OPINION: Recent Study Critical of Psychotropic Prescribing in the Elderly May Belie Real World Treatment

The number of retirement-age Americans taking at least three psychiatric drugs more than doubled between 2004 and 2013, even though almost half of them had no mental health diagnosis on record, according to a new study published in JAMA Internal Medicine and reported in today's New York Times. The new analysis, based on data from doctors’ office visits, suggests that inappropriate prescribing to older people is more common than previously thought.

In the last decade, prescription rates of drugs like antidepressants, sleeping pills and painkillers generally increased in older people, previous studies have found. The new report captures one important dimension, the rise in so-called polypharmacy — three drugs or more — in primary care, where most of the prescribing happens. One possible solution, the studies researchers offered "would be to give patients and doctors greater access to alternatives, like psychotherapy and stress management." Only about 10 percent of the visits in the analysis included one of these options.

In 1994, Medworks Media Inc., the company that publishes Psychopharmacology Bulletin and this site, launched a journal titled Primary Psychiatry, dedicated to teaching primary care physicians (PCPs) about psychiatry and psychiatrists about primary care medicine. This journal found and reported the undeniable fact that psychotropic medications were underprescribed and that psychiatric maladies were underdiagnosed in the primary care setting. Furthermore, when PCP's prescribed medications for psychiatric conditions, they often prescribed less than therapeutic doses.

Thanks to prominent psychopharmacologists like Stephen M. Stahl, MD, and Micheal E. Thase, MD, the current thinking among experts is to treat particular symptomology in patients with highly tailored pharmaceuticals. This strategy often utilizes "off-label" uses of drugs to help patients, regardless of the particular psychiatric diagnosis.

In no other population is this more important than in that of the elderly. Stahl's Essential Psychopharmacology (Cambridge University Press), for example, details how dementia in older populations may have the pathology and clinical features of comorbid psychiatric illnesses. According to Stahl, "One of the most difficult diagnostic and therapeutic management areas of modern psychopharmacology is depression in the elderly. Depression can not only be mistaken for dementia but can also precede the onset of dementia. In such patients, dementia and depression can be interrelated in many complex ways."

I was primary caregiver to my father for almost five years. He suffered from advanced COPD and esophageal cancer. He was in a wheelchair and on 24-hour oxygen. A brilliant New York trial lawyer, I was immensely fortunate to have his full mental faculties and companionship. His treatments were complex and varied — including both inhaled and oral steroids and antibiotics, diuretics, and treatments for medically induced diabetes, among many other things. He was treated by the best specialists and PCPs at UCLA.

Though he had never suffered a psychiatric illness in his lifetime, over the course of his physical illness, the very classes of drugs called out in JAMA were integrated into his daily regimen. Daily Trazadone and Ambien (PRN) for sleep were critically important since two consecutive nights of poor sleep would bring on pulmonary distress. We were prescribed OxyContin for occasional cuts and falls. Towards the end of his life, I 'snuck' an antidepressant into his cocktail with his pulmonologist's approval. During his three month home hospice, we had access to haloperidol, morphine, ativan, etc. (It is not clear whether the terminally ill elderly were part of the JAMA study.)

On the flip side, geriatric medical organizations have long warned against overprescribing to older people, who are more susceptible to common side effects of psychotropic drugs, such as dizziness and confusion. For more than 20 years, the American Geriatrics Society has published the so-called Beers Criteria for potentially inappropriate use, listing dozens of drugs and their mutual interactions.