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Utilisation of psychotropic medications

Department of Social Sciences, University of Applied Sciences, Kurt-Schumacher-Strasse 6, 33615 Bielefeld, Germany. E-mail: cornelia.thiels{at}fh-bielefeld.de

The timely article by Verdoux & Bégaud hopefully begins to redress the imbalance between randomised controlled trials and other ways of evaluating drug treatments. I would like to present further evidence for the ‘gap between guidelines and utilisation... for psychotropic medications’ (Verdoux & Bégaud, 2004).

Using the Drug Report of the German Public Health Insurance (Schwabe & Pfaffrath, 1996), which is a database of all prescriptions reimbursed by the general health insurance system (which accounts for more than 80% of all prescriptions), and a database from the Institute for Medical Statistics, Frankfurt/Main, which refers to a representative sample of 2806 physicians in private practice who report four times a year all prescriptions during 1 week, we found that only 14% of prescriptions for neuroleptic drugs were for schizophrenic psychoses, 18% for other paranoid psychoses and 5% for affective disorders (Linden & Thiels, 2001). Almost half of the neuroleptic prescriptions were written for patients aged 65 years or older. Over the period 1986 to 1995 the prescribing of neuroleptics increased steadily in parallel with a decrease in prescriptions for benzodiazepines.

Also I would like to contradict the assumption that antipsychotics are ‘mainly prescribed by specialists’ (Verdoux & Bégaud, 2004). Using the pharmaco-epidemiological data described above, we found that only 40% of neuroleptic drugs were prescribed by psychiatrists/neurologists (i.e. by Nervenärzten who trained in both specialties, as most German psychiatrists and neurologists do).

Data from a 6-month prospective drug utilisation observation study on 3858 women and 1594 men prescribed the selective serotonin reuptake inhibitor sertraline shows that it is not only the type of psychotropic drug that determines whether it is ‘commonly prescribed by primary care practitioners’ (Verdoux & Bégaud, 2004) but also the gender of the patient. A higher percentage of women with depression were treated by general practitioners, compared with men with depression who were more likely to be seen by psychiatrists, although women were more likely to present with recurrent rather than first-episode depression and to have been previously treated for depression.

EDITED BY KHALIDA ISMAIL

Declaration of interest

C.T. has twice been paid for writing publications for drug companies, most recently for Boehringer Ingelheim Pharma KG, Germany.

REFERENCES

Linden, M. & Thiels, C. (2001) Epidemiology of prescriptions for neuroleptic drugs: tranquillizers rather than antipsychotics. Pharmacopsychiatry, 34, 150 -154.[Medline]

Schwabe, U. & Paffrath, D. (eds) (1996) Arzneiverordnungsreport, 96. Jena: Gustav Fischer.

Thiels, C., Linden, M., Grieger, F., et al (2005) Gender differences in prescribing and treatment outcome of the SSRI sertraline in depressed outpatients. International Clinical Psychopharmacology, in press.

Verdoux, H. & Bégaud, B. (2004) Pharmaco-epidemiology: what do (and don't) we know about utilisation and impact of psychotropic medications in real-life conditions? British Journal of Psychiatry, 185, 93 -94.[Free Full Text]

Authors' reply

Université Victor Segalen Bordeaux 2, Hôpital Charles Perrens, 121 rue de la Béchade, 33076 Bordeaux Cedex, France. E-mail: helene.verdoux{at}ipso.u-bordeaux2.fr

EDITED BY KHALIDA ISMAIL

Declaration of interest

H. V. has acted as a consultant to the pharmaceutical companies Bristol-Myers-Squibb, Eli Lilly, Janssen-Cilag, Lundbeck and Sanofi-Synthélabo.

The German findings on antipsychotic prescription in naturalistic conditions provide a good illustration of the question raised in our editorial regarding the risk of widespread use of antipsychotics in primary care (Verdoux & Bégaud, 2004). Contrary to the statement of the author, there is no contradiction between her point of view and ours regarding the fact that antipsychotics are widely prescribed in primary care. The exact quotation of our text is ‘drugs assumed to be mainly prescribed by specialists, such as antipsychotics’, suggesting that there may be differences between assumptions and facts. The German findings are strikingly similar to those obtained using the social security insurance database in Aquitaine (south-west France), showing that general practitioners (GPs) were the most numerous prescribers (64%) of risperidone, followed by psychiatrists (34%) (Martin et al, 2004). More recently, we have carried out a survey questionnaire mailed to all GPs (n = 3829) practising in Aquitaine to explore management of early psychosis in primary care, with a response rate of 23% (further details available from the authors on request). As part of this survey, we collected data on prescription behaviour. We found that over the preceding month, one out of three GPs (34%) initiated at least one new treatment with one of the antipsychotic drugs marketed in France at this time (amisulpride, olanzapine, risperidone). Over the same 1-month period, nearly half of GPs (42%) reported a visit from at least one pharmaceutical company representative promoting these antipsychotic drugs. Hence, we have further reason to feel concerned by the widespread use of these drugs in primary care, probably, at least in part, as a result of drug promotion. As proposed by Thiels, it is thus of great interest to explore which specific subgroups are at greater risk of being exposed to increased use of antipsychotics. With respect to the hypothesis that there may be a trend favouring antipsychotic instead of benzodiazepine prescription in elderly patients, it is however difficult to conclude that such a strategy is more risky than beneficial for this population, considering the risks potentially associated with benzodiazepine prescription in the elderly (Verdoux et al, 2004).

REFERENCES

Martin, K., Bégaud, B., Verdoux, H., et al (2004) Patterns of risperidone prescription: a utilization study in south-west France. Acta Psychiatrica Scandinavica, 109, 202 -206.[CrossRef][Medline]

Verdoux, H. & Bégaud, B. (2004) Pharmaco-epidemiology: what do (and don't) we know about utilisation and impact of psychotropic medications in real-life conditions? British Journal of Psychiatry, 185, 93 -94.[Free Full Text]

Verdoux, H., Lagnaoul, R. & Bégaud, B. (2004) Is benzodiazepine use a risk factor for cognitive decline and dementia? A literature review of epidemiological studies. Psychological Medicine, 35, 1-9.

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