Thursday, 21 August 2003
This presentation is part of : Pharmacotherapy of Depression

S083-004 Policy of Pharmacotherapy in Elderly Depressed Patients in Primary Care; Guidelines and Sociodemographic and Clinical Determinants

Anita C. Volkers, Peter F.M. Verhaak, and Francois G. Schellevis. Mental Health Care, NIVEL (Netherlands Institute for Health Services Research), Utrecht, Netherlands

Objective: The Dutch primary care guidelines for depression (1994) recommend treatment with tricyclic antidepressants (TCAs) in case of severe depression. Selective Serotonin Reuptake Inhibitors (SSRIs) are the second choice in presence of contraindications, risk of suicide and severe side effects of TCAs. The new guidelines (2003) will reasonably advice an equal role for both antidepressants. We investigated the actual policy regarding antidepressant treatment by general practitioners (GPs) in elderly depressed patients. This policy was compared with the clinical guidelines and studied in relation to sociodemographic and clinical factors of the patients. Design: In the second Dutch national survey of general practice (2000-2001) GPs registered electronically during one year all contact diagnoses and prescriptions for medication. Disease episodes were constructed based on contact diagnoses belonging to the same health problem. From the patients >55 year (n=84663) we selected those with one or more episodes “depressive feeling” and/or “depression” (n=3326). Materials and Methods: GPs classified complaints and diseases according to the International Classification of Primary Care (ICPC). The ICPC codes P03 and P76 refer to a down/depressive feeling and depression respectively. Prescription rates of antidepressants were evaluated in relation to severity of depressive symptoms and first choice medication according to the guidelines. Chi-square tests were used to investigate whether sociodemographic factors (age, gender, educational level, ethnicity and insurance type) and clinical characteristics (severity of depressive symptoms and presence of somatic comorbidity and other psychological problems than depression) were determinants of the SSRIs/TCAs (number of patients) prescription rate. Results: Six hundred six patients had one or more episodes depressive feeling, 2654 patients one or more episodes depression and 66 patients both an episode depressive feeling and depression. Antidepressants were prescribed in 77.6% of the patients divided in 49.8% of the patients with an episode depressive feeling and 83.8% of the patients with an episode depression. SSRIs were most frequently prescribed (60.4%) and TCAs held the second place (23.7%). The prescription rate SSRIs/TCAs was significantly higher in men (4.0) than in women (2.8) (p<0.01). Severity of depressive symptoms and presence of cardiovascular diseases, diseases of the endocrine, metabolic and nutritional system and psychological problems did not influence this rate. Conclusion: The majority of elderly primary care patients with a diagnosis depression received antidepressant treatment. It was remarkable that GPs were not conservative in prescribing antidepressants in case of less severe symptomatology. SSRIs were most frequently prescribed, which was not in agreement with the existing guidelines, but more in line with the expected guidelines of 2003. The preference for SSRIs instead of TCAs was partly explained by gender but clinical characteristics seem to play no role. Future research will focus on the role of education and promotion activities of the pharmaceutical industry on the decision making process of GPs with regard to prescribing antidepressants.

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