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Mental health treatment varies by location

Mexican-Americans and blacks receive the least care for depression, researchers find. Another study says multiple prescriptions may be causing some harmful interactions.

By Susan J. Landers — Posted Feb. 8, 2010

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Two new studies have found different problems in the treatment some U.S. patients receive for mental health isssues.

One study determined that most adults diagnosed with depression are not receiving guideline-based care. A second study found that psychiatrists are prescribing multiple psychotropic medications to many patients, thus increasing the possibility of harmful drug interactions.

Both studies appear in the January Archives of General Psychiatry.

The study on depression care said 8.3% of nearly 16,000 adults interviewed had major depression, and more than half received therapy. But only about one in five treated had received therapy recommended by guidelines, such as those published by the American Psychiatric Assn., researchers said.

Depression is projected to become the second leading cause of disability in the world and the leading cause of disability in high-income nations, including the U.S., according to the study.

Researchers also examined differences in depression care received by whites, Mexican-Americans, Puerto Ricans, Caribbean blacks and African-Americans. The lowest rates of care were among Mexican-Americans and African-Americans, said lead author Hector M. Gonzalez, PhD, assistant professor of family medicine, public health and gerontology at Wayne State University in Detroit.

"This is not surprising to me as a clinician," he said. "It's what I see. There are blacks getting lousy care, and Mexicans are right in there with them."

The lack of health insurance plays a role in these treatment disparities. "About 40% of nonelderly Mexican-Americans are uninsured," he said.

Combining medications can be risky

A second study in the Archives of General Psychiatry found that an increasing number of U.S. adults are being prescribed multiple antidepressants, antipsychotics, mood stabilizers and sedative-hypnotics.

The study determined that office visits to psychiatrists in which two or more of the medications were prescribed increased from about 40% in 1996 to nearly 60% in 2006.

Some combinations are appropriate, said lead author Ramin Mojtabai, MD, MPH, associate professor in the department of mental health at Johns Hopkins Bloomberg School of Public Health in Baltimore. Combining medications may be done to alleviate side effects.

But many combinations may not be appropriate. For example, "There are very few indications for combining two antipsychotics or two SSRIs," he said.

The consequences of combining drugs can be harmful, Dr. Mojtabai said. "As the number of medications go up, the likelihood of drug-drug interactions increases, and the likelihood of the adverse events for each one of those medications increases."

In addition, many patients with psychiatric disorders also may take medications for medical conditions such as high cholesterol, diabetes or hypertension, further increasing the risk for interactions.

Dr. Mojtabai suggested that the lack of short-term side effects associated with the newer antipsychotics may be responsible for this increase in multiple prescriptions. "Psychiatrists may be more comfortable prescribing them," he said. But the new drugs may carry long-term effects, he cautioned.

Pressure by the pharmaceutical industry also may contribute to the prescribing growth, and younger physicians may be more inclined to prescribe additional medications, Dr. Mojtabai said.

He recommends that physicians increase their vigilance, scrutinize the medications patients take and eliminate those that might not be doing any good. He also urges physicians to be alert to evidence-based treatments.

"While some combining of medications is supported by clinical trials, many are of unproven efficacy," he said. "These trends put patients at risk for potentially harmful drug interactions while the gains from better outcomes are uncertain."

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ADDITIONAL INFORMATION

Trends in psychotropic medications

A study in the January Archives of General Psychiatry found a significant increase in the prescribing of multiple psychotropic medications by office-based psychiatrists. The number of visits during which two or more medications were prescribed increased from 39.9% in 1996 to 57.7% in 2006.

2 or more meds
199639.9%
199842.3%
200050.1%
200252.5%
200453.5%
200657.7%

Source: "National Trends in Psychotropic Medication Polypharmacy in Office-Based Psychiatry," Archives of General Psychiatry, January (link)

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External links

"National Trends in Psychotropic Medication Polypharmacy in Office-Based Psychiatry," abstract, Archives of General Psychiatry, January (link)

"Depression Care in the United States: Too Little for Too Few," abstract, Archives of General Psychiatry, January (link)

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