08/02/1999 – SSRI Prescribing in Primary Care Draws Fire

Note that 8% of all general hospital psychiatric admissions caused by
SSRI-induced psychoses!–Thanks to Ann Blake-Tracy for passing this along.
Mark
———–

FromClinical Psychiatry News

SSRI Prescribing in Primary Care Draws Fire

Todd Zwillich, Senior Writer

[Clinical Psychiatry News 27(6):34, 1999. © 1999 International Medical
News
Group.]

————————————————————————
More primary care physicians are prescribing antidepressants, but some
observers worry that patients aren’t being evaluated closely enough for
potential adverse reactions or monitored appropriately while taking the
drugs.

Research is beginning to show that “large numbers” of prescriptions for
selective serotonin reuptake inhibitors (SSRIs) aren’t accompanied by a
diagnosis of depression or any other mental condition, said Stephen
Crystal, Ph.D., a researcher who studies prescribing trends at Rutgers
University in New Brunswick, N.J.

“We have a massive uncontrolled experiment going on out there,” he
said.

The number of doctor office visits including an antidepressant
prescription more than doubled between 1985 and 1994 to more than 24
million, according to data from the National Ambulatory Medical Care
Survey (NAMCS). Researchers attribute the rise to the popularity of
SSRIs.

While an estimated 11 million psychiatrist appointments included an
antidepressant prescription in 1994, more than 10 million other
antidepressant prescriptions were written by primary care doctors.
Preliminary analysis of survey data extending through 1996 shows that
antidepressant prescriptions are now more common in primary care
offices than in psychiatrists’ practices, according to Dr. Crystal.

Managed care is at least partly responsible for the trend. Primary care
physicians acting as gatekeepers in HMOs have been encouraged to treat
potentially depressed patients rather than refer them to specialists.
At the same time, primary care doctors are becoming more comfortable
with the newer SSRIs because they are relatively easy to use.

Toxicity and overdoses are rare, and potential drug interactions are
far less common than with other drug classes. The drugs may also
provide a convenient way to treat somatizing patients who have a few
depressive symptoms without a full-blown depressive episode.

But relatively few data exist to support SSRIs’ efficacy in treating
the “subthreshold” patients often seen in primary care. Many of those
patients may get SSRIs without any official diagnosis, according to Dr.
Harold Pincus, who last year published a study on psychotropic
prescribing using NAMCS data.

Office-based psychiatry practices tend to aggregate around more
affluent and better-educated patients in medium and large cities. Most
observers agree that primary care’s new dominance in antidepressant
prescribing makes the drugs available to a wider range of patients.

“Those who are underserved by specialists are nonwhite and not wealthy.
They are the ones who benefit most from primary care physician
prescribing,” said Dr. Gregory Simon, a psychiatrist who studies
prescribing patterns at Group Health Cooperative of Puget Sound in
Seattle.

The American Psychiatric Association recommends in its depression
treatment guidelines that patients continue their SSRI prescription for
4-5 months after complete remission of their symptoms. But data from
Group Health Cooperative–an HMO that emphasizes primary care treatment
of mental conditions–show that only 34% of patients on SSRIs refill
their prescriptions often enough to suggest continuous use.

At the same time, new data from the Rutgers group show that Medicare
patients treated in primary care are more than twice as likely as
similar patients treated in psychiatric settings to fill their SSRI
prescriptions only once, Dr. Crystal commented.

Others worry that physicians are not paying enough attention to patient
factors that could make initiation of SSRIs dangerous. Dr. Malcolm B.
Bowers Jr., a psychiatrist at Yale University in New Haven, told
CLINICAL PSYCHIATRY NEWS that SSRI-induced psychosis has accounted for
8% of all general hospital psychiatric admissions over a recent
14-month period. [emphasis added]

The pattern suggests that while SSRIs are a help to the majority of
patients who take them, more needs to be done to make sure that doctors
prescribing the drugs evaluate patients for psychotic predispositions
vulnerable to SSRIs. Such patients may include those with a history of
psychotic illness or early signs of mania.

“What is surprising is that this particular group of side effects is
really
underplayed,” Dr. Bowers said.