Number of Patients Receiving Multiple Medications for a Single Condition is on the Rise

The number of patients receiving multiple medications for a single condition has recently been on the rise. Although polypharmacy  can be an effective weapon in a physician’s arsenal, one must be aware of the potential for over-reliance, drug-drug interactions (DDIs), and unproven efficacy rates.

Ramin Mojtabai, MD, PhD, MPH, and Mark Olfson, MD, MPH, assessed the number of medications being prescribed by psychiatrists after reviewing the data from 13,079 office visits by adults ≥18 years of age over a 10-year period. Mojtabai and Olfson found that the number of prescriptions for ≥2 antidepressants, antipsychotics, sedative-hypnotics, and antidepressant/antipsychotic combinations significantly increased during the study period. However, they found no increase in the number of mood stabilizer prescriptions.

The percentage of office visits increased from 42.6% to 59.8% between 1996 and 2006 and the percentage of office visits where a patient was prescribed ≥3 medications increased from 16.9% to 33.2%. They also found an average increase of 40.1% in the median number of medications prescribed per visit. In addition, they found that the number of medications being taken was dependent on the disorders the patients were suffering from. For example, patients with major depression received ≥2 antidepressants, patients with schizophrenia received ≥2 antipsychotics, patients with bipolar disorder received ≥2 mood stabilizers, and patients with anxiety disorders received ≥2 sedative-hypnotics.

In an e-mail interview, Dr. Mojtabai noted: “From these data it is not possible to know the positive or negative effects of polypharmacy as we could not separate the appropriate uses of multiple medications from inappropriate ones.

“With the growing number of both psychiatric and non-psychiatric medications that patients are taking, and the increasing recognition of medical comorbidities in psychiatric patients, considering DDIS is an increasingly important issue. However, we should reiterate that there are some known appropriate indications for the use of multiple psychiatric medications. Our report should not discourage clinicians from prescribing useful combinations when appropriate.” (Arch Gen Psychiatry. 2010;67(1):26-36.) –CN


Americans Receive Inadequate Treatment for Depression

Psychotherapy and pharmacology are among the guidelines established by the American Psychiatric Association for the effective treatment of depression. However, research shows that many individuals are undertreated or untreated. Many studies on treating depression do not break down the two treatment modalities and have also blended major racial and ethnic groups together, such as combining Mexican Americans and Puerto Ricans into one Latino group.

Using data from the National Institute of Mental Health’s Collaborative Psychiatric Epidemology Survey, Hector M. González, PhD, from Wayne State University in Detroit, Michigan, and colleagues, studied the prevalence and adequacy regarding the treatment of depression in certain racial and ethnic groups. Face-to-face interviews were conducted with 15,762 individuals ≥18 years of age throughout the United States from 2001–2003.

Among those surveyed, 8% of Mexican Americans had depression, along with 11.8% of Puerto Ricans, 7.9% of Caribbean blacks, 6.7% of African Americans, and 8.5% of non-Latino whites. In total, >50% of those with depression received at least one form of treatment, whereas only one in five received at least one form of therapy that conformed to the previous year’s established guidelines.

“Half of Americans meeting major depression criteria get some treatment,” Dr. González said. “However, few (20%) get the standard of care, particularly African Americans and Mexican Americans, the largest minority groups in the US.”

The most common treatment modality was psychotherapy, as opposed to pharmacotherapy, and those receiving psychotherapy were more likely to receive treatment in line with clinical guidelines than those taking medication. Individuals with the lowest odds of receiving any type of treatment or care in concordance with the established guidelines were Mexican Americans and African Americans.

“Having insurance did not ensure receiving the standard of depression care, particularly for Mexican Americans and African Americans,” Dr. González said. “My own clinical experiences, particularly with Mexican Americans, got me into this business in the first place. I observed that too many errors can arise when the patient and the healthcare system, including staff and primary care physicians, are unable to effectively communicate important clinical information. A workforce that can meet the needs of an increasingly diverse US population (one in three Americans will be Latino by midcentury) may be useful in remedying the disparities in depression care that were observed in our national study.”

Dr. González was surprised to discover that Puerto Rican individuals had good or better depression care than white individuals.

“Our other recent work has shown that the ‘Puerto Rican healthcare advantage’ is seen in other areas of health care, such as having a usual source of care,” he noted.

Breaking down larger racial and ethnic groups into subcategories stresses the importance of and more effectively analyzes the needs of Latino individuals, the largest and fastest-growing minority in the US, as well as Mexican Americans. Depression care for all Americans should improve with the recent passing of the US Mental Health Parity Act, as well as decrease the differences among certain racial and ethnic groups.

Funding for this research was provided by the National Institutes of Health, the National Institute of Mental Health, and the Robert Wood Johnson Foundation. (Arch Gen Psychiatry. 2010;67(1):37-46). –JV

Implications of Depression in the Workplace

Studies have highlighted the serious economic ramifications of depression. It has been previously estimated that the total economic burden of depression was $83.1 billion in 2000, with workplace costs accounting for 62% ($51.5 billion) of that figure.

Debra J. Lerner, MS, PhD, at Tufts Medical Center, and colleagues, recently published a study examining the implications of depression in the workplace, productivity in particular. Employees diagnosed with depression (n=286) were compared to employees without depression (n=193). Going to work as a depressed patient was associated with more severe depression symptoms, poorer overall health, a psychologically demanding job, and less job control.

The rate of absenteeism at baseline was three times higher for the depression group, compared to no depression. Severity of depression accounted for 19% of the variation in absence rates. At 18-month follow-up, the rate of absenteeism remained 2.3 times higher for the depressed group compared to the non-depressed group. (Am J Health Promotion. 2010;24(3):205-213.). –LS

Psychiatric dispatches is written by Christopher Naccari, Lonnie Stoltzfoos, and Jennifer Verlangieri.