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Potential Underuse, Overuse, and Inappropriate Use of Antidepressants in Older Veteran Nursing Home Residents

Authors

  • Joseph T. Hanlon PharmD, MS,

    1. From the Geriatric Research, Education and Clinical Center, and
    2. Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania;
    3. Division of Geriatric Medicine, Department of Medicine and
    4. Department of Biomedical Informatics, School of Medicine;
    5. Department of Pharmacy and Therapeutics, School of Pharmacy; Departments of
    6. Epidemiology,
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  • Xiaoqiang Wang MS,

    1. Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania;
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  • Nicholas G. Castle PhD,

    1. Health Policy and Management, and
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  • Roslyn A. Stone PhD,

    1. Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania;
    2. Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania;
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  • Steven M. Handler MD, PhD,

    1. From the Geriatric Research, Education and Clinical Center, and
    2. Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania;
    3. Division of Geriatric Medicine, Department of Medicine and
    4. Department of Biomedical Informatics, School of Medicine;
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  • Todd P. Semla PharmD, MS,

    1. Pharmacy Benefits Management Services, Department of Veterans Affairs, Hines, Illinois;
    2. Departments of Medicine and
    3. Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois;
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  • Mary Jo Pugh PhD,

    1. Veterans Evidence-Based Research Dissemination and Implementation Center, South Texas Veterans Affairs Health System, San Antonio, Texas;
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  • Dan R. Berlowitz MD, MPH,

    1. Center for Health Quality, Outcomes and Economic Research, Department of Veterans Affairs, Bedford, Massachusetts; and
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  • Maurice W. Dysken MD

    1. Geriatric Research, Education and Clinical Center, Department of Veterans Affairs, Minneapolis, Minnesota.
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  • Presentations: International Conference on Pharmacoepidemiology and Therapeutic Risk Management, August 17, 2009, Providence, Rhode Island, and Gerontological Society of America Annual Meeting, November 19, 2009, Atlanta, Georgia.

Address correspondence to Dr. Joseph T. Hanlon, Department of Medicine (Geriatrics), University of Pittsburgh, Kaufman Medical Building-Suite 514, 3471 5th Ave, Pittsburgh, PA 15213. E-mail: jth14@pitt.edu

Abstract

OBJECTIVES: To examine prevalence and resident- and site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants in older Veterans Affairs (VA) Community Living Center (CLC) residents.

DESIGN: Longitudinal study.

SETTING: One hundred thirty-three VA CLCs.

PARTICIPANTS: Three thousand six hundred ninety-two veterans aged 65 and older admitted between January 1, 2004, and June 3, 2005, with long stays (≥90 days).

MEASUREMENTS: Prevalence of potential underuse, inappropriate use, and overuse of antidepressants in residents with and without depression (as documented according to International Classification of Diseases, Ninth Revision, Clinical Modification, codes or Depression Rating Scale).

RESULTS: Selective serotonin reuptake inhibitors were the most commonly prescribed antidepressant. Of the 877 residents with depression, 25.4% did not receive an antidepressant, suggesting potential underuse. Of residents with depression who received antidepressants, 57.5% had potential inappropriate use due primarily to problems seen with drug–drug and drug–disease interactions. Of the 2,815 residents who did not have depression, 1,190 (42.3%) were prescribed one or more antidepressants; only 48 (4.0%) of these had a Food and Drug Administration–approved labeled indication, suggesting potential overuse. Overall, only 17.6% of antidepressant use was appropriate (324/1,844). The only consistent resident factor associated with potential underuse and overuse use was taking an antipsychotic without evidence of schizophrenia (underuse: adjusted relative risk ratio (ARRR)=0.56, 95% confidence interval (CI)=0.33–0.94; overuse: adjusted odds ratio=1.52, 95% CI=1.21–1.91). Having moderate to severe pain (ARRR=1.54, 95% CI=1.08–2.20) and the prescribing of an anxiolytic or hypnotic (ARRR=1.33, 95% CI=1.02–1.74) increased the risk of potential inappropriate antidepressant use.

CONCLUSION: Potential problems with the use of antidepressants were frequently observed in older U.S. veteran CLC residents. Future studies are needed to examine the true risks and benefits of antidepressant use in CLC and non-VA nursing homes.

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