Characteristics Associated With Purchasing Antidepressant or Antianxiety Medications Through Primary Care in Israel

The study received institutional review board approval from the Helsinki Committee of Clalit Health Services. We randomly sampled 30,000 primary care patients over the age of 22 as of January 2006 from Clalit Health Services' computerized medical registry.

Of the 30,000 randomly selected patients, 591 died in 2006 and 4,446 individuals had incomplete physician data; these categories were not mutually exclusive. Thus the final sample consisted of 25,092 primary care patients, listed with 1,418 physicians working in 850 clinics all over the country. There were significant differences between those excluded from analysis because of death or missing physician data and the final sample. Those excluded from analysis were more likely to purchase antidepressant or antianxiety medications compared with the final sample (N=1,016, 20%; N=4,762, 19%, respectively; p=.003). In addition, those excluded from analysis were more likely to be older than 66 (N=1,271, 26%; N=4,806, 19%, respectively) and less likely to be between 46 and 65 (N=1,428, 29%; N=8,801, 35%, respectively; p<.001), had a higher mean±SD Charlson score (2.1±2.8 versus 1.7±2.1, respectively), and were less likely to have a somatic diagnosis (common nonpsychiatric somatic conditions for which antidepressant or antianxiety medications are indicated) (N=1,397, 28%; N=8,474, 34%, respectively; p<.001) compared with the final sample. Those excluded were also more likely to be of high socioeconomic status (N=1,151, 24%; N=4,514, 18%, respectively) and less likely to be of low socioeconomic status (N=1,762, 36%; N=10,494, 42%, respectively; p<.001) compared with the final sample. Finally, those excluded were less likely than the final sample to be Jews born in Israel (N=1,913, 39%; N=11,093, 45%, respectively) and more likely to be Arabs (N=851, 17%; N=3,639, 14%, respectively; p<.01), compared with the final sample (Table 1).

Overall, 4,762 (19%) of the sample purchased antidepressant or antianxiety medications in 2006. There were significant differences between those who purchased medications and those who did not for all patient-level variables, with the exception of years in Israel. Women, older patients, those with a psychiatric or somatic diagnosis, those with greater medical comorbidity, and those of higher socioeconomic status were more likely to purchase antidepressant or antianxiety medications. Israeli Arabs were less likely to purchase medications, and Israeli Jews born abroad (immigrants) were more likely to purchase medications compared with Jews born in Israel (Table 1).

Table 2 presents results of the logistic analysis, showing that women, older adults, those with greater medical comorbidity, and those with a psychiatric or somatic diagnosis were more likely than others to purchase medications. Jews born outside the country (with the exception of those born in Asia or Africa) were more likely than Jews born in Israel to purchase medications. In contrast, Arabs and Jews born in Asia or Africa were less likely than Jews born in Israel to purchase medications. Finally, those of higher socioeconomic status were more likely to purchase medications.

This study evaluated the purchase of antidepressant or antianxiety medications in Israel by using medical registry data of the largest health care fund in Israel. The most notable finding was the high rate of antidepressant or antianxiety medications purchased (4,762; 19%) relative to the low rate of documented relevant psychiatric diagnoses, which amounted to 865 patients (3%) in the entire sample and 678 (14%) of those purchasing psychotropic medications. This overall rate of 3% likely is an underestimate given epidemiological studies that have shown much higher prevalence rates of psychiatric conditions in primary care (28). Thus, similar to past research (4), this study clearly demonstrated a tendency to underrecord mental disorders in primary care. This may be due to patient-related or physician-related causes such as the stigma associated with psychiatric illness (41–44). Although the reported rates of purchase seem to coincide well with general estimates of the prevalence of depression and anxiety in primary care (3–5), the use of antidepressant and antianxiety medications is also indicated for nonpsychiatric conditions. Thus undertreatment may prevail in this population.

As expected, having a psychiatric diagnosis was the best predictor of antidepressant or antianxiety medications. Nevertheless, the presence of somatic diagnosis based on nonpsychiatric symptoms, such as pain or insomnia, was also a strong predictor of purchase. In fact, although only 14% of those purchasing antidepressant or antianxiety medications had a relevant psychiatric diagnosis, 51% of purchasers had a nonpsychiatric somatic diagnosis. Therefore, it is possible that some mental conditions were labeled as somatic either erroneously or due to the stigma of mental illness. Further research is needed to clearly verify the source of this finding and to better tailor educational interventions to improve the diagnosis of mental illness and potentially improve the treatment quality of depression and anxiety in primary care.

Rates of medication purchase identified in this study were substantially higher than prevalence rates obtained by self-report measures in a previous national study (27,45). The stigma associated with the use of psychotropic medications might be responsible for a lower rate found in past research that was based on self-report data. This should be taken into consideration in future epidemiological studies concerning psychotropic use.

Another interesting finding is population group differences in the purchase of psychotropic medications. Israel has a universal health care system that covers psychotropic use. Yet, those of higher socioeconomic status were more likely to purchase medications, potentially because socioeconomic status is a proxy of education and reduced stigma of mental illness. In addition, consistent with past research (45), the purchase of medications does seem to be higher among immigrants (with the exception of those born in Africa or Asia) and lower among Israeli Arabs and immigrants from Asia and Africa (25,26). Research has consistently shown that migration is a stressful situation that often has deleterious effects on one's mental health (46,47). This study may provide further support to these findings because it demonstrates that immigrants, with the exception of those coming from Asia or Africa, are more likely to purchase antidepressant or antianxiety medications. Alternatively, this may reflect a cultural preference toward psychotropic use in these particular groups.

Israeli Arabs were substantially less likely than Jews born in Israel to purchase medications, with multivariate analyses controlling for all other demographic and clinical variables. These findings are particularly intriguing given past research that found substantially higher levels of depression among Israeli Arabs than among Israeli Jews (48). Low levels of psychotropic purchase may be explained by culturally incompatible services offered to this population (49). This may also be due to the stigma of mental illness in this population (50,51). Further efforts to improve culturally sensitive services and to reduce the stigma associated with mental illness are indicated particularly for Israeli Arabs. It is possible that Israeli Jews born in Asia or the Middle East may also benefit from such interventions. Nevertheless, we cannot rule out the possibility that those groups in the population who were less inclined to purchase antidepressant or antianxiety medications used other modalities to manage mental distress. However, because psychotherapy is not included in the basket of services provided by universal health care funds in Israel and because community services that offer psychotherapeutic interventions are overburdened by demand (52), it is unclear whether disadvantaged groups have access to other formal modalities to address their mental health needs. Finally, it is possible that the use of informal services, such as religious counseling or assistance by family and friends, successfully replaces formal services in these groups.

An interesting lack of significant finding should also be noted. In contrast to past research adamantly advocating multilevel analysis of primary care data (22), we found physician-level variations to be too low to justify such an analysis. This is also in contrast to past research that found physician characteristics to be of importance in the treatment of mental illness (17,18). Possibly, the focus on purchase rather than prescription is partly responsible for this difference, because the purchase of medications likely is more dependent on patient characteristics than on physician characteristics. Although less common in Israel, the fact that many psychotropic medications are directly advertised to patients and not only to physicians may account for the findings (53). Another explanation may be related to the implementation of guidelines and massive educational efforts of Clalit Health Services in the past few years to increase primary care physicians' awareness of and ability to treat depression and anxiety (35). These efforts may have possibly reduced differences among physicians of varying specialties and experience levels.

Several limitations should be noted. Our study focused on the purchase of antidepressant or antianxiety medications in primary care and not on the treatment of depression or anxiety, which would include other important approaches, such as psychotherapy, appropriate follow-up and planning, and case management (54). Because under current laws psychotherapy is not included in the basket of services provided by universal health care funds to primary care patients in Israel, data on these treatments are not recorded in Clalit Health Services' medical records, and thus we were unable to conduct a comprehensive evaluation of the treatment of depression or anxiety in primary care. In addition, this study focused on the purchase of medications rather than on the prescription of medications. The focus on cross-sectional analysis does not allow for inferences about cause and effect. Furthermore, the individuals excluded from analysis were substantially different from the remaining sample, suggesting that some groups may be underrepresented. Finally, we did not have data on physicians' ethnic origin, a variable that might be related to patients' purchasing behaviors.

The findings demonstrate that despite universal health care access to all, variations exist by population groups. Further research is needed to ascertain reasons for underpurchase among the different groups (Arabs, Jews born in Asia or Africa, men, younger adults, people of lower socioeconomic status). Specifically, despite the high rates of mental distress reported by the Arab population in past research (25,26), the low usage of medications suggests that services should be specifically tailored to address the needs of this population. Finally, given the relatively minor association found between primary care physician characteristics and medication purchase, educational efforts regarding mental illness and the use of psychotropic medications should target both patients and physicians.

This study was funded by a research grant from Clalit Health Care. This work is dedicated to the memory of Prof. Revital Gross, who has been the authors' inspiration.

The authors report no competing interests.