'Doing the right thing': factors influencing GP prescribing of antidepressants and prescribed doses.

BACKGROUND: Antidepressant prescribing continues to increase, with 5-16% of adults receiving antidepressants annually. Total prescribing growth is due in part to increased long-term use, greater selective serotonin re-uptake inhibitor (SSRI) use and the use of higher SSRI doses. Evidence does not support routine use of higher SSRI doses for depression treatment, and factors influencing the use of such doses are not well known. The aim of this study was to explore factors influencing GPs' use of antidepressants and their doses to treat depression. METHODS: Semi-structured interviews with a purposive sample of 28 practising GPs; sampled by antidepressant prescribing volume, practice size and deprivation level. A topic guide drawing on past literature was used with enough flexibility to allow additional themes to emerge. Interviews were audio-recorded and transcribed verbatim. Framework analysis was employed. Constant comparison and disconfirmation were carried out across transcripts, with data collection being interspersed with analysis by three researchers. The thematic framework was then systematically applied to the data and conceptualised into an overarching explanatory model. RESULTS: Depression treatment involved ethical and professional imperatives of 'doing the right thing' for individuals by striving to achieve the 'right care fit'. This involved medicalised and non-medicalised patient-centred approaches. Factors influencing antidepressant prescribing and doses varied over time from first presentation, to antidepressant initiation and longer-term treatment. When faced with distressed patients showing symptoms of moderate to severe depression GPs were confident prescribing SSRIs which they considered as safe and effective medicines, and ethically and professionally appropriate. Many GPs were unaware that higher doses lacked greater efficacy and onset of action occurred within 1-2 weeks, preferring to wait 8-12 weeks before increasing or switching. Ongoing pressures to maintain prescribing (e.g. fear of depression recurrence), few perceived continuation problems (e.g. lack of safety concerns) and lack of proactive medication review (e.g. patients only present in crisis), all combine to further drive antidepressant prescribing growth over time. CONCLUSIONS: GPs strive to 'do the right thing' to help people. Antidepressants are only a single facet of depression treatment. However, increased awareness of drug limitations and regular proactive reviews may help optimise care.

Patient factors associated with SSRI dose for depression treatment in general practice: a primary care cross sectional study.

BACKGROUND: Antidepressant prescribing continues to rise. Increased long-term prescribing and higher doses are contributing to current growth; however, patient factors associated with the use of higher doses remain unknown. This study's aim was to investigate patient factors associated with selective serotonin re-uptake inhibitor (SSRI) prescribed daily dose for depression treatment in general practice. METHODS: A stratified sample of low to high prescribing practices were selected. Routine individual patient-level data were extracted one practice at a time: September 2009 to January 2011. Patients included were ≥18 years, and prescribed an SSRI for depression. Logistic regression analysis was undertaken to assess individual predictor variables on SSRI daily dose by standard therapeutic dose versus higher dose, as SSRIs demonstrate flat dose response curves for depression treatment. Predictor variables included: age, gender, deprivation, co-morbidity, smoking status, being prescribed the same SSRI for ≥2 years, and patients' general practice. For a subgroup of patients a second sub-group analysis included long-term benzodiazepine and/or z-hypnotic (B&Z) as a predictor variable. RESULTS: Inter-practice SSRI prescribing varied significantly; practice point prevalence ranged from 2.5% (94/3697) to 11.9% (359/3007) of the practice population ≥18 years old; median 7.3% (250/3421) (χ2 = 2277.2, df = 10, p < 0.001). Overall point prevalence was 6.3% (3518/52575), with 5.8% (3066/52575) prescribed SSRIs for depression of whom 84.7% (2596/3066) had data for regression analysis. Higher SSRI doses were significantly associated with, in descending order of magnitude, individual practice attended, being prescribed the same SSRI for ≥2 years (Odds Ratio (OR) 1.80, 95% CI 1.49 to 2.17, p < 0.001) and living in a more deprived area (OR 1.55, 95% CI 1.11 to 2.16, p = 0.009). Higher SSRI doses in the B&Z subgroup were significantly associated with individual practice attended, being prescribed a long-term B&Z (OR 2.05 95% CI 1.47 to 2.86, p < 0.001) and being prescribed the same SSRI for ≥2 years (OR 1.94, 95% CI 1.53 to 2.47, p < 0.001). CONCLUSION: Higher SSRI doses for depression were associated with practice attended and being prescribed the same antidepressant for ≥2 years. As long-term antidepressant use increases, the use of higher doses may further contribute to prescribing growth.

Obesity in individuals with schizophrenia: a case controlled study in Scotland.

BACKGROUND: Despite extensive clinical concern about rates of obesity in patients with schizophrenia, there is little evidence of the extent of this problem at a population level. AIMS: To estimate levels of obesity in a national population sample by comparing patients with schizophrenia with matched controls. METHOD: We calculated levels of obesity for each patient with schizophrenia from the national Primary Care Clinical Informatics Unit database (n=4658) matched with age, gender and neighbourhood controls. RESULTS: We demonstrated a significant increased obesity hazard for the schizophrenia group using Cox regression analysis, with odds ratio (OR) of 1.94 (95% CI 1.81-2.10) (under the assumption of missing body mass index (BMI) indicating non-obesity) and OR=1.68 (95% CI 1.55-1.81) where no assumptions were made for missing BMI data. CONCLUSIONS: People with schizophrenia are at increased risk of being obese compared with controls matched by age, gender and practice attended. Priority should be given to research which aims to reduce weight and increase activity in those with schizophrenia. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.