Prescribing of Psychotropic Medications to Patients Without a Psychiatric Diagnosis

In 2009, a total of 5,132,789 individuals filled prescriptions for psychotropic medications, of whom 2,985,553 (58.2%) had no documented psychiatric disorder during the entire year. Among all individuals filling prescriptions for psychotropic medications, 64% were female, 37% were younger than age 40, and 40% were between ages 50 and 64. Less than 20% of patients filling a psychotropic prescription had utilized any mental health specialty care services (Table 1).

Antidepressants were prescribed more often than any other psychotropic medication, followed by anxiolytics (prescribed to 62% and 46%, respectively, of individuals filling psychotropic prescriptions). The proportion of prescriptions for patients without psychiatric diagnoses was highest for anxiolytics (61%), followed by anticonvulsant mood stabilizers (58%) and antidepressants (52%) (Table 2). Among patients prescribed psychotropic medications, the proportion without a psychiatric diagnosis was much smaller among mental health care utilizers than among non–mental health care utilizers (14% and 67%, respectively).

The proportion of individuals who filled a psychotropic prescription but did not have a psychiatric diagnosis increased with age. Age 50 to 64 was the peak at-risk age group for this practice for each class of psychotropic medication (Figure 1). These same age trends were also noted for mental health care utilizers and nonutilizers (Figure 2).

The proportion of patients who had specific medical indications and who were prescribed psychotropic medication but did not have a psychiatric diagnosis was essentially the same for all age groups. The one exception to this trend was among patients with pain diagnoses—the oldest patients were more likely than younger patients to be prescribed psychotropic medications (ages 50–64, 25%; 40 to 49, 22%, and <40, 16%).

A Pearson product-moment correlation coefficient was calculated to assess the magnitude of the association between the number of clinical encounters and the likelihood of having a psychiatric diagnosis. There was a weak positive correlation between the two variables (r=.13, p<.001).

The odds of being prescribed a psychotropic medication without a psychiatric diagnosis were 2.9 times higher among individuals aged 50 to 64 compared with individuals younger than 40 (odds ratio [OR]=2.87) (Table 3). Mental health specialty care utilization had the largest effect of any covariate (OR=.10), indicating that the odds of being prescribed a psychotropic medication in the absence of a psychiatric diagnosis were 90% lower among mental health care utilizers than among nonutilizers. Covariates representing the presence of a potential general medical indication for use of psychotropic medications and the CCI of severity of general medical illness were only weakly associated with being prescribed a psychotropic medication in the absence of a psychiatric diagnosis. Infusion of the number of encounters as a covariate did not alter the basic findings.

Analysis of a national sample of individuals covered by commercial health insurance indicated that a majority of outpatients, proportionally largest among older adults, were prescribed psychotropic medications in the absence of a clear indication for such use, even after adjustment for medical use and severity of comorbid general medical conditions. Patients who did not use any mental health specialty care services accounted for an overwhelming majority of psychotropic prescriptions among persons without a psychiatric diagnosis. Hence this phenomenon largely occurred in primary care and general medical and surgical settings. Nonetheless, it is concerning that one in seven mental health care utilizers who were prescribed a psychotropic medication had no psychiatric diagnosis in the same year.

Our findings are similar to previous results about antidepressant prescribing in the absence of psychiatric diagnosis. Both Pagura and colleagues (7) and Mojtabai and Olfson (6) found high rates of such prescribing by nonpsychiatrists. The proportions of patients prescribed antidepressants (52%) and antipsychotics (31%) in the absence of a past-year psychiatric diagnosis were similar to those reported by others using different methods (6–9,11). Rates of prescribing without a psychiatric diagnosis were lower for lithium, stimulants, and antipsychotics than for other classes of medications. It is unclear why these classes were so closely linked to diagnoses. One possibility is that these medications have more narrowly defined clinical indications for use and lower rates of off-label prescribing than the other classes studied. Another explanation may be that medications such as antipsychotics and lithium are more likely to be prescribed to patients with severe mental illness, who have a greater number of clinical encounters related to mental illness, and hence are more likely to receive a psychiatric diagnosis. We found that the number of encounters and the likelihood of having a psychiatric diagnosis were significantly but weakly correlated.

Our work expanded upon previous studies in several key ways. First, we evaluated prescribing trends for a much broader set of medications, including six different classes of psychotropics, and we found similar trends by age for each. Second, our analyses adjusted for general medical indications for use of psychotropic medications as well as for a measure of severity of general medical illness. The fact that assessments of general medical use and comorbidity were not strongly associated with increased risk suggests that the presence of general medical diagnoses did not account for the practice of prescribing psychotropic medication for patients without a psychiatric diagnosis. Third, we included a broader definition of mental disorder than in previous work, increasing the generalizability of our findings. Pagura and colleagues (7) studied patients with a limited number of mood, anxiety, substance use, and eating disorders, and Milea and colleagues (8) included only approved indications for antidepressant use.

There are several possible explanations for the practice of prescribing psychotropic medication in the absence of a psychiatric indication. First, there may be concerns about stigma associated with psychiatric diagnosis in general medical settings, where an overwhelming majority of prescriptions for psychotropic medications without a psychiatric diagnosis were written. Previous work has found that prescribers are reluctant to record mental health diagnoses on claims data because of concerns about lower reimbursement rates for mental illness (13,14). Second, it is possible that there is an especially strong emphasis on symptom-based rather than diagnosis-based treatment in general medical settings, although there is little empirical evidence to support this practice. Previous studies have noted that subthreshold or mild psychiatric symptoms were associated with antidepressant prescribing in the absence of psychiatric diagnosis (6,7,10). In addition, previous work has shown that among adults treated with antidepressants, patients treated by general medical providers were less likely than those treated by psychiatrists to meet criteria for mood or anxiety disorders based on structured interviews (5). These trends are of potential concern, given the ongoing controversy surrounding the efficacy of antidepressants for treatment of mild depressive symptoms (15–17).

Third, patient or caregiver requests may be driving some of this practice. With increased exposure to direct-to-consumer advertising, direct requests for a specific medication may be more frequent. Fourth, prescriptions for psychotropic medications may be continued when clinical indications are no longer present. Fifth, poor documentation of diagnostic indications for use of psychotropic medication may also account for some component of our findings, but it also represents inadequate record keeping, which may impede communication with other providers.

Several methodological limitations deserve comment. Administrative data may not reflect clinical indications that are more fully described in clinical notes, even in the absence of relevant diagnoses on billing forms. There may be a variety of reasons for differences in documentation of diagnoses on encounter forms versus clinical notes, such as reimbursement rates and limits on the allowable number of diagnoses. Furthermore, precise data on date of initiation of medication use were not available. Patients with chronic mental illness requiring long-term use of psychotropic medications may have been diagnosed in the past, but subsequent refills of medications captured during our study period lacked a coded diagnosis. Finally, the generalizability of these findings is uncertain. We did not have data on the extent to which claims in the MarketScan database are representative of commercially insured Americans generally. Patients in this database are likely to be quite different from those treated in public-sector programs or in a system like the Veterans Health Administration. Application of the methods used in this study to other health systems would be informative.

Large numbers of outpatients, especially those who were not utilizers of mental health specialty care and those aged 50 to 64, were prescribed a variety of psychotropic medications in the absence of a psychiatric diagnosis. This practice may represent either incomplete record keeping or possible exposure of patients to the risks of psychotropic medications without clear indications for use. Further research to better understand this phenomenon and its relationship to quality of care is warranted.

This research was supported by the Hartford Foundation Yale Center for Geriatric Excellence; the Department of Veterans Affairs (VA) Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment; the VA New England Mental Illness, Research, Education and Clinical Center; the VA Connecticut Healthcare System; and the VA National Center for Posttraumatic Stress Disorder.

Dr. Rosenheck has received research support from Janssen Pharmaceutica, AstraZeneca, and Wyeth Pharmaceuticals. He has been a consultant to Otsuka. He was testifying expert in Jones ex rel the State of Texas v Janssen Phamaceutica et al. The other authors report no competing interests.