Study Shows Antidepressants Are Often Prescribed Inappropriately in Long-Term Care Facilities

Older long-term care (LTC) residents often experience depression, which has been associated with an increased risk of functional decline, hospitalization, and death in this population. In 1987, a landmark study that included residents of an 1100-bed nursing facility found that more than 40% met the clinical criteria for major or minor depression.¹ Currently, more than 47% of US nursing home residents receive antidepressants, making it the most commonly prescribed treatment for depression in the LTC setting²; however, it is unclear whether antidepressants are being used appropriately in depressed, older LTC residents. A study published in the August issue of the Journal of the American Geriatrics Society found that many LTC residents who require antidepressants are not receiving them and that others are receiving them inappropriately.²

The longitudinal study, led by Joseph T. Hanlon, PharmD, University of Pittsburgh, PA, indicates that a significant number of LTC residents with depression are receiving the wrong antidepressant medications or are being prescribed none at all. Equally worrisome, the study suggests that a significant number of older residents are prescribed
antidepressants despite never receiving a diagnosis of depression or having a health problem that would warrant off-label use of these agents. This is cause for concern because these drugs may have anticholinergic effects, resulting in potentially serious side effects, such as increased risk of falls.

Hanlon and colleagues’ study, which is one of the first to investigate potential overuse of antidepressants in LTC facilities, examined the records of more than 3600 veterans, ≥65 years of age, residing in Veterans Affairs (VA) Community Living Centers. The veterans were admitted to the centers between January 2004 and June 2005 and had stays of ≥90 days. Of the nearly 900 veterans who had a diagnosis of depression, more than 25% did not receive antidepressant therapy, the researchers found. Of those who did receive antidepressants, approximately 43% were prescribed potentially inappropriate drugs, increasing the risk of adverse drug-drug or drug-disease interactions. In addition, underdosing and overdosing problems were seen in nearly 9% of depressed residents. At the same time, 43% of residents who did not have a diagnosis of depression were prescribed antidepressants, despite the lack of any other health problem that might warrant off-label use of these agents.

The researchers note certain limitations to their study. They acknowledge that the prevalence of undertreatment may actually be lower than it appears. For example, they note that a depressed patient may be receiving a form of therapy other than medication. They also note that residents were classified as depressed based on their ICD-9 codes or Minimum Data Set (MDS) assessments, rather than receiving the diagnosis from an independent research psychiatrist, which may have resulted in misclassification.

Despite the study’s limitations, the authors conclude that their findings are a strong indicator that prescribing quality problems exist in VA Community Living Centers. They also warn that these problems are likely not unique to VA facilities.  

The VA is now launching a number of initiatives that will increase the availability and integration of nonpharmacologic services for depression in its nursing facilities, and is stepping up staff education in this area. Additional research examining the treatment of depression and other mental illnesses in public and private nursing facilities, and ways to enhance treatment, are also needed.

References

1. Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Washington, DC: American Psychiatric Association; 1987.

2. Hanlon JT, Handler SM, Castle NG. Antidepressant prescribing US nursing homes between 1996–2006 and its relationship to staffing patterns and use of other psychotropic medications. J Am Med Dir Assoc. 2010;11(5):320-324.