Psychotropic drug use and correspondence with psychiatric diagnoses in the mental health in the general population survey

OBJECTIVES: The aims of this study were to assess the lifetime prevalence rate of psychotropic drugs use in the French general population and the correspondence between psychotropic drug use and psychiatric diagnoses. METHODS: Data were derived from the multicentric survey mental health in the general population, carried out in 47 French public sites between 1999 and 2003. A face-to-face questionnaire was used to interview a representative sample of French metropolitan subjects, aged 18 and over, noninstitutionalized or homeless. These subjects were recruited using quota sampling for age, sex, socioprofessional and education levels, according to data from the 1999 national French population census. Lifetime use of psychotropic drugs was explored by an open question. Psychiatric diagnoses were identified using the mini international neuropsychiatric interview (MINI). A national database was then constituted by pooling data from all sites, weighted for age, sex, level of education, socioprofessional level and work status, to be representative of the French general population. RESULTS: Of the 36785 individuals included in this study, more than one out of three subjects reported having used at least one psychotropic drug during their life. Anxiolytics were the most commonly used drugs, reported by 19.4% of the sample. The other frequently used psychotropic drugs were antidepressants (11.6%) and hypnotics (9.2%). Nearly half of the subjects with a MINI diagnosis reported no lifetime psychotropic drug use. Among the subjects meeting criteria for a diagnosis of mood disorder, 66.3% used psychotropic drugs. However, less than one out of three subjects with a diagnosis of major depressive disorder used antidepressants while 37.2% reported having used anxiolytics. Less than one out of four subjects with a diagnosis of anxiety disorder used antidepressants while 34.3% used anxiolytics. Among subjects with a diagnosis of anxiety disorder, antidepressants and anxiolytics were the most commonly used drugs for subjects with a diagnosis of panic disorder with agoraphobia (46.4 and 58.1%, respectively). Conversely, these were the treatments used the least by subjects with a diagnosis of generalized anxiety disorder (21.9 and 31.5%, respectively). Only 14.9% of subjects with a psychotic syndrome reported having used neuroleptics. Lastly, the highest proportion of subjects with at least one psychiatric diagnosis was found in mood stabilizer and neuroleptic users. However, one third of mood stabilizer users, a quarter of neuroleptic users and less than half of antidepressant and anxiolytic users presented no psychiatric disorder identified by the MINI. CONCLUSION: This study highlights the high frequency of exposure to psychotropic drugs in the general French population, and the marked inadequacy between the presence or absence of a psychiatric diagnosis and the lifetime presence or absence of a psychotropic drug treatment.     

Integration of a psychiatric service in a long-term charitable facility for people with intellectual disabilities: a 5-year medication survey

Since the implementation of a psychiatric service in a long-term facility for people with intellectual disability, the usage of psychotropic and anti-convulsant drugs has been surveyed over the 5-year period 1994-1999. At that time, although the overall prevalence rate of residents on medication was not declining significantly, a decrease in number, dosage and polypharmacy of those receiving neuroleptic drugs occurred than 1994. A reduction also resulted among the in-patients prescribed anxiolytic preparations, despite a relative increase in their mean daily intake. Anti-convulsant drugs climbed slightly during the same interval with a parallel increase in the mean daily dosage. A retrospective comparison of current findings to prevalence, dosage and type of psychoactive medications dispensed 10 years previously in 1989 revealed no trend towards drug rationalisation. Until interdisciplinary training programmes as well as effective community services combining disability and mental health needs are forthcoming, a therapeutic approach involving early psychiatric inputs may contribute to ensure a more rational prescribing practice for long-stay adults with intellectual disability who are referred for neuro-psychiatric consultation.     

Prevalence and appropriateness of psychotropic drug use in old age: results from the Berlin Aging Study (BASE)

BACKGROUND: The aim of this epidemiological study is to examine the prevalence and correlates of psychotropic drug use in the very old and to evaluate the appropriateness of psychotropic drug use in very old age. METHODS: Data from the Berlin Aging Study (BASE), a multidisciplinary study of an age- and gender-stratified, randomly selected sample of elderly people living in Berlin are presented. Over-sampling, especially very old men, allows for powerful analyses of this population. All participants went through extensive psychiatric and somatic examinations. Medication intake was assessed by different data sources (interviewing patients and their family physicians, drug inspection at home). Results were brought together in a consensus-conference and research physicians gave operationalized ratings of medication appropriateness. RESULTS: The prevalence of elderly people who were taking at least one psychotropic medication within the 14 days immediately preceding investigation was 29.8%. Of these medications, 68.4% had been taken for longer than one year. There was no effect of age or gender on the scope of psychotropic drug use. Benzodiazepines were taken by 19.8% of the elderly. Antidepressants, neuroleptics and anti-dementia drugs were taken by about 3-4% each. People taking psychotropic drugs had significantly higher levels of psychiatric morbidity, as measured by syndromes and specified diagnoses. Psychotropic drugs were significantly less often judged to be indicated than somatic medications. This is mostly due to benzodiazepines. CONCLUSIONS: Psychotropic drug use is common in old age, but there is no additional increase in usage beyond the age of 70. Intake of psychotropics is mostly oriented at symptoms or syndromes, which explains why benzodiazepines are still the most commonly prescribed psychotropics.     

A follow-up study of prescribing for people with learning disabilities previously in National Health Service care in Leicestershire, England

A 6-year follow-up was undertaken of 486 people with learning disabilities who in 1990 had lived in institutional care. Despite changes to the nature of accommodation and an extensive drug review programme, the overall proportion of people receiving the different categories of psychotropic drugs remained similar in 1990 and 1996. Only the prescribing of antidepressants was markedly changed. Contrary to expectations the prevalence of prescribing of many psychotropic drugs rose in the community settings.     

Polypharmacy among psychiatric patients.

The purpose of the present study is to determine the frequency of polypharmacy among psychiatric patients in Helsinki, and to ascertain whether this practice is supported by clinical trials. The drugs prescribed in 1 day to a sample of patients (n = 694) in mental hospitals and outpatient clinics in Helsinki were studied. 69% of patients received more than on psychotropic drug in 1 day (61% received "proper" psychotropic drugs). On the average there were 2.1 different psychotropic drugs per patient, and the maximum was 6. A review of controlled clinical trials on the simultaneous use of more than one proper psychotropic drug in psychiatric diseases (excluding fixed combinations) revealed 14 trials. In only three trials was the combination better than its single components or placebo. Thus, there seems to be no evidence from clinical trials defending the frequent polypharmacy. A radical reduction in the number of psychotropic drugs prescribed for psychiatric patients is apparently desirable.     

Prescription of psychotropic drugs in adolescent psychiatry wards in Finland

This point-prevalence study was designed to assess adolescent psychiatrists' practices of prescribing psychotropic drugs in hospital settings, and to compare the practices between the years 1991 and 1999. Data on patients' gender, age, diagnosis and psychotropic medication were obtained by means of a questionnaire sent to four hospital units in Finland. The sample represented 49% in 1991 and 29% in 1999 of all adolescent psychiatric inpatient beds in Finland. Of the patients included in the study, 30% (20/66) in 1991 and 68% (53/78) in 1999 were treated with drugs. The increase was biggest in the proportion of depressive patients and in the proportion of depressive patients receiving drugs. The results of this study suggest that the use of medication may have increased in recent years as new antidepressants and atypical neuroleptics have become available. Prescribing practices appeared to be appropriate, on the understanding that drug therapies are adjunct to other interventions.     

Concomitant psychotropic medication for youths

OBJECTIVE: This study reviewed the clinical research and practice literature relating to the prevalence and patterns of concomitant psychotropic medication given to youths with emotional and behavioral disorders. METHOD: A MEDLINE search from 1996 through spring 2002, including a review of references from relevant published articles and reports, was undertaken to identify available information on concomitant psychotropic medication for youths. RESULTS: The data supporting concomitant psychotropic medication for youths are almost exclusively based on case reports and small-scale, nonblind assessments. In the mid-1990s, over 20% of outpatient youths treated in community mental health centers and over 40% of youths treated in inpatient psychiatric facilities were given concomitant psychotropic medication. The rate has since increased. Psychiatrists more than primary care physicians prescribe concomitant psychotropic medication, and they show great variability in their prescribing habits. Youths with aggressive behavior, male gender, severe emotional illness, and disabling social maladjustment are most likely to receive concomitant psychotropic medication. CONCLUSIONS: Substantive systematic evidence is needed to clarify this increasingly common, inadequately researched child psychopharmacologic practice.     

High-dosage and versatile drug therapy with treatment-resistant psychotic patients.

The author believes that many of the chronic patients in psychiatric institutions and mental health facilities could be helped if physicians were more willing to try different combinations and higher dosages of psychotropic drugs than are commonly used. He presents case studies of two chronic patients who were helped by innovative use of drugs and discusses factors to be considered in implementing high-dosage and versatile drug therapy.     

Psychotropic drug versus psychotropic drug-update

Psychotropic drugs are not necessarily the drugs of psychiatry. Seventy percent of antidepressants, and 90% of anxiolytics are prescribed by nonpsychiatric physicians. Since psychotropic medications are so frequently employed by nonpsychiatric physicians, e.g., neurologists, primary care physicians, internists, and because large numbers of their patients are concurrently on medical drugs for somatic reasons, the interactions of psychotropic versus medical drugs and psychotropic versus psychotropic drugs as listed below must be understood before primary care physicians or psychiatrists prescribe psychotropic medications, especially to the medically ill. Seventy commonly prescribed psychotropic drugs were examined for their interactions with other psychotropic medications using six reference tools: 1) MEDLINE (PubMed) employing the first generic psychotropic drug name, the second generic psychotropic drug name, and the term "interaction;" 2) Hanston's Drug Interaction Analysis and Management Text (quarterly updated version); 3) Drug Interactions Facts (Facts and Comparisons) (July 2001 quarterly updated version); 4) Micromedex Drug-dex; 5) American Hospital Formulary Service Drug Information; and 6) Food and Drug Administration (MedWatch) (Dear Doctor Letters and new labeling) ( for (1999, 2000, and 2001). The authors recognized that all of the above sources do not necessarily cover the entire information database regarding drug-drug interactions. (Citations regarding children, reports in foreign languages or concerning food, animals, in vitro experiments, analgesics, and naturalistic-herbal or natural products-treatment interactions were excluded).     

The use of drug monotherapy in psychiatric inpatient treatment

OBJECTIVE: Monotherapy has always been the goal in psychiatric drug treatment, but it does not seem to be very common in everyday practice. METHOD: The available literature on the frequency of monotherapy or polytherapy with psychotropic agents in psychiatric inpatient treatment is reviewed. FINDINGS: Taken all together (28 studies on 42 treatment facilities), the mean number of psychotropics prescribed was 2.47, the rate of monotherapy was 36.2% and 37.9% of inpatients received > or = 3 different drugs. Comparing the last three decades, a significant decline of the rate of monotherapy was found, topping at 47.8% in the 70s and falling to 19.6% in the 90s. The mean number of psychotropic drugs prescribed rose from 2.2 to 2.9 and the number of patients receiving > or = 3 psychotropics rose from 27.5 to 49.7%. CONCLUSION: Though it is still mandatory to avoid unsound polypharmacy, we must assume that the occasions for polypharmacy are increasing. New psychotropic drugs, increasing comorbidity and augmentation strategies may be incentives for polydrug use. Since in most countries the number of psychiatric beds declines, inpatient treatment has to deal with the most severe, often treatment-resistant patients requiring special therapies.     

Off-label psychopharmacologic prescribing for children: History supports close clinical monitoring

The review presents pediatric adverse drug events from a historical perspective and focuses on selected safety issues associated with off-label use of medications for the psychiatric treatment of youth. Clinical monitoring procedures for major psychotropic drug classes are reviewed. Prior studies suggest that systematic treatment monitoring is warranted so as to both minimize risk of unexpected adverse events and exposures to ineffective treatments. Clinical trials to establish the efficacy and safety of drugs currently being used off-label in the pediatric population are needed. In the meantime, clinicians should consider the existing evidence-base for these drugs and institute close clinical monitoring.     

Characteristics of nursing home patients who receive medications with the potential for addiction on a regular and long-term basis: A retrospective pilot study

Benzodiazepines are among the most commonly prescribed drugs in nursing homes. Other potentially addictive drugs, including other sedative/hypnotics and oral narcotics, are also prescribed quite frequently. These drugs are not always prescribed for appropriate clinical indications, may be prescribed for extended periods of time and may cause significant side-effects. Among the concerns about the regular use of these medications is their potential for abuse and dependence. In this study, we examined the records of 253 consecutive psychiatric consultations in nursing homes. All consultations were performed by the senior author. At the time of consultation, one-third of the subjects were receiving a potentially addictive drug on a regular, and usually daily basis. We compared the group receiving these drugs and the group not receiving these drugs on several variables, including psychiatric and family histories, psychopharmacologic treatments, personal and family addiction histories, psychiatric diagnoses and clinical symptoms. This article presents the results of this study. There were 84 patients in the addictive drug use group and 167 patients in the addictive drug non-use group. We found that regular use of these drugs was associated with several variables. These included the possibility of a biologic vulnerability to addiction, the presence and severity of the psychiatric disorder(s) of the patients, and the third was the presence of major depression or depressive symptoms. The implications of these data are reviewed. In addition, methodologic and diagnostic issues are discussed. The implications for clinical practice and future research in this area are also discussed.     

National prescribing practices of adolescent psychiatrists for psychotropic medications in outpatient care in Finland

We studied national prescribing practices for psychotropic drugs in adolescent psychiatric outpatient care in Finland in the cross-sectional survey study in 1999. A questionnaire was sent to the adolescent psychiatrists employed in the community outpatient clinics covering all Finland. The response rate was 81% (n=34). On average, the respondents reported that 33% of their outpatients were treated with drugs. Selective serotonin reuptake inhibitors (SSRIs) were the drug of choice in the treatment of depression and obsessive-compulsive disorder (OCD). Atypical antipsychotics played an important role in the treatment of psychotic adolescents. Adolescent psychopharmacology is an important and developing part of treatment of mentally disordered young people, on the understanding that drug therapies are adjunct to other treatment interventions.     

Direct service staff and their perceptions of psychotropic medication in non-institutional settings for people with intellectual disability

Previous studies have surveyed a variety of service providers in school and institutional settings, and reported a pervasive lack of education and training with regard to the use of psychotropic medication in people with intellectual disability. Because an increasing number of people with intellectual disability are living in the community and since many of these people receive psychotropic medications, the present study extended research in this area by surveying direct service staff to determine their perceptions, knowledge and opinions with regard to the use of psychotropic medication in non-institutional settings for individuals with developmental disabilities. Consistent with the findings of previous studies, a majority of the 334 respondents in the present study reported that they had not received adequate training in the area of drug treatment. The knowledge and skills deficits of direct service staff appear to represent a significant barrier to the appropriate monitoring and management of pharmacotherapy for individuals with intellectual disability. Therefore, a systematic training programme to educate direct service staff about psychotropic medication needs to be designed, implemented and disseminated on a broad scale.