Original Study
Antidepressant Prescribing in Older Primary Care Patients in Community and Care Home Settings in England and Wales

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Abstract

Objective

To compare the prevalence and predictors of antidepressant prescribing in older care home and community residents in England and Wales.

Design

Retrospective analysis of primary care consultation and antidepressant prescribing data.

Setting

The setting included 326 general (family) practices in England and Wales supplying data to The Health Improvement Network database between 2008 and 2009.

Participants

Participants were 10,387 care home and 403,259 community residents aged 65 to 104.

Main Outcome Measure

Antidepressant prescription in the last 3 months of recorded data for each patient.

Results

Prevalence rates for antidepressant prescribing were 10.3% (95% confidence interval 10%–10.6%) for community and 37.5% (36.2%–38.9%) for care home residents. After excluding low-dose tricyclics (often used for other indications) prevalences were 7.3% (7.1%–7.5%) and 33.6% (32.3%–34.9%) respectively; of these, 21.7% (20.8%–22.6%) of community and 4.8% (3.9%–5.6%) of care home prescriptions were for antidepressants advised as best avoided in this age group. After indirect standardization for age, sex, and chronic disease prevalence, the ratio for prescribing was 2.4 (2.3–2.5) in care homes compared with the community; 28.3% (26.6%–30.1%) of community and 42.5% (39.4%–45.7%) of care home residents prescribed antidepressants had no appropriate recorded indication.

Conclusions

This national sample confirms the high prevalence of antidepressant prescribing to older people, particularly in care homes, frequently without a documented indication. The strong association found between chronic disease and antidepressant prescribing did not explain the higher care home prescribing rate. Widespread community use of nonrecommended antidepressants is also a concern.

Section snippets

Data Source

The Health Improvement Network is an established primary care database collecting anonymized data from UK general (family) practices using the Vision computer system.18 It includes a full longitudinal registration, consultation, diagnosis and prescribing record and allows anonymized patient postcode (zip code) linkage. A UK postcode identifies on average 15 residential addresses; communal establishments may be the only address in a postcode. We commissioned postcode linkage to identify patients

Prevalence of Antidepressant Prescribing

The prevalence of antidepressant prescribing was very similar in nursing and residential homes, so these have been combined into a single care home category (Table 1 and Figure 1): 10.3% (95% confidence interval [CI] 10.0%–10.6%) of community and 37.5% (36.2%–38.9%) of care home patients were prescribed an antidepressant in the last 3 months; after excluding low-dose TCAs these figures were 7.3% (7.1%–7.5%) and 33.6% (32.3%–34.9%) respectively. Most of these antidepressant prescriptions were

Statement of Principal Findings

This nationally representative study confirms the high prevalence of antidepressant prescribing to older people and directly demonstrates the higher prescribing rates to those living in care homes compared with the community. The strong associations found between chronic diseases, including dementia, and antidepressant prescribing do not explain the higher care home prescribing rate and high levels of comorbidity do not strongly predict antidepressant prescribing in care homes. In both settings

Conclusion

We believe that our findings provide an important direct comparison of antidepressant prescribing to older people in care homes and the community. They suggest high levels of prescribing, frequently without a documented indication, particularly in care homes, and continued prescribing of inappropriate antidepressants, particularly in the community.

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  • Cited by (0)

    The study was supported by a grant from the BUPA Foundation, an independent medical research charity. The funder had no role in the design, execution, analysis, interpretation or writing of this paper. Researchers were independent from funders and had access to all the data.

    None of the authors have any financial involvement or affiliation with any organization whose financial interests may be affected by material in the manuscript, or which might potentially bias it. The study was approved by the UK South-East Multicentre Research Ethics Committee (Study Reference: 08/H1102/33).

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