By Nell Lake
Are we over-treating the elderly with psychiatric drugs?
That's the natural question arising from a recent report that found adults over 65 are receiving psychotropic medications at twice the rate of younger adults. The study, published in this month's Journal of the American Geriatrics Society, also found that elders are much less likely to get their mental health care from psychiatrists or to receive psychotherapy.
What's the problem? First, psychotropic drugs generally pose greater risks to the elderly than they do to younger patients, and non-drug approaches, from therapy to meditation, may be as effective as psychotropic medications for some seniors’ mental disorders, without the risks.
The findings suggest that physicians and insurers should reassess psychotropic drug use among the elderly, says lead author Donovan Maust, a geriatric psychiatrist and assistant professor of psychiatry at the University of Michigan.
Maust’s team used 2007-2010 data from the CDC’s National Ambulatory Medical Care Survey and from the U.S. Census to compare the rates at which older and younger adults — those 65 and older, and those 18-64 — get prescribed psychotropic medications during outpatient doctors’ visits. After analyzing more than 100,000 of these doctor visits, and taking into account the fact that the younger population is much larger than the older one, the researchers found that older adults were much more likely to be prescribed psychiatric drugs for anxiety, depression and other mental health conditions. Researchers also found that these seniors were less likely to receive other types of non-drug treatment for their mental distress.
The importance of all this is fairly clear: The elderly population is booming, and seniors use the health care system more than any other demographic. So, finding safe, effective and appropriate treatments for their mental health problems is critical -- for the well-being of a large swath of people, and as a policy matter.
Too Many Meds, And The Wrong Kind?
Psychotropic drugs pose both direct and indirect risks to the elderly: First, the drugs themselves can be dangerous. The American Geriatrics Society lists many psychotropic medications as potentially inappropriate for elderly patients.
“Probably the clearest concerns would be in the anxiolytic [drug] group,” in particular, anti-anxiety medications, like Ativan and Xanax, Maust says. Evidence suggests that these medications increase the risk of falls in older adults, which can cause a cascade of problems — from fracture to hospitalization to surgery and even increased risk of death. Anti-anxiety medications may double the risk of motor vehicle accidents. Recent research also shows a possible increased risk of dementia if the drugs are used long term.
Antidepressants, while somewhat safer than anti-anxiety meds, may increase blood pressure and, Maust says, “medicines that work on serotonin can increase bleeding risk — very slightly. But in an older adult who’s also taking [blood thinners] like aspirin or Coumadin,” this risk should be a concern.
A more basic, practical worry is that of loading patients — often already on multiple medications — with yet another drug to keep track of: “These patients can be on 10, 12 medications,” Maust says. “Even if the [psychiatric] medication doesn’t have side effects or otherwise cause trouble, adding one more medication — increasing the complexity of the regimen — increases the potential of getting things mixed up.” An elderly patient might take the wrong dose, forget doses or mix up the order in which drugs should be taken.
Add to this the issue of dementia: more common, of course, among people over 65. “It’s very common that a person with dementia might have depression or anxiety, so use of these medications might be appropriate,” Maust says. But studies have shown that the benefits are often minimal. And “in general if someone’s brain isn’t functioning at a 100 percent,” he says, “I would worry about adding a medication that… affects the brain.”
Young Vs. Old
The study’s main finding — this stark difference in the rate of psychiatric drugs -- could be the result, Maust says, of an over-correction. In recent decades, health care providers have worried that the elderly aren’t receiving enough treatment of mental disorders. As a result, there's been an effort to make sure doctors recognize depression and anxiety when they're present. So physicians and insurers have instituted more screening in primary care.
But the pendulum may have swung too far, and because the drugs are often the easiest treatment to turn to, depressive and anxious symptoms may now too often get treated with drugs.
The “newer” antidepressants — think Zoloft and Prozac — are easier to use than the drugs of decades ago, and have fewer side effects. Part of what’s driving the rise of these treatments is that “they’re perceived to be safer,” Maust says. “By and large that really is true,” he says, but doctors should proceed with caution.
Another likely reason for the disparity is oddly circumstantial, a question of exposure — to doctors. Older people are more likely to be in contact with the people who do the prescribing. Because they often face complex health problems, seniors tend to see their doctors more often than younger people do. So an elderly man, for example, who goes often to his doctor for management of his multiple chronic conditions, such as diabetes, high blood pressure, arthritis, might complain one day that he’s feeling distress. His wife has died, and he’s more housebound than ever. His doctor sees symptoms of depression, and considers what course to take.
“Ultimately,” Maust says, “physicians sort of do what they know best. For a lot of people, that’s prescribing. Something like Zoloft seems pretty safe. You hope that it will help your patient.”
This patient’s doctor might suggest what’s readily at hand: She prescribes the antidepressant.
Follow The Money
Reimbursement systems also reinforce the use of psychiatric drugs. Physicians, Maust says, might want to refer a patient to therapy, or to send their patient down the hall to talk with a social worker. “But they might not have those resources available to them,” Maust says, adding that insurers often gear reimbursements toward prescribing medications rather than toward non-drug approaches.
“I do think providers are trying to help their patients. But we know that a lot of times for mild or even moderate depression and anxiety, a ‘watchful waiting’ approach often works, and symptoms will improve on their own without the medication.”
Psychotherapy can also be helpful. But sometimes, with drugs readily available, a physician starts a medication, a patient shows improvement, “and then [the physician is] reluctant to stop it and [the patient is] on the medication indefinitely.”
“It’s a time to think about whether there might need to be a little bit of a course correction,” Maust says. He recommends renewed restraint in prescribing psychotropic drugs, and support for alternatives to medication when appropriate -- for psychotherapy, for the help of social workers, for a “wait and watch” approach.
Others agree. There's renewed interest in a medical model called collaborative care, one of the approaches gaining ground through health care reform and the Affordable Care Act. The primary care physician gets support from a team -- including, usually, a nurse manager, a consulting psychiatrist, a social worker -- who coordinate care for patients with anxiety, depression and other chronic conditions. The team might decide to take a “wait and watch” approach, monitoring symptoms. A social worker might counsel patients in cognitive and behavioral strategies. A psychiatrist might provide advice about reasons to avoid certain medications. Through such collaborative care, physicians have more support in considering alternatives to drugs.
Asked if, in some cases, such alternatives might include activities to elevate elderly patients’ moods, Maust was cautious. No one is suggesting that an art class, for instance, will totally cure depression. Maust wants to be clear: Medications are important and appropriate care in many cases. “But for some of these [elderly] people,” he adds, “an art class might work pretty well.”
Nell Lake, a journalist and magazine writer, wrote the book, “The Caregivers: A Support Group’s Stories of Slow Loss, Courage And Love,” in which she chronicles the lives of family caregivers over two years. She lives in western Massachusetts.