This study documents that antidepressant prescribing in nursing homes between 1996 and 2006 has increased by 216%. The rise in the rate of antidepressant prescribing seems to have plateaued to 49.1% as per 2009 third quarter Minimum Data Set 2.0 public quality indicator and resident reports listed on the Centers for Medicare and Medicaid Services (CMS) Web site.19
The rate of antidepressant prescribing in US nursing homes is considerably higher than the rate of 33% reported by Nishtala et al15
of 500 elderly residents of aged care homes in 2008 from Australia. Similarly, Cherma et al20
studied nursing homes in Sweden and documented that 38% were prescribed an antidepressant. The increased rate of prescribing seen in our longitudinal US study may be because of the introduction of newer antidepressants perceived to be safer and have greater sensitivity by health care professionals to address undertreatment of major depression and perhaps dysthymic disorders.3,21
The high rate of antidepressant prescribing is of potential concern given their potential to cause clinically significant adverse consequences because of which require specific monitoring and careful consideration of relative risks and benefit.21
This may be in part why CMS included antidepressants in the most recent list of potentially unnecessary medications included in the revised F-tag 329.22
However, several organizations have expressed concern for antidepressants being included in F-tag 329 because antidepressants can be prescribed for conditions other than depression including generalized anxiety disorders, posttraumatic stress disorder, obsessive compulsive disorder, insomnia, neuropathic pain (eg, diabetic peripheral neuropathy), migraine headaches, and urinary incontinence.21,23,24
It is may be informative to examine the factors associated with increasing antidepressant use found in the current study. It would appear that antidepressants are not being used as substitutes for antipsychotics or anxiety agents given the point estimates for the odds ratio for both being less than one. Indeed the use of both classes of these other psychotropic drugs has also increased over the same 11-year time period despite their being heavily regulated in CMS surveyors interpretive guidelines.16
Also of note is that the more time spent by physician extenders and nurse aides, the more likely that antidepressants were prescribed. Although it is not clear what the reason is for the relationship with physician extenders and registered nurses, the finding with nurse aides confirms information from other studies about their important role in influencing decisions about psychotropic medications.10–13
Currently, nursing homes are under increasing legislative pressure to improve staffing levels.25
Our findings would seem to indicate that if the least expensive increases in staffing are initiated (eg, just more nurse aides), then this may influence antidepressant use.
It was reassuring though that the more time spent on-site by primary physicians and medical directors may counteract the rise in antidepressant use. This is consistent with a recent article by Rowland et al,26
that the presence of certified medical directors is an independent predictor of nursing home quality (including the number and severity of deficiency citations, including F-329). This is also consistent with the countervailing influence clinically trained staff can have on quality of care in nursing homes.
There are several potential limitations worth noting. Information about the type, dose, duration, or specific indication for antidepressant prescribing was not available. Therefore, inferences about the quality of prescribing cannot be made. However, a previous study by Brown et al5
found that nearly one third of nursing home residents either received a suboptimal antidepressant choice (ie, tricyclic antidepressants) or dose. Another limitation is that additional information about physician characteristics was not available in these data sources. Having additional information about physician characteristics, such as their type of training (internal versus family medicine), whether or not they completed a geriatric medicine fellowship, or completed additional nursing home–specific training (eg, certified medical director) would help to better understand prescribing patterns. Finally, it is unknown what the generalizability of this study is to other countries because antidepressant prescribing rates seem to be significantly higher in the United States when compared with other countries.