Antidepressants in primary care: Is this how to treat depression?

Antidepressants, now the third-most commonly prescribed class of drugs in the United States, are routinely offered to patients with vague complaints of fatigue, pain and malaise but who are not classified as suffering from a mental disorder by the physician who recommends the treatment, says a new study. And among primary care provider as well as specialists who are not psychiatrists, the practice of prescribing these medications without diagnosing depression is rising steeply, the study finds.

Published Thursday in the journal Health Affairs, the survey of office visit records between 1996 and 2007 tallies the growing role of Americans’ busy primary care physicians as first-line providers of mental health care to American patients. But it also suggests a disturbing implication of that trend: that many patients may not be getting the treatment most likely to help them.

“In general medical practice, antidepressant use appears to be becoming concentrated among people with less severe and poorly defined mental health conditions,” wrote Johns Hopkins University public health researcher Ramin Mojtabai and Columbia University psychiatrist Mark Olfson. Yet, mounting research evidence has found that “antidepressants have little or no therapeutic effect on these milder conditions,” the authors said.

Meanwhile, they wrote, “a large proportion of patients with common mental disorders do not receive needed treatment because their primary care providers do not detect their conditions.”

Dr. William Narrow, associate director for research at the American Psychiatric Assn. called the study well done and “very valuable.”

“What this data suggests is that there’s likely to be a tendency to err on the side of treatment” when a patient complains to his or her physician about generally low mood or energy, said Narrow. In such cases, referring a patient to psychotherapy, or recommending behavioral changes such as reducing alcohol consumption or getting more sleep and exercise would be a preferable first step, he added. But for a physician pressed for time, a prescription might seem a better bet.

In the 12-year period leading up to 2007, almost one-in-ten visits to a primary care physician (9.3%), resulted in the patient coming away with a prescription for an antidepressant, the study found. But in only 44% of such cases did the doctor make a formal diagnosis of major depression or anxiety disorder. A visit to a medical specialist who was not a psychiatrist (say, a cardiologist or an endocrinologist) was less likely to result in an antidepressant prescription (3.6% of visits did so). But these specialists were even less likely than were primary care doctors to diagnose a mental disorder justifying the prescription (they did so in only 12.8% of such visits), the study showed.

That trend escalated between 1996 and 2007, as both primary care physicians and specialists stepped up their prescribing of antidepressants. Even as they did so, fewer and fewer of the patients who got those prescriptions got a psychiatric diagnosis along with their pills, the authors found.

Physicians’ concerns that a psychiatric diagnosis could be stigmatizing to a patient have often discouraged some from putting such a finding into that patient’s medical record. But such concerns do not help explain the trend found by Mojtabai and Olfson, since the researchers were looking at records in which both patients’ and care providers’ identities are protected. In the records they reviewed, the researchers declared, physicians “have little motivation to deliberately withhold psychiatric diagnoses.”

And yet, withhold them they did.

Dr. Jeffery Huffman, a consulting psychiatrist at Massachusetts General Hospital, said that primary care physicians are often best positioned to recognize changes in a longtime patient’s mood that might suggest disabling depression or anxiety. But without an accurate evaluation, careful and sometimes complex medication management, and proper follow-up, “we’re kind of in the dark ages,” he said.

One problem, says Huffman: Primary care physicians and medical specialists rarely have partnerships that would make a mental health professional easily accessible to their patients. So, many patients who could benefit from behavioral guidance and psychotherapy don’t get it. In an interview, Huffman said that may start to change with research such as that published this week, and as more “collaborative care” practices spring up, encouraged by provisions of the new federal healthcare lawt. Such practices would integrate the mental health care and medical treatment of patients with chronic diseases and complex health issues.

Americans spend $10 billion on antidepressants yearly. To explore further the data on antidepressant prescribing collected by Practice Fusion, a San Francisco provider of free, web-based electronic health record applications, check this out.

And to learn about depression and its link to heart disease, see here. To read about depression and its link to pain, read this. To read about alternatives and adjuncts to medication for depression, look here.