Do co-existing psychosocial problems influence the prescription of psychotropic medication in depressive and anxiety disorders?

Introduction

Antidepressant treatment is recommended when a patient's symptoms meet the criteria for a depressive disorder or an anxiety disorder. Treatment with benzodiazepines is considered to be effective for acute insomnia, acute anxiety and alcohol detoxification when prescribed for a restricted period of time [1–4]. In guidelines for the prescription of these two types of psychotropic drug, no reference is made to specific factors in a patient's circumstances that might cause or contribute to the above-mentioned disorders.

Recently, we systematically explored the opinions of general practitioners (GPs) on the management of depressive and anxiety disorders. They were found to modify their management of depressive and anxiety disorders according to patient-context variables, and they were less inclined to prescribe antidepressants when psychosocial problems or deprivation accompanied a depressive disorder [5]. This was in contrast with benzodiazepines, as these were often prescribed for psychosocial problems [6], [7]. Consequently, we expected that the prescription of antidepressants and benzodiazepines is co-determined by a patient's psychosocial circumstances. Therefore, our objective was to study the influence of co-existing psychosocial problems on the prescription of antidepressants and benzodiazepines in patients with depressive and/or anxiety disorders.

Methods

This case-control study was nested in a study on GPs’ management of mental health problems in 1756 general practice patients [8]. Thirty-two GPs identified participants' mental health problems from their computerized files and recorded them on a pre-constructed list that included depressive disorders, anxiety disorders and psychosocial problems. For the use of the diagnosis of depressive and anxiety disorders in this study, reference was made to widely used national guidelines [1–4]. The prevalence figures of mental health problems in this study are comparable to other Dutch studies [9]. Antidepressant and benzodiazepine prescriptions were identified from the computerized general practice prescription files. Differences in antidepressant and benzodiazepine prescription were assessed in patients with depressive and anxiety disorders with and without co-existing psychosocial problems.

Results

In 124 of the 1756 patients, GPs diagnosed a (mixed) depressive or anxiety disorder: 73 depressive disorders, 30 anxiety disorders and 21 mixed depressive-anxiety disorders. GPs also diagnosed psychosocial problems in 25 of the 73 patients with a depressive disorder, in seven of the 30 patients with an anxiety disorder and in 11 of the 21 patients with a mixed depressive-anxiety disorder.

In the total group of 124 patients, 46 were prescribed an antidepressant only, 49 were prescribed benzodiazepines only, and 20 were prescribed antidepressants and benzodiazepines. The odds ratios for the prescription of the different drugs are presented in Table I. Patients with a depressive disorder and psychosocial problems were more likely to receive prescriptions for benzodiazepines and less likely for antidepressants compared to patients with a depressive or anxiety disorder alone. In the patients with anxiety disorders or a mixed depressive-anxiety disorder, no association was found between the prescription of psychotropics and co-existing psychosocial problems.

Table I.  Odds ratios (95% CI) for antidepressant and/or benzodiazepine prescription by GPs to patients with a (mixed) depressive or anxiety disorder and co-morbid psychosocial problems, compared to patients with a (mixed) depressive or anxiety disorder alone.

Mental health problem	Odds ratio (95%CI) for antidepressant prescription	Odds ratio (95%CI) for benzodiazepine prescription	Odds ratio (95%CI) for prescription of both an antidepressant and a benzodiazepine
Depressive disorder and psychosocial problems	0.4 (0.1–1.1)	5.4 (1.7–16.6)	1.5 (0.3–7.2)
Anxiety disorder and psychosocial problems	1.1 (0.1–3.9)	0.2 (0.02–1.7)	1.1 (0.1–12.4)
Mixed depressive and anxiety disorder	2.6 (0.5–15.3)	2.5 (0.2–32.8)	7.0 (0.1–50.5)

Discussion

The presence of co-existing psychosocial problems seems to influence the prescription of psychotropics by GPs. To our knowledge, this is the first report to present empirical data on the association between psychosocial problems and the prescription of antidepressants and/or benzodiazepines to patients with depressive disorders. These results definitely need confirmation in a larger sample, given the limited power which is reflected in relatively wide confidence intervals. A vignette study on intention-to-treat decisions made by GPs and psychiatrists showed that the prescription of both antidepressants and benzodiazepines increased in patients exposed to stressors and in patients with a lack of social resources [10]. Our data partly support these features in patients with depressive disorders. It remains difficult to explain the variation in psychotropic prescription behaviour.

The importance of these findings is highlighted by the poorer outcomes reported in depressive patients with psychosocial problems than in depressive patients without these problems [11]. It has been argued that, in general practice, there is a role for benzodiazepines to help patients deal with emotional distress, even in the absence of psychiatric disorders [7]. Given the lack of benefit of long-term treatment and the potential hazards of benzodiazepine use, this point of view can be questioned [12–14]. Reductions in depression scores were correlated with reductions in life events and difficulties in patients with a combination of depression and psychosocial problems. It was not established whether single antidepressant drug treatment had a beneficial effect [15].

To guide the treatment decisions of general practitioners (and other mental health care professionals), it is important to study the clinical effectiveness of antidepressants and benzodiazepines in primary care and to take into account the modifying effects of psychosocial problems, such as (major) life events, chronic morbidity and other patient-context characteristics. Given the lack of effectiveness and potential hazards of (long-term) use of psychotropic drugs, GPs should be cautious in prescribing these drugs to patients with mental health problems and psychosocial problems, especially in the long term.