Original Study
Antidepressant Prescribing in US Nursing Homes Between 1996 and 2006 and Its Relationship to Staffing Patterns and Use of Other Psychotropic Medications

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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.

Section snippets

Study Design, Sample, and Source of Data

This is a longitudinal panel study of residents admitted to nursing homes between 1996 and 2006. The sample included 12,556 nursing homes from 1996 to 2006. Data sources used in this study included the 1997 through 2007 On-line Survey Certification and Reporting (OSCAR) system8 and the Area Resource File (ARF).9 OSCAR contains both organizational (eg, staffing levels) and resident characteristic data elements (eg, use of antipsychotics). The ARF represents a compilation of data sources such as

Results

Table 1 compares information about resident, organizational, and market factors in 1996 and 2006 in more than 12,000 nursing homes. During that time period physical restraint use decreased despite an increase in the percentage of residents with a psychiatric diagnosis (both comparisons, P < .05). The other statistically significant change (P < .05) was an increase in the percentage of nursing homes with Alzheimer special care units between 1996 and 2006.

Figure 1 shows the increase in

Discussion

This study documents that antidepressant prescribing in nursing homes between 1996 and 2006 has increased by 216%. The rise in the rate of antidepressant prescribing seems to have plateaued to 49.1% as per 2009 third quarter Minimum Data Set 2.0 public quality indicator and resident reports listed on the Centers for Medicare and Medicaid Services (CMS) Web site.19 The rate of antidepressant prescribing in US nursing homes is considerably higher than the rate of 33% reported by Nishtala et al15

Conclusion

Despite these potential limitations, we conclude that the use of antidepressants has increased substantially 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

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      Citation Excerpt :

      Nurse staffing was measured 19 different ways (see Table 2 for details). Hours per resident day was more frequently used (n = 19) (Hyer et al., 2011; Bowblis et al., 2013; McGregor et al., 2014; Backhaus et al., 2017; Konetzka et al., 2008; Alexander, 2008; Boscart et al., 2018; Bowblis and Roberts, 2020; Spector et al., 2013; Hongsoo et al., 2009; Kim et al., 2009; Park and Stearns, 2009; Temkin-Greener et al., 2010; Lee et al., 2014; Chen and Grabowski, 2015; Lerner, 2013; Lin, 2014) compared to full-time equivalents (FTEs) (n = 9) (Castle, 2011; Castle et al., 2011b, 2011a; O'Malley et al., 2011; Hanlon et al., 2010; Wagner et al., 2013; Heeren et al., 2014; Havig et al., 2011) (Castle and Engberg, 2008), full-time equivalents per resident (n = 2) (Heeren et al., 2014; Havig et al., 2011), full-time equivalents per 100 beds (n = 2) (Zuniga et al., 2015; Stutte et al., 2017), minutes per resident day (n = 1) (Flynn et al., 2010), nursing hours per resident week (n = 1) (Cherubini et al., 2012), and nursing staff resident ratio (n = 2) (Cassie, 2012; Cassie and Cassie, 2012). When full-time equivalents were converted to hours per resident day using a formula of (full-time equivalents x 1920 h) / (resident census x 365 days), the average of RN average hours per resident day was 0.43 with a range of 0.15 (Boscart et al., 2018) to 0.85 (Flynn et al., 2010).

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    The authors have indicated that they have no other conflicts of interest regarding the content of this article. This study was supported by National Institute of Aging grants (R01AG027017, P30AG024827, T32 AG021885, K07AG033174, R01AG034056), a National Institute of Mental Health grant (R34 MH082682), a National Institute of Nursing Research grant (R01 NR010135), an Agency for Healthcare Research and Quality grant (R01 HS017695), a VA Health Services Research grant (IIR-06–062), and a NIH Roadmap Multidisciplinary Clinical Research Career Development Award Grant (K12 RR023267).

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