Results of a brief survey on the prescribing practices for monoamine oxidase inhibitor antidepressants

Four hundred eighty-five psychiatrists in Pennsylvania and Delaware responded to a survey of prescribing practices for the monoamine oxidase inhibitor (MAOI) antidepressants. Although the low response rate (34%) limited the generalizability of the results, the similarity between respondents and the total sample surveyed argued against gross sampling bias. The authors found that only a minority of psychiatrists (25%) prescribe MAOIs regularly, despite a relatively low rate of reports of serious sequelae from hypertensive crises or other side effects. They also found that a substantial number of psychiatrists who regularly prescribe MAOIs also report prescribing high doses and combining therapy with tricyclics, lithium, neuroleptics, and psychostimulants. These findings have implications for postmarketing research on psychotropic drugs.     

Psychiatrists and their prescribing practices

Of all the variables that influence the decision to treat psychiatric symptoms with medication, the characteristics of the physician have been studied the least. A survey questionnaire was sent to one-third of the Massachusetts Psychiatric Society membership; 48% responded. They were asked to note their prescribing practice for four common psychiatric symptoms (anxiety, depression, mood swing, and though disorder) at three levels of magnitude (mild, moderate, and severe). The results were evaluated with the respondent's age, sex, type of practice and treatment orientation acting as independent variables. At the mild and severe symptom extremes, there was generally little disagreement about the use of medication. In the moderate range, however, differences in ideology influenced practice significantly. Age and gender differences were also found to exert a significant influence.     

A preliminary study of serotonergic antidepressants in treatment of dysthymia

Rosenthal, Jesse et al. A Preliminary Study of Serotonergic Antidepressants in the Treatment of Dysthymia. Prog. Neuro-Psychopharmacol. & Biol. Psychiat. 1992, 16(6): 933–941.

1. 1. There is increasing evidence that antidepressants may alleviate symptoms of dysthymia, but few prior studies on selective serotonergic agents.

2. 2. Twenty patients meeting criteria for dysthymia, but not meeting criteria for major depression, received open label trials of a serotonergic antidepressant, either fluoxetine or trazodone.

3. 3. Seventeen (85%) completed three-month medication trials, and of these, twelve (70.6% of completers) responded to treatment. Seven (41.2% of completers) were still in remission on followup at five months.

4. 4. Both fluoxetine and trazodone were well tolerated in dysthymics, and showed similar short-term effectiveness in treating dysthymic symptoms.

Editor's introduction: antipsychotic prescribing practices

This commentary is an introduction to a set of articles reviewing antipsychotic prescribing practices for individuals with schizophrenia, noting where these practice patterns conform to or deviate from evidence-based practice, and identifying the pressing research questions raised by these variations. The delineation of practices supported by the evidence base is crucial for the practical concerns of creating practice guidelines and monitoring performance, as well as for identifying areas where the reach of clinical practice must exceed the grasp of current knowledge. These gaps in knowledge should guide the development of a research agenda that addresses pressing questions commonly confronted in everyday practice. We know from the Schizophrenia Patient Outcomes Research Team (PORT) project and other surveys that clinically significant research findings are not making their way into practice. Additionally, as the articles assembled here indicate, questions of pressing importance in routine practice have yet to make their way into research agendas.     

Antidepressant prescribing practices for the treatment of children and adolescents

OBJECTIVE: This study evaluates pediatric antidepressant prescribing practices of Nebraska clinicians. METHODS: Surveys were sent in July, 2005, to 1,521 prescribing clinicians throughout Nebraska to assess pediatric antidepressant use along with any practice changes following the U.S. Food and Drug Administration (FDA) "black box" warning issued in October, 2004. RESULTS: Over half (n = 866) of the clinicians responded to the survey, of which 96.8% reported awareness of the FDA "black box" warning. Of the respondents, 76.9% (n = 666) were prescribing antidepressants to children and/or adolescents. Clinicians reported decreased prescribing frequency for both children (15.5%) and adolescents (36.6%), with 36% having increased referrals to specialists. While 31.9% reported seeing patients more frequently upon initiation of antidepressants, only 7.5% reported weekly visits for the first month of treatment, as recommended by the FDA. Over one fifth (21.9%) reported a caregiver or patient had refused antidepressant medication treatment due to the FDA's warning. CONCLUSION: Clinicians in Nebraska report changes in clinical practice due to the issuance of the FDA "black box" warning, with a decrease in prescribing antidepressants to pediatric patients and an increase in referrals to specialists. Although awareness of the FDA's warning was evident among clinicians and patients, adherence to recommended guidelines was low.     

A survey of prescribing practices for monoamine oxidase inhibitors.

OBJECTIVE: A survey examined prescribing practices for monoamine oxidase inhibitors (MAOIs) and explored reasons for the widely noted decline in their use. METHODS: A one-page questionnaire was sent in 1997 to 1,129 members of the Michigan Psychiatric Association. A total of 717 responses were received, for a response rate of 64 percent. Only data from the 573 psychiatrists who were currently practicing were used. RESULTS: Twelve percent of the respondents never prescribed MAOIs, 27 percent had not prescribed them for at least three years, and 17 percent had prescribed them from one to three years ago. Thirty percent of the respondents had prescribed an MAOI within the past three months, and 14 percent between three and 12 months ago. The most frequent reasons for not prescribing the drugs were side effects and interactions with other medications (46 percent), preference for other medications (30 percent), and dietary restrictions necessary for patients taking MAOIs (19 percent). Ninety-two percent of respondents believed that MAOIs were useful for atypical depression, 64 percent for major depression, 54 percent for melancholic depression, 56 percent for panic disorder, 44 percent for social phobia, 27 percent for dysthymia, 12 percent for obsessive-compulsive disorder, and 19 percent for posttraumatic stress disorder. However, only 2 percent said they would use MAOIs as their first-line treatment in atypical depression, and only 3 percent would use them a first-line treatment in social phobia. CONCLUSIONS: The results document the commonly held view that practicing psychiatrists believe MAOIs are efficacious but use them infrequently, primarily due to concerns about side effects and drug interactions.     

Haloperidol prescribing practices in the general hospital

This study investigates the clinical use of haloperidol within a general hospital. Patients who were prescribed haloperidol were often elderly, seriously ill, and stayed in the hospital longer than average. Only 23% received a psychiatric consultation. Of the patients under study, 80% were prescribed haloperidol on a PRN basis. The most common reason for neuroleptic treatment was to symptomatically manage severe agitation. Organic mental syndromes were rarely documented. Mental status exams were generally absent; the neuroleptic's effect was often omitted, and its use was rarely noted in the discharge summary. It is recommended that more education regarding the use of neuroleptic medication is indicated.     

The impact of psychopharmacology education on prescribing practices

The authors describe a pharmacology education program on the psychiatry service of a Veterans Administration medical center. The program, directed by a clinical pharmacist, includes weekly lectures to medical students and weekly psychopharmacology review rounds for psychiatric residents that are also attended by staff psychiatrists. To determine the impact of the psychopharmacology review rounds on prescribing practices, the authors conducted a retrospective chart review of psychopharmacologic treatment methods before and after the rounds were instituted. The review compared prescribing practices in the two periods and focused particularly on changes in practices related to multiple daily dosages, polypharmacy, prophylactic anticholinergics, and drug use in alcohol withdrawal. The review demonstrated that the teaching effort resulted in a use of psychotropic medications that was more in line with recommendations in the literature.     

Psychiatric prescribing trends and practices in Iowa's prisons

In response to rising pharmacy costs in the Iowa Department of Corrections prison system, a retrospective analysis of psychiatric drug use and expenditures was performed for fiscal years 1990 through 2000. Population-adjusted changes in use and expenditures over time were analyzed in aggregate and by drug class. Expenditures for psychiatric drugs increased 28-fold from $7,974 in 1990 to $381,893 in 2000, or from $291 to $8,138 per 100 inmates, while use increased fivefold. The use of antipsychotics remained relatively constant, but expenditures increased ninefold. In contrast, both use of and expenditures for antidepressants increased tremendously, from $215 to $1,929 per 100 inmates.     

Antipsychotic drugs: can education change prescribing practices?

Forty-two VA Hospitals participated in an evaluation of educational techniques for physicians on the use of psychotherapeutic drugs. The purpose of the study was to determine whether educational techniques, such as articles and videotapes can be instrumental in changing physician prescribing practices so that they are more in conformity with current recommendations. The 2 major findings of the study were that there was less polypharmacy--less use of antiparkinson drugs and less use of antiparkinson drugs for longer than 6 months--and that there were no statistically significant differences among educational groups.     

Managing treatment-emergent sexual dysfunction associated with serotonergic antidepressants: before and after sildenafil

Sexual dysfunction is a common and troublesome side effect associated with selective serotonin reuptake inhibitors and other antidepressants that reportedly occurs in 40%-70% of patients prescribed selective serotonin reuptake inhibitors. Management of this iatrogenic condition has relied on "clinical wisdom" derived over decades primarily from open-label, non-placebo-controlled, selected case and literature review studies. Management approaches fall into four broad categories: 1) antidote, 2) avoidance, 3) augmentation/switching, and 4) adaptation. Until the development of sildenafil (Viagra), none of the existing managements demonstrated clear efficacy in systematic, double-blind, placebo-controlled trials. Renewed interest in treatment-associated sexual dysfunction emerged because of advances in our knowledge of the biological mechanisms of sexual functioning, awareness that sexual dysfunction compromises patient adherence to treatment, and an improved focus on improving disease management outcomes of depression. Recent placebo-controlled studies provide evidence for questioning the effectiveness of earlier approaches to the management of sexual dysfunction side effects, and suggest improved treatment options with sildenafil. Effective management of treatment-emergent sexual dysfunction is a medical necessity in order to prevent relapse and recurrence of serious disorders such as major depression, which are highly treatment responsive but frequently compromised by medication noncompliance due to side effects such as sexual dysfunction.     

Psychiatric resident and attending diagnostic and prescribing practices.

OBJECTIVE: This study investigates whether two patient population groups, under resident or attending treatment, are equivalent or different in the distribution of patient characteristics, diagnoses, or pharmacotherapy. METHODS: Demographic data, psychiatric diagnoses, and pharmacotherapy data were collected for 100 random patient charts of psychiatric residents, and were then compared with 100 random patient charts of attending psychiatrists. RESULTS: Student's t test and chi square analysis suggested no statistically significant differences in the average number of comorbid Axis I diagnoses, percentages of patients with Axis II diagnoses, or major differences in the specific percentages of the 10 most common Axis I diagnoses. Furthermore, there were no statistically significant differences in the average number of psychiatric medications prescribed for pharmacological management of mental illness, or ratios of specific drug classes utilized. CONCLUSION: There seems to be no major differences in patient characteristics or in the treatment techniques that were utilized.     

Effects of chronic antidepressants and electroconvulsive shock on serotonergic neurotransmission in the rat hypothalamus

The hypothalamus may play a critical role in the pathophysiology and treatment of depression. There are two main lines of evidence for this: firstly, many of its functions correspond to those altered in depression; and secondly, many hypothalamic functions are regulated by the serotonergic system, which is a common target of antidepressant treatments. In keeping with observations from other laboratories, we have found that chronic antidepressants and electroconvulsive shock increase serotonergic neurotransmission in the rat hypothalamus by inducing desensitization of presynaptic autoreceptors. We have also found that chronic hypercorticosolemia, which constitutes a model of depression, has an opposite effect. We postulate that presynaptic autoregulation of serotonergic neurotransmission in the hypothalamus may play a critical role in the pathophysiology and treatment of depression.     

Effects of chronic antidepressants and electroconvulsive shock on serotonergic neurotransmission in the rat hippocampus

The hippocampus may play a critical role in the pathophysiology and treatment of depression. There are two main lines of evidence for this: firstly, many of its functions correspond to those altered in depression, and secondly, many hippocampal functions are regulated by the serotonergic (5-HT) system, which is a common target of antidepressant treatments. Chronic effects of antidepressants and electroconvulsive shock (ECS) have been studied by various methods using electrophysiology, in vivo microdialysis or ex vivo neurochemical measurements. The aim of the current review is to point out possible correlations between these studies based on different methods and to suggest neurochemical mechanisms that result in the observed changes in hippocampal physiology and neurogenesis. These changes in hippocampal neurochemistry are reviewed and compared with the abnormalities associated with stress, corticosterone or depression.     

A survey of prescribing practices in the treatment of depression

BACKGROUND: With the increasing number and type of antidepressants available to clinicians, there is a need to better understand current prescribing practices and to what degree these practices reflect research findings. The purpose of this study was to examine prescribing practices in a sample of psychiatrists attending a psychopharmacology review course and compare these results with empirical evidence. METHOD: 439 of 800 clinicians asked (55%) responded to a 10-item questionnaire that was given prior to beginning the review course. Items covered three major content areas: first-line preferences in the treatment of depression, antidepressant agents most associated with certain side effects, and first-line preferences in the treatment of certain depressive subtypes. RESULTS: 214 (49%) clinicians indicated a belief that one antidepressant type is more efficacious than others. Of these 214 clinicians, 103 (48%) indicated selective serotonin reuptake inhibitors (SSRIs) as being most efficacious, while 53 (25%) indicated venlafaxine as being most efficacious; 378 (93%) clinicians indicated SSRIs as their first-line treatment preference. Mirtazapine (56%) was endorsed as most likely to be associated with weight gain, fluoxetine (57%) with sexual dysfunction, paroxetine (48%) with a discontinuation syndrome, and fluoxetine (52%) with agitation. For the treatment of anxious, atypical, and melancholic depression, SSRIs were the first choice of treatment (58%, 57%, and 57%), and for depression with prominent insomnia, mirtazapine and nefazadone (31% and 27%) were the first choices of treatment. CONCLUSIONS: Despite the lack of evidence of a significant difference in efficacy between older and newer agents, clinicians perceive the newer agents to be more efficacious than the older drugs [tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs)] even in the melancholic and anxious depressive subtypes. Similarly, although sexual dysfunction and agitation appear to occur at similar rates with all the SSRIs, fluoxetine was perceived to be most likely to cause these side effects. These findings are significant as they highlight the discrepancy between empirical evidence and clinical practices and suggest that other factors influence clinicians' medication choices in the treatment of depression.