Antidepressant use in older people: family physicians' knowledge, attitudes, and practices.

OBJECTIVE To explore the knowledge, attitudes, and practices of primary care physicians regarding treatment of depression in older people.

DESIGN Mailed survey.

SETTING Offices of primary care physicians.

PARTICIPANTS Random sample of 11% of the primary care physicians in Ontario.

MAIN OUTCOME MEASURES Most commonly prescribed antidepressant, maximum dose of this antidepressant, antidepressants avoided, and duration of maintenance therapy.

RESULTS Response rate was 67%. Maximum doses of antidepressants physicians were willing to prescribe were below maximum doses recommended in the 2001 Compendium of Pharmaceuticals and Specialties. Many physicians were not willing to consider titrating the dose of their most commonly prescribed antidepressant beyond the lower half of the therapeutic range even when patients were tolerating the medications without side effects but were not responding to treatment. Two thirds (65%) indicated they would attempt to discontinue antidepressants after 9 months of therapy or less; 50% would discontinue therapy after 6 months or less. This is in contrast to published guidelines recommending maintenance periods of 1 to 2 years. Although fluoxetine is generally avoided in geriatric populations because of its markedly prolonged half-life and potential for drug-drug interactions, 6% of respondents reported prescribing it as a first-line antidepressant.

CONCLUSION With the exception of fluoxetine, most Ontario-based primary care physicians choose appropriate first-line antidepressant medications for their older patients. This study demonstrates that primary care physicians are extremely careful, if not overly cautious, in titrating the dose of antidepressants. Many restrict treatment to lower doses and shorter courses of therapy than dosages and durations recommended for full clinical effect and prevention of relapse. This practice could limit the therapeutic efficacy of that first medication trial, exposing patients to unnecessary medication switches or incomplete therapeutic response when an increased dose might have resulted in a complete resolution of depressive symptoms. Suboptimal management might be the result of ineffective dissemination of guidelines that are often published in subspecialty literature not readily available to primary care physicians.