Seniors Receiving Multiple Psychiatric Drug Prescriptions More Often

A new study concludes that the rate of outpatient visits that result in seniors being prescribed 3 or more drugs that affect the central nervous system (CNS) has more than doubled over a 10-year span.

A team of researchers used survey data from the 2004 through 2013 National Ambulatory Medical Care Survey (NAMCS) to evaluate how frequently 98,000 patients age 65 and older were prescribed at least 3 CNS medications during a single office visit between the years 2004 and 2013.
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The investigators included antipsychotics, benzodiazepines, non-benzodiazepine benzodiazepine receptor agonists, tricyclic antidepressants, selective serotonin reuptake inhibitors, and opioids in their examination. They recorded up to 3 visit diagnoses and included NAMCS-collected information such as chronic medical conditions, whether psychotherapy was provided or ordered, whether stress management or other mental health counseling services were provided or ordered, and time spent with physician.

Overall, the authors found that estimated polypharmacy visits in the United States rose from 1.5 million to 3.68 million in the timeframe they studied, with the largest increases found among rural patients and those with a pain diagnosis. Women and rural patients accounted for 68.1% and 16.6% of CNS polypharmacy visits, compared with 55% and 10.5% of non-polypharmacy visits. While mental health or pain diagnoses were more common among the polypharmacy group, 45.9% of the polypharmacy visits included neither mental health nor pain diagnoses. A small minority of polypharmacy visits included psychotherapy (5.3%) or stress management (6.7%), according to the authors.  

Given these findings, "I would hope that primary care providers talk with their patients about the rationale for each medication that is prescribed and whether the benefit outweighs the risks, especially when opioids are also being prescribed," said Donovan Maust, MD, MS, an assist professor of psychiatry at the University of Michigan Health System, and lead author of the study. "While patients may get accustomed to particular medications, many do well with a gradual taper."

At the individual patient level, "the results suggest that increased efforts should be made in primary care to make non-pharmacological treatments available for common health complaints of older adults," added study co-author Mark Olfson, MD, MPH, a professor of psychiatry at Columbia University Medical Center. These efforts, he said, might include psychotherapy and behavioral relaxation techniques for anxiety, sleep hygiene for insomnia, and physical therapy, exercise, and NSAIDs for some forms of chronic pain, for example.

"At a systems level," continued Olfson, "expansion of collaborative care, which involves embedding mental health professionals in primary care practices, and telehealth may help provide older patients with greater access to non-pharmacological treatment options for these common complaints."

—Mark McGraw

Reference

Maust DT, Gerlach LB, Gibson A et al. Trends in central nervous system-active polypharmacy among older adults seen in outpatient care in the United States [published online February 13, 2017]. J Intern Med. doi:10.1001/jamainternmed.2016.9225.