By Whom Are Psychotropie. Drugs Prescribed?

Although psychiatrists and neurologists as a specialty group prescribe psychotropic agents at a greater rate than any other physician specialty, over 70 percent of all prescriptions for psychotropic agents are written by general practitioners, internists, and surgeons. Psychiatrists and neurologists prescribe major tranquilizers and antidepressant agents at a rate five times that expected from their numbers in the overall population of physicians in private practice. Gen. eral practitioners also employ psychotropic drugs at a high rate and we find them consistently over-represented on use all classes of psychotropic agents. On an overall basis osteopaths employ psychotropes at about the rate expected for their representation in the total physician population. But when distribution of prescribing among the major drug classes is considered, they are found to employ stimulants at three times the rate expected. More understandable is the high rate of prescribing of hypnotic drugs by surgeons and the high rate of prescribing sedative drugs by general practitioners. Because of the extensive use of psychotropic drugs among almost all types of physicians, serious efforts must be made in undergraduate and postgraduate training to insure the rational use of psychotropic agents.

In interpreting data on the extent of psychotropic drug usage, it should be recognized that neither drug prescribing nor drug acquisitions are uniformly distributed among the individuals in the reference populations; namely, physicians and patients. The top 25 percent of the prescribers may account for as much as 50 percent of the prescriptions written, and similarly a small proportion of the patients, as little as • 28 percent in a recent study, may account for 48 percent of the acquisitions.

For What Are Psychotropic Drugs Prescribed?

In some ways this question comes closer to the issue of over-prescribing and over-use than any other. Unfortunately, it is a difficult issue on which to obtain meaningful data and the interpretation of the data must be done very carefully so as not to jump to erroneous conclusions. Ideally, one would like to be able to discuss with the physician, at the time of his prescribing a psychotropic drug, the reason for this decision or to review well-kept clinical records in order to obtain information on the rationale for prescribing a psychotropic drug. Short of this, however, we can ask what is the diagnosis of the patient receiving a psychotropic drug and, perhaps even more

importantly, what was the desired action of the medication prescribed. For example, at first glance the prescribing of a minor tranquilizer for a patient with a diagnosis of coronary artery insufficiency may seem inappropriate but when the desired action is known to be anxiety reduction to try to prevent an increased cardiac load due to heightened anxicty, then this becomes an understandable and rational procedure.

For the year 1968, Chart 5 gives the main diag. noses for which representative drugs in each of the six major classes of psychotropic agents were given. Considering the appropriateness of the diagnosis to the drug class, we find that the use of these drugs is, by and large, rational. For example, in the minor tranquilizer category only 3 percent of the representative drugs are prescribed for schizophrenia while 27 percent of the major tranquilizers are prescribed for this disorder. Likewise, up to 64 percent of the time when antidepressants are given for a psychiatric disorder they are given for depressive reactions, whereas minor tranquilizers are given only 8 to 20 percent of the time and major tranquilizers 21 percent of the time for this same disorder.

Somewhat surprising at first glance is the frequency with which these representative drugs are employed in non-psychiatric diagnoses. Sixty-four percent of all prescriptions for the antidepressant category are for psychiatric diagnoses but only 10 percent for the representative drug in the sedative category. In the minor tranquilizer category the percentages range *between 26 and 34 while for major tranquilizers there is a 50 percent use for mental disorders.

The caveat presented earlier however must be kept in mind before any conclusions are reached regarding the appropriateness or inappropriateness of these therapeutic practices.

Chart 6 presents data on the same representative drugs of the major psychotropic classes but this time cross-tabulated with desired action rather than diag. nosis. The minor tranquilizer class is prescribed 70 to 78 percent of the time for tranquilization or seda. tion while the previous table showed that by diagnostic categories the minor tranquilizers were prescribed for mental disorders only 26 to 34 percent of the time. Likewise, in the sedative class, while these are prescribed only 10 percent of the time for mental disorders, the desired therapeutic action is tranquilization or sedation 75 percent of the time. Hypnotic drugs are used almost exclusively for sleep induction, while the vast use of stimulant drugs is for appetite suppression to aid in weight reduction, with 5 percent of stimulant drug prescribing aimed at relief of de

pression. The conclusion drawn is that psychological or psychiatric symptomatology occurs to a large extent in patients who are not diagnosed as having a mental disorder, and physicians' prescribing reflects the treatment of these symptoms in patients who are not primarily mentally ill.

The data presented so far on the question of "For What Are Psychotropic Drugs Prescribed?" apply only to the year 1968. But what has been the trend over the past several years? Data on this question unfortunately are not available for each of the sepa rate major classes of psychotropic agents but for a conglomerate grouping referred to as ataraxics con. sisting primarily of the classes major and minor tranquilizers. Data on this topic are available from the year 1960. The percent of prescriptions for

ataraxics written for conditions diagnosed as mental disorders between 1960 and 1968 has fluctuated very mildly between 31 and 41 percent. In 1968 the percentage stood at an intermediate 37 percent. A similar analysis of ataraxic prescribing for sub-diagnoses within mental disorders (as listed in Chart 5), over the past 5 years, indicates that there has been little change in this aspect of psychotropic drug therapy.

Considering desired actions of the ataraxics over the 8-year period between 1960 and 1967, we find that, if anything, there has been an increase from a low of 73 percent in 1960 to a high of 85 percent in 1967 for indications dealing with mental symptoma. tology. This 85 percent figure for desired actions

'Prochlorperazine is included in this class.

pertaining to mental symptoms can be contrasted with the 39 percent figure for use of psychotropes in patients who were diagnosed as having mental disorders. Taking both these figures into consideration, we again conclude that psychotropic drugs are being prescribed overwhelmingly for psychiatric symptomatology but a large part of this symptomatology is occurring in patients with diagnoses other than mental disorders. The number of properly controlled studies in which psychotropic drugs have been evaluated for efficacy in patients with non-psychiatric disorders is, to our knowledge, very small and more attention should be given to studies of this type in view of the fact that this is the group for whom a majority of prescriptions for psychotropic agents is being written. These studies should also attempt to provide data on any possible dangerous drug interaction between agents of other therapeutic classes and the psychotropes being used. The enzyme-inducing effect of phenobarbital on the rate of metabolism of anti-coagulant agents is the kind of interaction to which I refer.

In What Manner Are Psychotropic Drugs
Being Prescribed and Used?

Among private practitioners prescribing patterns for psychotropic drugs are fairly uniform. For both major and minor tranquilizers the modal prescription provides for 40 to 45 tablets or capsules to be taken at the rate of three per day for a period of 12 to 14 days. Daily dosages tend to be moderate to low and the mechanics of consumption so arranged that a patient usually takes only one pill per administration. Prescribing practices differ with the medical setting and the average days of therapy provided in the original prescription may vary depending on whether the physician is dealing with patients that are well known to him, or whether the system encourages phone contacts and reports, and similar factors. Among internists and general practitioners, minor tranquilizers are often prescribed on an asneeded basis rather than on a regular extended reg. imen which probably reflects a prophylactic intent where stress has serious implications for an organic illness such as heart disease.

Average prescription sizes for the antidepressants tend to be larger than those for the tranquilizers, approaching 50 units, and the average number of days of therapy provided is closer to 17-a probable reflection of a common therapeutic belief that antidepressants are fairly slow-acting. The average number of days of therapy allowed on prescriptions for hypnotics and sedatives is larger than that for either

antidepressants or tranquilizers. In the case of hypnotics, days of therapy average close to 25 and for sedatives close to 1 month. Prescription sizes for the sedatives, principally phenobarbital, are much larger than those for any other class of psychotropic drugs, averaging close to 80 units of medication. However, it should be pointed out that sedatives and hypnotics are frequently used in middle-aged and older patients with more chronic illnesses.

In general medical settings it is not uncommon to find one-third of the patients being treated with psy. chotropic drugs for a single acute episode of 1 to 3 months' duration, another one-third being treated for several episodes of similar duration that occur over a period of several years, and one-third or less who are chronically ill and receiving psychotropic drugs on a fairly continuous basis.

Preliminary data at our disposal also indicates that outpatients often do not obtain all the refills they are permitted and frequently reduce the prescribed daily dosage when they begin to feel better in what appears to be a self-titrating procedure.

Attitudes Toward Psychotropic Drug Use

We have found that attitudes toward psychotropic drugs and mental illness along with demographic variables influence psychotropic drug usage in the general population. We suspect that attitudinal factors also influence prescribing behavior and hope to study the problem in detail in the near future. We emphasize attitudinal considerations because we feel that many of the judgments about overprescribing, inappropriate prescribing, and overuse of psychotropic drugs will turn on value issues that go beyond the specific medical consequences of drug ingestion.

Early returns of recent survey studies indicate that the attitudes of the American public toward the use of psychotropic drugs remain generally conservative and a majority of those currently taking tranquilizing drugs, or who have done so in the past, express a discomfort with the idea. Aş might be expected, attitudes toward the use of tranquilizers tend to be more conservative in the middle and older age groups, who, paradoxically, because of a greater need, are more prone to obtain psychotropic drugs from a physician. Nonetheless, negative attitudes toward psychotropic drugs are more likely to act as a deterrent to use among the middle and older age groups than in the younger generation who seem to have fewer compunctions about using a psychotropic drug if they feel they need it. Final conclusions on these matters will have to await the outcome of current studies and

an upcoming national survey that will be carried out by the Social Research Group of George Washington University as part of our program of collaborative research on the extent and nature of psychotropic drug usage in the United States.

The data available to us at this time do not indicate that a large proportion of Americans are becoming chronic or dependent users of psychotropic drugs, or are in danger of becoming so in the near future. On the other hand, we suspect that the occa sional use of psychotropic drugs to improve adequate

social functioning and offset or prevent mild discomfort may be on the rise.

We hope this information will be of value to the Subcommittee and will result in even better health care for the nation.

Sources of Data for Charts 2 Through 6

Data in Charts 2 to 4 are derived from the National Prescription Audit of Gosselin & Co. and data in Charts 5 and 6 are derived from the National Disease and Therapeutic Index of Lea & Associates.