration of intake, dose and type of BZD dependence are discussed. Withdrawal was completed under standardized inpatient conditions reducing the BZD dose to 50% of the previous dose once every 5 days and maintaining control through regular measurements of the BZD urine concentrations. The course of the somatic, psychological and perceptual withdrawal phenomena was documented according to Lader's BZD withdrawal symptom checklist (Lader, M. (1983) J. Clin. Psychiatry 44, 121-127). The reduction scheme proved to be safe and efficient; no major withdrawal syndromes developed. Abstinence phenomena largely disappeared within 10 days of discontinuation.

Diagnoses associated with the prescription of psychotropic drugs at a Swedish health centre

Data on drug prescribing to residents of the municipality of Tierp in 1978 were linked to data on visits to the Tierp health centre in order to examine which diagnoses were associated with psychotropic drug prescribing. The diagnostic patterns were analyzed with respect to sex, age, and level of drug use of patients. Only one quarter of the patients for whom psychotropic drugs were prescribed in connection with a visit to the health centre were also given a psychiatric diagnosis. Even among those patients who were prescribed five or more psychotropic drugs, only four out of ten had a psychiatric diagnosis. Among those patients who were prescribed an antidepressant, only six out of ten had a psychiatric diagnosis. A relation between psychotropic drug use and certain non-psychiatric diagnoses such as hypertension, diabetes and ischaemic heart disease was observed.

Patterns of psychotropic drug use in a Swedish community

In this study individual data on prescription drug purchases in the total population of a Swedish municipality have been analyzed in order to study changes in the use of psychotropic drugs (in this study mainly hypnotics, sedatives and minor tranquillizers) over time. The number of psychotropic prescriptions decreased by 27% during the twelve-year period 1972-1983. The proportion of psychotropic drug users in the total population decreased from 16 to 11%. This decrease in psychotropic drug use was not evenly distributed within the population. The proportion of users decreased from 10 to 4% in the age group 15-44 years and from 23 to 15% in the age group 45-64 years, while the higher proportion of users in the oldest age group, 65 years and older, only decreased from 33 to 28%. Psychotropic drug use was almost twice as common among females as compared to males throughout the study period. Psychotropic drug use among heavy users of prescription drugs in general--identified with the use of a sex- and age-specific definition--was also studied. The decrease in psychotropic drug use during the time period studied was much greater among non-heavy users as compared to heavy users.

Patients, prescribing, and benzodiazepines

In order to establish the current status of benzodiazepine prescribing and also to assess patients' attitudes towards the use of these drugs, we interviewed 450 consecutive patients in 16 community pharmacies about their use of benzodiazepines. Prescribing rates increased ten-fold from the age of 20 to 70 years and were higher in women than in men. The average dose used in the elderly seemed excessive and the choice of hypnotic often inappropriate. The median duration of benzodiazepine use was 2.5 years (range 0-25) and 66% of the patients had been taking benzodiazepines for one year or more. Most of the patients (97%) found the drugs effective in the treatment of anxiety or insomnia. Twenty-two percent took a lower dose than prescribed and 7.5% a higher dose. These data suggest that benzodiazepines are prescribed for excessively long periods and that greater caution is needed in prescribing benzodiazepines for older patients.

Treatment of mental problems in general practice. A one year prospective study from an island community in northern Norway

The aim of the study was to provide a basis for improving the treatment and prevention of mental problems in a defined local community. The prescribing of psychotropic drugs has been recorded as well as the use of non-drug therapy and the factors which worsened the patients' mental problems. The rate of psychotropic drug-users was 15% for females and 9% for males. The total prescribing during one year amounted to 59 defined daily doses (DDD) per thousand inhabitants per day. Hypnotics/sedatives constituted 30%, anti-histamines 23%, neuroleptics 18%, minor tranquillizers 16%, and antidepressants 13%. About 1/4 of the psychotropic drug-users was prescribed more than 180 DDD per year, representing a risk group for chronic use. The majority of all psychotropic drugs (65%) was prescribed through indirect contacts implying a danger of developing "repeat prescription syndromes". Less than one half of the patients who might have benefited from referral to a psychiatrist had, in fact, been referred during the previous three years. Somatic disease (among the psychotropic drug-users) and illness among other family members were frequently reported as worsening factors. This indicates the importance of holistic therapy and prophylaxis in general practice. Among our advice for prevention of mental problems to the local authorities was the arrangement of weekly social meetings and clubs for disabled pensioners and elderly people.

Long-term use of benzodiazepines in psychiatric inpatients

During the past few years the problem of over-prescribing benzodiazepines has been increasingly discussed. However, up to now exact data on the extent of an abuse of these substances are relatively scarce and controversial. An analysis done at the Psychiatric State Hospital Weinsburg from 1974 to 1983 regarding the frequency of the diagnosis "Benzodiazepine-dependence" showed that in only 150 cases (0.5%) out of almost 33,000 admitted patients was the diagnosis benzodiazepine-abuse justified, with an increase since the year 1980. During a prospective study of the quarterly incidence in 1984, 18.5% of the patients admitted met the criterion of long-term use of benzodiazepines (continuous use for more than 3 months). Sociodemographic and clinical data are presented and an index of abuse/dependence is proposed.

Psychotropic drug prescribing in general practice. II. A three year retrospective study from an island community in northern Norway

In a rural community in the northern part of Norway, the prescribing of psychotropic drugs has been recorded. The total prescribing during three years amounted to 60 defined daily doses per thousand inhabitants per day. Hypnotics and sedatives comprised together with antihistamines, 50% of the total amount of defined daily doses. Neurosis was the dominating indication for prescribing. The majority of the patients (59%) received less than 50 defined daily doses per year, indicating that most patients have a moderate consumption of psychotropic drugs. One of five users were prescribed more than 180 defined daily doses per year (71% of all DDD), representing a probable risk-group for chronic use.

Are benzodiazepines overused and abused?

1 Drug use has to be viewed in the context of symptoms or illnesses for which they are prescribed. It is concluded that overall psychotropic drugs are used conservatively. 2 The benzodiazepines are safe drugs and in contrast with other centrally acting agents overuse will rarely have severe consequences. 3 Abrupt discontinuation may lead to temporary withdrawal reactions in patients who have been taking benzodiazepines regularly for 4 months or longer. Such reactions may occur more frequently in patients taking high doses.

Auditing hospital drug utilisation by means of defined daily doses per bed-day. A methodological study

The utilisation of hypnotics, sedatives, and minor tranquillisers (HSmT) was studied by means of drug-delivery and hospital occupancy statistics for 1975-1977 in a Swedish university hospital. A total of 0.53 so-called defined daily doses (DDD)/bed-day were delivered in 1975, implying that every second patient might have regularly been prescribed HSmT. The benzodiazepines were predominant with 71% of the deliveries. Five major drugs accounted for 88%. The drug pattern and the range of DDD/day-bed (0.09-1.18) differed considerably between the departments. Drugs not recommended by the hospital's Pharmacy and Therapeutics Committe accounted only for 3% of deliveries. In a drug surveillance study performed in two medical wards, HSmT were prescribed for 43% of 274 patients. Drug delivery and prescription data were in broad agreement. Drug information activities in the hospital had a clearly discernable influence on the delivered DDD/bed-day. This measure is an inexpensive indicator of drug utilisation in a hospital and a suitable basis for therapeutic audit.