Determinants of antidepressant medication prescribing in elderly residents of aged care homes in Australia: A retrospective study

Risk of adverse outcomes associated with mirtazapine compared to sertraline use among older people living in long-term care facilities

BACKGROUND

Antidepressants are used by 60% of residents of long-term care facilities (LTCFs). Mirtazapine and sertraline are the most commonly used antidepressants, despite little safety information for their use in LTCFs.

OBJECTIVE

To investigate risk of adverse outcomes (falls, fractures, cardiovascular-, dementia-, and delirium-related hospitalisations, all-cause mortality) associated with mirtazapine compared to sertraline use post-LTCF entry.

DESIGN

Active new user retrospective cohort study.

SUBJECTS

Individuals aged 65-105 years entering LTCFs in three Australian states during 1 January 2015 to 31 October 2018, who initiated mirtazapine or sertraline ≤60 days post-LTCF entry, with follow-up to 31 December 2019.

METHODS

The inverse probability of treatment weighting of individuals' propensity scores was used to adjust Cox and Fine-Gray regression models to estimate the risk of outcomes of interest associated with mirtazapine compared to sertraline use in LTCFs. Weighted (adjusted) hazard ratios (aHRs), subdistribution hazard ratios and 95% confidence intervals (95% CIs) are presented.

RESULTS

A total of 5409 residents initiated mirtazapine (71%, n = 3837) or sertraline (29%, n = 1572) post-LTCF entry. After weighting, mirtazapine was associated with a higher risk of mortality (aHR 1.16, 95% CI 1.05-1.29) compared to sertraline. The risk of falls and fractures within 90 days was not statistically significantly different between the groups but was lower in mirtazapine users thereafter. No differences in risk of cardiovascular-, dementia- or delirium-related hospitalisations were observed.

CONCLUSIONS

Compared to sertraline, mirtazapine use is associated with a higher risk of mortality and, after 90 days of use, a lower risk of falls and fractures. This risk of harm should be balanced with limited evidence for effectiveness when considering antidepressant therapy in LTCFs.

Setting of initiation and factors associated with antidepressant use on entry to long-term care facilities

AIMS

Antidepressant use increases around long-term care facility (LTCF) entry, and initiation during hospitalizations may contribute to this. This study characterized the care setting (i.e., community-based, hospital or LTCF) where antidepressants were initiated and determined associated resident characteristics.

METHODS

A cross-sectional study including non-Indigenous individuals aged 65-105 years who entered LTCFs in two Australian states during 2015-2019, and were dispensed an antidepressant within 2 months, was conducted. Care settings (community-based, hospital or LTCF) were determined from linked LTCF records, and hospitalizations ≤30 days before LTCF entry. Pharmaceutical claims before and after LTCF entry were screened to determine antidepressant initiation. Multivariate multinomial logistic regression estimated adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) for resident characteristics associated with care settings of antidepressant initiation.

RESULTS

This study included 34 525 residents from 1046 LTCFs. Overall, 27 160 (78.7%) commenced antidepressants prior to entry, 2552 (7.4%) in hospital and 4813 (13.9%) in LTCFs. Mirtazapine constituted 44.8% (n = 1143) of antidepressants initiated in hospitals and 39.5% (n = 1902) in LTCFs. Residents who were aged ≥90 years were more likely to start an antidepressant in the LTCF compared to community-based settings (aOR = 1.97, 95% CI 1.74-2.23). Residents recently using a psychotropic were more likely to start an antidepressant in community-based settings before LTCF entry, compared to a hospital or LTCF.

CONCLUSIONS

Individuals receiving antidepressants during transition to LTCFs are often already taking antidepressants prior to entry. Future interventions to optimize antidepressant use in LTCFs should consider setting, recency and indication for antidepressant initiation, and ongoing monitoring for safety.

Medications use among women with dementia: a cohort study

BACKGROUND

Older population with dementia use huge range of medications. In this study, we aimed to determine the prevalence of commonly used medications a year before and after first recorded dementia diagnosis among older Australian women.

METHODS

The study utilized Australian Longitudinal Study on Women's Health (ALSWH) data from 2090 women with known dementia, linked with administrative health datasets. The Pharmaceutical Benefits Scheme (PBS) data provided detailed information about prescribed medications. We applied latent class analysis (LCA) to the post-dementia data to identify patterns of medication use. Logistic regression model was used to explore the impact of potential predictors for medication utilization.

RESULTS

Antipsychotic use increased from 5% before dementia to 19% after dementia, while antidementia medication use increased from < 1 to 28%. There was a modest increase in benzodiazepines and antidepressants. Post-dementia, four distinct groups were identified using LCA (names based on probabilities of medications use) as: "High Psychotropic-Low Cardiovascular" (16% of the sample); "Moderate Psychotropic-High Cardiovascular" (12%); "Low Psychotropic-High Cardiovascular" (27%); and "Low Psychotropic-Low Cardiovascular" (45%). Living in Residential Aged Care (RAC) and frailty were associated with increased odds of being in the higher psychotropic use groups.

CONCLUSIONS

Substantial utilization of psychotropic medications by older people with dementia indicates a need for a careful review of the use of these medications. Appropriate alternative approaches to the management of dementia should be practiced with a special focus on RAC residents with frailty.

Efficacy of antidepressant drugs in the treatment of depression in Alzheimer disease patients: A systematic review and network meta-analysis

BACKGROUND

Depression is considered as one of the most common neuropsychiatric symptoms (NPS) in Alzheimer's disease (AD) patients. Prescription of antidepressants is a current clinical practice well-established as the first-line treatment for such patients. Our study was aimed at systematically examining the evidence on the efficacy of antidepressants in the treatment of depression in AD patients.

METHODS

We conducted a network meta-analysis of randomized controlled trials retrieved by systematic search of the Cochrane Central Register of Controlled Trials, PubMed, Embase, and CNKI databases. Primary outcomes included mean depression score and safety. Secondary outcomes were cognition. The surface under the cumulative ranking curve was performed to estimate a ranking probability for different treatments.

RESULTS

A total of 25 studies including 14 medications met the inclusion criteria. Compared with placebo, only mirtazapine (standard mean deviation [SMD], -1.94; 95% confidence interval [CI], -3.53 to -0.36; p < 0.05) and sertraline (SMD, -1.16; 95% CI, -2.17 to -0.15; p < 0.05) showed a slightly better effect in treating symptoms of depression. Clomipramine increased risk of adverse events than placebo (odds ratio, 3.01; 95% CI, 1.45 to 4.57; p < 0.05). In terms of cognitive function, there was no statistically significant difference between antidepressants and placebo.

CONCLUSION

Overall, in the short-term treatment, these data suggest that commonly used antidepressants sertraline and mirtazapine should be considered as an alternative treatment for depression in AD patients. However, more high-quality trials with large samples and longer following-up are proposed.

Therapeutic Dose of Amitriptyline for Older Patients with Burning Mouth Syndrome

OBJECTIVE

To assess the therapeutic dose and safety of amitriptyline and the outcome following treatment with amitriptyline among older patients with burning mouth syndrome (BMS).

METHODS

187 consecutive patients were prescribed amitriptyline as a first-line medication from April 2016 to September 2018 and followed-up for >1 month. Patients were divided into 3 groups: group 1, 113 patients aged <65 years; group 2, 52 patients aged between 65 and 74 years; and group 3, 22 patients aged 75 years or older. The visual analog scale (VAS), Pain Catastrophizing Scale (PCS), Somatic Symptom Scale-8 (SSS-8), Patient Global Impression of Change (PGIC), and Short-form McGill Pain Questionnaire (SF-MPQ) were used for analysis.

RESULTS

Thirty-two patients (17 in group 1, 10 in group 2, and 5 in group 3) stopped taking amitriptyline due to side effects. There were no differences among the groups with respect to sex; scores of VAS, PCS, and SSS-8; and drop-out ratio. There were no significant differences in the VAS, PCS, and PGIC scores among the groups after 1 month. The mean daily dose after 1 month was 20.4 ± 8.6 mg in group 1, 17.3 ± 8.7 mg in group 2, and 13.2 ± 5.8 mg in group 3; this difference was significant (p value = 0.003). About 76% of patients showed improvements in their symptoms (PGIC ≥ 3). About 90% of patients reported side effects. No serious side effects occurred.

CONCLUSION

The therapeutic dose of amitriptyline may be lower for older BMS patients than for younger patients.

Use of Central Nervous System (CNS) Medicines in Aged Care Homes: A Systematic Review and Meta-Analysis

BACKGROUND

Both old age and institutionalization in aged care homes come with a significant risk of developing several long-term mental and neurological disorders, but there has been no definitive meta-analysis of data from studies to determine the pooled estimate of central nervous system (CNS) medicines use in aged care homes. We conducted this systematic review to summarize the use of CNS drugs among aged care homes residents.

METHODS

MEDLINE, EMBASE, CINAHL, Scopus, and International Pharmaceutical Abstracts (IPA) databases were searched (between 1 January 2000 and 31 December 2018) to identify population-based studies that reported the use of CNS medicines in aged care homes. Pooled proportions (with 95% confidence interval), according to study location were calculated.

RESULTS

A total of 89 studies reported the use of CNS medicines use in aged care. The pooled estimate of CNS drugs use varied according to country (from 20.3% in Ireland to 49.0% in Belgium) and region (from 31.7% in North America to 42.5% in Scandinavia). The overall pooled estimate of psychotropic medicines use was highest in Europe (72.2%, 95% CI, 67.1-77.1%) and lowest in ANZ region (56.9%, 95% CI, 52.2-61.4%). The pooled estimate of benzodiazepines use varied widely from 18.9% in North America to 44.8% in Europe. The pooled estimate of antidepressants use from 47 studies was 38.3% (95% CI 35.1% to 41.6%) with highest proportion in North America (44.9%, 95% CI, 35.3-54.5%).

CONCLUSION

The overall use of CNS drugs varied among countries, with studies from Australia-New Zealand reported the lowest use of CNS drugs. The criteria for prescribing CNS drugs in clinical practice should be evidence-based. The criteria should be used not to prohibit the use of the listed medications but to support the clinical judgement as well as patient safety.

Sauver J, Rocca WA, Sutor B. Frequency and predictors of the potential overprescribing of antidepressants in elderly residents of a geographically defined U.S. population

The purpose of this study was to estimate the extent of potential antidepressant overprescribing in a geographically defined U.S. population, and to determine the indications and factors that account for it. We conducted a cohort study of new antidepressant prescriptions for elderly residents of Olmsted County, Minnesota, 2005-2012, using the Rochester Epidemiology Project medical records-linkage system. Indications for antidepressants were abstracted from health records for all cohort members. Potential antidepressant overprescribing was defined based on regulatory approval, the level of evidence identified from a standardized drug information database, and multidisciplinary expert review. Predictors of potential antidepressant overprescribing were investigated using logistic regression models, stratified by general antidepressant indication (general medical indication, specific psychiatric diagnosis, and non-specific psychiatric symptoms). Potential antidepressant overprescribing occurred in 24% of 3199 incident antidepressant prescriptions during the study period, and involved primarily newer antidepressants that were prescribed for non-specific psychiatric symptoms and subthreshold diagnoses. Potential antidepressant overprescribing was associated with nursing home residence, having a higher number of comorbid medical conditions and outpatient prescribers, taking more concomitant medications, having greater use of urgent or acute care services in the year preceding the index antidepressant prescription, and being prescribed antidepressants via telephone, e-mail, or patient portal. In conclusion, potential antidepressant overprescribing occurred in elderly persons and involved mainly newer antidepressants used for non-specific psychiatric symptoms and subthreshold diagnoses, and was associated with indicators of higher clinical complexity or severity and with prescribing without face-to-face patient contact.

Factors associated with antidepressant use in residents with and without dementia in Australian aged care facilities

OBJECTIVE

Depressive symptoms are highly prevalent in residential aged care facilities (RACFs). The prevalence of antidepressant use is increasing but the effectiveness of antidepressants in people with dementia is uncertain. The objective of the study was to investigate factors associated with antidepressant use in residents with and without dementia.

METHODS

This was a prospective cross-sectional study of 383 residents in six Australian RACFs. Data on health status, medications and demographics were collected by trained study nurses from April to August 2014. Logistic regression was used to compute adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for factors associated with antidepressant use. Analyses were stratified by dementia and depression.

RESULTS

Overall, 183 (47.8%) residents used antidepressants. The prevalence of antidepressant use was similar among residents with and without dementia. Clinician-observed pain was inversely associated with antidepressant use in the main analysis (AOR = 0.56, 95% CI = 0.32-0.99) and in subanalyses for residents with documented depression (AOR = 0.51, 95% CI = 0.27-0.96). In residents with dementia, moderate quality of life was associated with a lower odds of antidepressant use compared with poor quality of life (AOR = 0.35, 95% C I= 0.13-0.95). In residents without dementia, analgesic use was associated with antidepressant use (AOR = 2.34, 95% CI = 1.07-5.18).

CONCLUSIONS

The prevalence of antidepressant use was similar in residents with and without dementia. Clinician-observed pain was inversely associated with antidepressant use but there was no association between self-reported pain and antidepressant use.

Concurrent Use of Benzodiazepines and Antidepressants and the Risk of Motor Vehicle Accident in Older Drivers: A Nested Case-Control Study

INTRODUCTION

Aging of the population results in an increase in senior drivers. Elderly are frequently treated with benzodiazepines and antidepressants. The objective of this study was to determine whether the concurrent use of benzodiazepines and antidepressants is associated with motor vehicle accidents (MVAs) in the elderly.

METHODS

This was a nested case-control study within a cohort of drivers aged 67-84 years between 1990 and 2000, identified from the Société de l'Assurance Automobile du Québec and the Régie de l'Assurance Maladie du Québec databases. First cases of MVAs during follow-up were matched with up to ten controls from the cohort. Odds ratios (ORs) for the association between MVA and the use of benzodiazepines and antidepressants were estimated using conditional logistic regression.

RESULTS

The cohort included 373,818 drivers, with 74,503 MVA cases matched with 744,663 controls. The risk of MVA was higher in current users of long-acting benzodiazepines [OR 1.23; 95% confidence interval (CI) 1.16-1.29] than in current users of short-acting benzodiazepines (OR 1.05; 95% CI 1.02-1.08). The risk of MVA was increased in current users of selective serotonin reuptake inhibitors (SSRIs; OR 1.13; 95% CI 1.04-1.22), while it was not in current users of tricyclic antidepressants (TCAs; OR 1.04; 95% CI 0.96-1.14). The highest ORs of MVA were observed in long-acting benzodiazepines users concurrently using SSRIs (OR 1.37; 95% CI 1.07-1.77, P value for interaction = 0.964) or TCAs (OR 1.54; 95% CI 1.21-1.95, P value for interaction = 0.077).

CONCLUSION

Use of long-acting benzodiazepines is associated with an increased risk of MVA in the elderly, particularly in those concurrently using SSRIs or TCAs.

The use of antidepressants in Belgian nursing homes: focus on indications and dosages in the PHEBE study

BACKGROUND

Since antidepressants are prescribed for multiple indications, the use of an antidepressant cannot be equated with a diagnosis of depression.

OBJECTIVE

The objective of this study was to examine the quality of antidepressant prescribing in Belgian nursing homes, with a critical evaluation of indications and dosages, to see whether depression was appropriately treated in terms of drug choice, the indications for which antidepressants were being prescribed and whether there was underdosing.

METHODS

This analysis was based on data obtained in the Prescribing in Homes for the Elderly in Belgium (PHEBE) study, a cross-sectional, descriptive study of a representative, stratified, random sample of 1,730 residents from 76 Belgian nursing homes. The PHEBE study investigated overall drug utilization in Belgian nursing homes in 2006. Clinical and medication data for the present study were obtained from this study. A 28-item checklist of clinical conditions was designed ad hoc for the PHEBE study and sent to the residents' general practitioners (GPs) to collect clinical information. We copied the residents' medication charts, classified the drugs using the Anatomical Therapeutic Chemical (ATC) classification system codes and transferred the drug names and dosages into a database. Information on indications was retrospectively obtained from the GPs, so that we could link the indication to each medication. Minimum effective doses (MEDs) of antidepressants to treat major depression were obtained from the literature to assess underdosing.

RESULTS

The overall use of antidepressants in nursing homes was 39.5 % (95 % CI 37.2, 41.8). The physicians classified 34.2 % (95 % CI 32.0, 36.4) of the residents as having depression, and 80.9 % of these patients were treated with an antidepressant. Indications among the single antidepressant users (n = 551) were depression (66.2 %), insomnia (13.4 %), anxiety (6.2 %) and neuropathic pain (1.6 %). In the indication of depression, 74.8 % used a selective serotonin reuptake inhibitor (SSRI), predominantly citalopram, sertraline and escitalopram. Venlafaxine was used by 10.7 % of the residents. Dosages for these antidepressants were equal to or higher than the MED. But when trazodone, amitriptyline or mirtazapine were used to treat depression, respectively, 92.3, 55.5 and 44.5 % of prescribed dosages were below the MED. In the indication of insomnia, most of the time, trazodone (90.5 %) or mirtazapine (5.4 %) were used, and in lower dosages than those required for depression treatment (<MED). Tricyclic antidepressants were predominantly used for the treatment of neuropathic pain and were also used at lower dosages. Of all the residents receiving a medication for anxiety, only 13.9 % received an antidepressant (mostly an SSRI), and the remaining received a benzodiazepine.

CONCLUSIONS

The number one indication for the use of an antidepressant was depression. Within this indication, mostly the recommended SSRIs were used, in dosages equal to or higher than the MED. Furthermore, we noticed that there was substantial use of sedative antidepressants for insomnia and that the physicians preferred to prescribe benzodiazepines over the recommended SSRIs to treat anxiety chronically.

Prescribing in care homes: the role of the geriatrician

Large numbers of frail elderly people spend some time of their lives in care homes. Increasing age is associated with altered physiology, multiple diagnoses and complex comorbidity, and polypharmacy. Those living in care homes often take larger numbers of medications than those who live in the community and the risk of morbidity as a direct or indirect result of medications is high. Many methods have been suggested to revise the number and type of medications prescribed for individuals at risk of adverse drug reactions (ADRs), both in the community and in hospital with variable success and implementation. Assessment of prescribed and nonprescribed medications by pharmacists, nurses and general practitioners all have a role in optimizing therapeutics with evidence that improved prescribing can reduce the risk of ADRs. In conjunction with these professionals, community geriatricians undertaking a comprehensive geriatric assessment can reduce the number of medications prescribed or optimize therapy where there may be underprescribing (e.g. in depression), thereby reducing the overall risk of hospital admission ADRs.

Dose-response relationship between selective serotonin re-uptake inhibitors and injurious falls: a study in nursing home residents with dementia

AIM

The contribution of selective serotonin re-uptake inhibitors (SSRIs) to injurious fall risk in patients with dementia has not been quantified precisely until now. Our objective was to determine whether a dose-response relationship exists for the use of SSRIs and injurious falls in a population of nursing home residents with dementia.

METHODS

Daily drug use and daily falls were recorded in 248 nursing home residents with dementia from 1 January 2006 until 1 January 2008. For each resident and for each day of the study period, data on drug use were abstracted from the prescription database, and information on falls and subsequent injuries was retrieved from a standardized incident report system, resulting in a dataset of 85,074 person-days.

RESULTS

We found a significant dose-response relationship between injurious falls and the use of SSRIs. The risk of an injurious fall increased significantly with 31% at 0.25 of the Defined Daily Dose (DDD) of a SSRI, 73% at 0.50 DDD, and 198% at 1.00 DDD (Hazard ratio = 2.98; 95% confidence interval 1.94, 4.57). The risk increased further in combination with a hypnotic or sedative.

CONCLUSIONS

Even at low doses, SSRIs are associated with increased risk of an injurious fall in nursing home residents with dementia. Higher doses increase the risk further with a three-fold risk at 1.00 DDD. New treatment protocols might be needed that take into account the dose-response relationship between SSRIs and injurious falls.

Prevalence and predictors of antidepressant prescribing in nursing home residents in the United States

BACKGROUND

Late-life depression is a common psychiatric disorder associated with increased morbidity and mortality. Depression is often under-detected and undertreated in elderly nursing home residents.

OBJECTIVES

The aim of this study was to examine the prevalence of antidepressant drug use and to identify the factors associated with its use among elderly nursing home residents.

METHODS

The study involved the analysis of a nationally representative sample of prescription and resident files from the 2004 National Nursing Home Survey (NNHS). The study sample included all elderly nursing home residents ≥65 years of age. The analysis focused on prescribing from any antidepressant class, including selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), serotonin modulators, serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), and others. Descriptive weighted analysis was performed to examine antidepressant use prevalence patterns in elderly nursing home residents. Multiple logistic regression analysis within the conceptual framework of Anderson's behavioral model was used to examine the predisposing, enabling, and need characteristics associated with antidepressant use.

RESULTS

According to the 2004 NNHS, overall prevalence of antidepressant use among elderly nursing home residents was 46.22% (95% CI, 45.16-47.27). Most antidepressant users were ≥85 years of age (49.7%), female (75.7%), non-Hispanic (96.4%), and white (91.1%). The most prescribed class of antidepressants was SSRIs (31.09%; 95% CI, 30.12-32.07), followed by serotonin modulators (4.65%; 95% CI, 4.22-5.09), SNRIs (2.78%; 95% CI, 2.45-3.12), TCAs (2.34%; 95% CI, 2.03-2.65), and MAOIs (0.01%; 95% CI, 0.00-0.03). Citalopram (12.92%; 95% CI, 12.21-13.63) was the most prescribed individual antidepressant, followed by mirtazapine (10.19%; 95% CI, 9.55-10.84). Among the predisposing characteristics, age, race, and marital status were significantly associated with antidepressant use. The odds of receiving an antidepressant were lower for those aged ≥85 years and those who were unmarried elderly residents, when compared with their counterparts; whites were more likely to receive an antidepressant than nonwhites. Enabling factors such as Medicaid and bed capacity significantly predicted antidepressant use. Having Medicaid was positively associated with antidepressant prescription, whereas an increase in the total number of beds decreased the probability of an antidepressant prescription. Among need characteristics, the likelihood of antidepressant prescription use decreased with increased dependence in decision-making ability and out-of-bed mobility. The presence of depressed mood indicators and a history of falls/fractures increased the likelihood of antidepressant prescription use. The odds of receiving an antidepressant increased with diagnosis of depression but decreased with diagnosis of anxiety.

CONCLUSION

Nearly half of elderly nursing home residents received antidepressants. In addition to need factors, predisposing and enabling factors played an important role in influencing the use of antidepressants in elderly nursing home residents.

Antidepressant prescribing in older primary care patients in community and care home settings in England and Wales

OBJECTIVE

To compare the prevalence and predictors of antidepressant prescribing in older care home and community residents in England and Wales.

DESIGN

Retrospective analysis of primary care consultation and antidepressant prescribing data.

SETTING

The setting included 326 general (family) practices in England and Wales supplying data to The Health Improvement Network database between 2008 and 2009.

PARTICIPANTS

Participants were 10,387 care home and 403,259 community residents aged 65 to 104.

MAIN OUTCOME MEASURE

Antidepressant prescription in the last 3 months of recorded data for each patient.

RESULTS

Prevalence rates for antidepressant prescribing were 10.3% (95% confidence interval 10%-10.6%) for community and 37.5% (36.2%-38.9%) for care home residents. After excluding low-dose tricyclics (often used for other indications) prevalences were 7.3% (7.1%-7.5%) and 33.6% (32.3%-34.9%) respectively; of these, 21.7% (20.8%-22.6%) of community and 4.8% (3.9%-5.6%) of care home prescriptions were for antidepressants advised as best avoided in this age group. After indirect standardization for age, sex, and chronic disease prevalence, the ratio for prescribing was 2.4 (2.3-2.5) in care homes compared with the community; 28.3% (26.6%-30.1%) of community and 42.5% (39.4%-45.7%) of care home residents prescribed antidepressants had no appropriate recorded indication.

CONCLUSIONS

This national sample confirms the high prevalence of antidepressant prescribing to older people, particularly in care homes, frequently without a documented indication. The strong association found between chronic disease and antidepressant prescribing did not explain the higher care home prescribing rate. Widespread community use of nonrecommended antidepressants is also a concern.

Antidepressant prescribing in US nursing homes between 1996 and 2006 and its relationship to staffing patterns and use of other psychotropic medications

BACKGROUND

Few studies have examined factors associated with antidepressant prescribing in older nursing home residents.

OBJECTIVE

The primary objective was to describe the change in antidepressant prescribing for nursing home residents between 1996 and 2006. An additional objective was to examine the association between any change in antidepressant prescribing and staffing patterns or coprescribing of other psychotropic medications in the same cohort.

DESIGN

Longitudinal.

SETTINGS

Settings were 12,556 US nursing homes in 1996 and 2006.

DATA SOURCES

Online Survey Certification and Reporting (OSCAR) data and the Area Resource File (ARF).

MEASUREMENTS

Increasing prescribing of antidepressants analyzed using multivariable multinomial generalized estimating equations (GEE).

RESULTS

Antidepressant prescribing significantly increased (P < .05) from 21.9% in 1996 to 47.5% in 2006. After controlling for resident, organizational, and market factors, increased antidepressant prescribing was associated with more time spent by physician extenders (adjusted odds ratio [AOR] 2.21; 95% confidence interval [CI] 1.96-2.51), registered nurses (AOR 1.06, 95% CI 1.02-1.10), or nurse aides (AOR 1.08; 95%CI 1.04-1.12) in a facility, as well as the coprescribing of sedative/hypnotics (AOR 1.12; 95% CI 1.08-1.16). Factors found to be protective of increasing antidepressant prescribing (ie, decrease antidepressant prescribing) included having medical directors and physicians spend more time in the facility (AOR 0.60; 95% CI 0.53-0.69 and AOR 0.62; 95% CI 0.54-0.71, respectively), or coprescribing of antianxiety or antipsychotic agents (AOR 0.70; 95% CI 0.68-0.72 and AOR 0.74; 95% CI 0.72-0.77, respectively).

CONCLUSIONS

Prescribing of antidepressants has increased dramatically in the past decade in older nursing home residents and seems to be associated with certain staffing characteristics and the coprescribing of psychotropic medications. Further research is needed to determine if antidepressants are appropriately prescribed, and if overuse is determined, develop interventions to improve the quality of prescribing of these medications in older nursing home residents.

Quality of mental health care for nursing home residents: a literature review

Because of the high proportion of nursing home residents with a mental illness other than dementia, the quality of mental health care in nursing homes is a major clinical and policy issue. The authors apply Donabedian's framework for assessing quality of care based on the triad of structure, process, and outcome-based measures in reviewing the literature on the quality of mental health care in nursing homes. Quality measures used within the literature include mental health consultations and hospitalizations, inappropriate use of medications, and mental health survey deficiencies. Factors related to the resident's welfare (nurse staffing), provider norms (locality), and financial factors (payer mix) were associated with the quality of mental health care. Although future research is necessary, the extant literature suggests that persons with mental illness are frequently admitted to nursing homes and their care is often of poor quality and related to a series of resident and facility factors.