Research report
Clinical factors influencing the prescription of antidepressants and benzodiazepines:: Results from the European study of the epidemiology of mental disorders (ESEMeD)

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Abstract

Objective

To examine factors associated with the use of antidepressants (AD) and benzodiazepines (BZD) in 6 European countries.

Methods

A cross-sectional, population-based study was conducted in: Belgium, France, Germany, Italy, the Netherlands and Spain. 21,425 non-institutionalized individuals aged 18 years and over were interviewed using the third version of the Composite International Interview (CIDI-3.0). Respondents were asked about AD and BZD use, and whether they consulted formal health services for emotional problems in the previous year. Sociodemographic variables, presence of mood/anxiety disorders and of painful physical symptoms were collected.

Results

34.38% and 9.17% of the sample reported the use of AD and BZD respectively in the previous 12 months. Only 29.95% of subjects with a 12-month prevalence of major depressive episode (MDE) had been taking antidepressants. After controlling for several clinical and non-clinical factors, help seeking for emotional problems was the most important independent predictor for the use of AD or BZD (OR: 13.58 and 5.17, respectively). Higher age was the second important predictor (OR: 6.52 and 4.86, respectively). A 12-month or lifetime prevalence of MDE or an anxiety disorder were also predictors for AD or BZD use (OR for MDE: 5.00 and 2.82, OR for anxiety disorders: 2.13 and 1.85). Finally, the presence of painful physical symptoms also predicted the use of AD and BZD, while female gender, lower education and higher age predicted only the use of BZD.

Conclusion

Less than one third of subjects with a 12-month prevalence of MDE had been taking antidepressants. But seeking help for emotional problems was a more important predictor of the use of ADs or BZDs than a formal (DSM-IV) psychiatric diagnosis, suggesting that usage of ADs is not always according to the licensed DSM-IV indication.

Introduction

Epidemiological studies have shown that antidepressants and benzodiazepines are the most common used psychotropic medications in the general population (Allgulander and Nasman, 1991). In a pan-European study (N = 18,679), Ohayon et al. found that at the time of interview 6.4% took a psychotropic medication (Ohayon and Lader, 2002). Anxiolytics were reported by 4.3% of the sample, hypnotics by 1.5% and antidepressants by 1.0%.

For many years, the antidepressant market has been experiencing a double digit percentage sales growth, although sales seem to stabilize more recently (IMS Health). However, the appropriateness of the prescription of antidepressants or benzodiazepines has repeatedly been questioned (Linden et al., 1999). A rather poor relation between diagnosis and prescription has indeed been suggested. On one hand, recent investigations have highlighted that most of those who have a mental disorder are not treated adequately because they do not seek help for emotional problems or because they not always get adequate treatment when they do so. Indeed, results from the National Comorbidity Survey Replication (NCS-R) Study have shown that nearly 58.1% of the persons with a depressive disorder have not used any health service for the treatment of these disorders (Wang et al., 2005). Results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) have shown that 63.5% of those with a 12-month diagnosis of any mood disorder did not consult any type of formal health services and that among those seeking help medication was prescribed in only 71% of the cases (Alonso et al., 2004). Similarly, 73.9% of those with a 12-month anxiety disorder did not consult and among those seeking help medication was prescribed in only 57.3% of the cases. On the other hand, psychotropic medication is also prescribed ‘for a wider range of emotional problems', i.e. in patients without a formal DSM diagnosis. For example, only 31% of subjects in a UK general population study using one psychotropic had a determined current mental disorder, compared with 58% of those using two psychotropics and 85% of those three or more. In a Finnish primary care study, psychotropic medication was prescribed to 70% of the patients with mental symptoms (which was defined much larger than only a formal DSM diagnosis) and to 13% of the patients without any mental symptoms (Joukamaa et al., 1995).

Several studies investigated variables that might influence the (adequacy of) prescription of psychotropic medication. Health care system, physician and patient characteristics have been investigated as well in general population, primary care and psychiatric care samples.

Health care system and physician characteristics have been found to be predictive for prescription patterns. Data from the Psychological Problems in General Health Care (PPGHC) study, an international primary care survey directed by the World Health Organization (WHO), a physician diagnosed depressive disorder (multiple choice list for physicians to report a diagnosis) resulted in the prescription of antidepressants and anxiolytics in respectively 32% and 25% of cases while a Composite International Diagnostic Interview (CIDI) diagnosis of a depressive disorder (depressive disorder current or dysthymia) resulted in even lower prescription rates, i.e. 24% and 25% respectively, suggesting that physicians use other than ICD-10 criteria to make prescription decisions (Linden et al., 1999). For example, physicians working in a ‘client centered’ practice (each patient has an identified personal physician, continuity of care, scheduled visits) prescribed significantly more antidepressants and anxiolytics but significantly less hypnotics than in a ‘clinic centered’ practice (no identified personal physician, walk-in appointments) suggesting that the doctor–patient relationship significantly interferes with the ‘from diagnosis to treatment’ decision making process (Kisely et al., 2000). Female physicians also prescribed psychotropic medication more commonly. Physicians who had had further postgraduate training in psychiatry prescribed significantly more antidepressants but significantly less anxiolytics and hypnotics. The National Comorbidity Survey showed that patients seeking help for depressive or anxiety disorders within the past 12 months received more commonly antidepressants, but only when seeing psychiatrists and not when seeing primary care physicians (Mojtabai, 1999). Moreover, patients with a disorder received more commonly psychotropic medication when they were seen by a psychiatrist while patients without a disorder received more commonly psychotropic medication when they were seen by a primary care physician.

Patient characteristics were also found to be predictive for prescription patterns. Age is probably the most consistent predictor of taking psychotropic medication: the consumption of antidepressants and especially of benzodiazepines increases with age (Joukamaa et al., 1995, Kisely et al., 2000, Nielsen et al., 2004, Ohayon et al., 1998, Olfson et al., 1998, Paulose-Ram et al., 2004). Gender is another predictor of taking psychotropic medication: most studies found that consumption of psychotropic medication is higher in women than in men although some studies no longer found a gender difference after controlling for mental problems (Joukamaa et al., 1995, Kisely et al., 2000, Ohayon et al., 1998, Olfson et al., 1998, Paulose-Ram et al., 2004). Lower educational level, living below the poverty level and being unemployed are other predictors of taking antidepressants and especially of benzodiazepines, although not all studies controlled for different prevalence rates of depressive or anxiety disorders (Joukamaa et al., 1995, Kisely et al., 2000, Paulose-Ram et al., 2004).

A concomitant physical disorder was found to increase the likelihood of using a psychotropic agents. In a large European study (N = 18.679), 2.3% of respondents without mental/sleep disorders or physical disorder, 6.0% of respondents with a physical disorder only, 10.8% of respondents with a mental/sleep disorder only and 24.4% of respondents with a mental/sleep disorder and a physical disorder had a current use of psychotropic medication (Ohayon and Lader, 2002). In a UK study, subjects currently treated for a physical disorder (especially arthritis, backaches, other musculo-skeletal pains and cancer) were more likely to use a psychotropic agent, compared to subjects with no physical disorder (Ohayon et al., 1998). In the same study, subjects were also asked whether they had been consulting a physician for mental health reasons and interestingly this was found to be a highly significant predictor of psychotropic use with about the same relative risk (RR: 3.4, C.I. 2.8–3.9) as a diagnosis of a depressive or anxiety disorder (RR: 2.4, C.I. 1.9–2.9 and 4.9, C.I. 4.4–5.4 respectively). It has also been documented that the proportion of subjects using a psychotropic medication increases significantly with the number of consultations in the previous year (4.8% in those who consulted once or twice; 10.2% in those who consulted a physician 3 to 5 times; and 13.9% in those who consulted 6 times or more) (Ohayon and Lader, 2002).

The aim of this paper was to investigate patient characteristics associated with the use of antidepressants and benzodiazepines. Based on the data collected in the ESEMeD/MHEDEA project that involved an adult population of 21,425 in six European countries (Belgium, France, Germany, Italy, the Netherlands, Spain), we examined the influence of (1) sociodemographic factors, (2) help seeking, (3) diagnosis of mood (major depression episode (MDE) and dysthymia) and anxiety disorders, (4) painful physical symptoms (PPS) and presence of chronic somatic disorders on the use of antidepressants and benzodiazepines.

Section snippets

Sample

The study was cross-sectional in nature and individuals were assessed in person at their homes using computer-assisted interview (CAPI) techniques. The target population was the non-institutionalized adult population of Belgium, France, Germany, Italy, the Netherlands and Spain, a total of 212,000,000 Europeans. In total, 21,425 respondents were interviewed between January 2001 and July 2003. Prevalence estimates were weighted to account for the known probability of selection as well as to

Antidepressants/benzodiazepines use

Table 1 provides the overall prevalence (%) of AD/BZD use according to sociodemographical and clinical factors. Overall, 4.38% (SE = 0.00) of the total sample reported having taken ADs during the 12 months prior to the interview. This was about half of those who reported having used BZDs (9.17%, SE = 0.00) during the same period. In total, 11.68% (SE = 0.00) had used either ADs or BZDs, implying that approximately four in ten of those who used ADs also took BZDs. As expected, the crude prevalence

Discussion

The present study, as a part of the ESEMeD project, investigated the factors associated with the use of ADs or BZDs in a general European adult population. The present results confirm that psychotropic medications are commonly prescribed medications. Indeed, 11.68% of the respondents in these 6 European countries had used ADs and/or BZDs during the last one year.

The main finding in the present study is the suboptimal relation between formal DSM-IV diagnosis and prescription or use of

Summary

Less than one third of subjects with a 12 month prevalence of MDE had been taking ADs. But ‘seeking help for emotional or mental health problems’ was a more important predictor of the use of ADs (and of BZDs) than a formal DSM-IV psychiatric diagnosis suggesting that usage of ADs is often not always according to the licensed indication. Individuals with co-occurring PPS were more likely to take ADs and individuals with PPS or a somatic disorder were more likely to take BZDS in the past

Role of funding source

The EU funding and the GSK funding (see also Acknowledgements) did not interfere with the design, the analysis or the preparation of the manuscript.

Conflict of interest

The authors declare that they do not have a conflict of interest in submitting this manuscript.

Acknowledgements

The ESEMeD survey included in this report were carried out in conjunction with the World Health Organization World Mental Health (WMH) Survey Initiative. We thank the WMH staff for assistance with instrumentation, fieldwork, and data analysis. These activities were supported by the United States National Institute of Mental Health (R01MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (R13-MH066849, R01-MH069864, and R01 DA016558),

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