Antidepressant use doubled from 1996-2005: surveys show number of Americans treated with medication climbed from 13 million to 27 million.

The number of Americans treated with antidepressants doubled in less than a decade, from about 13 million in 1996 to 27 million in 2005, according to a report in the August issue of the Archives of General Psychiatry.

National surveys show that the number of antidepressant prescriptions per user also increased, as did the number of people who received antipsychotic medications or mood stabilizers in addition to antidepressants. Meanwhile, the number of people who underwent psychotherapy declined.

These broad trends "vividly illustrate the extent to which antidepressant treatment has gained acceptance in the United States and the growing emphasis on pharmacologic rather than psychologic aspects of care," said Dr. Mark Olfson of Columbia University and the New York State Psychiatric Institute, New York, and Steven C. Marcus, Ph.D., of the University of Pennsylvania, Philadelphia.

However, in the wake of the Food and Drug Administration's black box requirement for selective serotonin reuptake inhibitors, more recent data indicate that psychiatrists and general physicians are prescribing fewer antidepressants than they were before the warnings ("Are Warnings on Antidepressants Backfiring?" CLINICAL PSYCHIATRY NEWS, JULY 2007, p. 8.)

The study of older trends by Dr. Olfson and Dr. Marcus is the first to document trends in antidepressant use by using surveys of nationally representative samples--the Medical Expenditure Panel Surveys (MEPS) for 1996 (18,993 subjects) and 2005 (28,445 subjects).

The MEPS tracks the use of all health care services for 1 year among all members of participating households who are aged 6 years and older. The data are verified through contact with all hospitals, medical care providers, home health agencies, and pharmacies used by the survey respondents.

Between 1996 and 2005, the annual rate of antidepressant use increased from 5.8% to 10.1% of the population, which corresponds to a national increase from 13.3 million to 27 million people (Arch. Gen. Psychiatry 2009;66:848-56). This rise was seen in both males and females, across all age groups, and regardless of the subjects' marital status, education level, type of health insurance, and employment status. However, the rates of antidepressant use remain low among African Americans and Hispanics, compared with whites.

"Much remains to be learned about the roles of culturally mediated beliefs, attitudes, and social norms and physician factors in shaping racial/ethnic trends in antidepressant use," Dr. Olfson and Dr. Marcus wrote. The mean number of antidepressant prescriptions per person also increased, from 5.6 in 1996 to 6.9 in 2005.

Dr. David Fassler, who was not involved with the study, said in an interview that the overall increase in the use of antidepressants during that period makes sense, because physicians and the general public are more aware of the signs and symptoms of depression, and treatment with medication is more widely accepted. However, he called the significant decline in referrals for psychotherapy unfortunate.

"Research clearly demonstrates that psychotherapy is a valuable and important component of treatment for many people with depression," said Dr. Fassler, a clinical professor of psychiatry at the University of Vermont, Burlington. He also noted that although the findings are interesting, they "can't tell us if there's been an overall improvement in the care of people with depression. For example, we don't know if the diagnoses were accurate or if people actually complied with treatment.

"In the long-run, the real issue isn't simply how many people are taking antidepressant medication," said Dr. Fassler, a child and adolescent psychiatrist who practices in Burlington. "The more relevant question is whether or not the right people are getting the most effective and appropriate intervention possible."

Dr. Olfson and Dr. Marcus found that the use of antidepressants markedly increased for the treatment of anxiety, depression, adjustment disorders, back pain, and neuropathy, but did not increase significantly for the treatment of bipolar disorder, headache, fatigue, or sleep-related disorders. The number of antidepressant users who received antipsychotic medications or mood stabilizers also increased. When the analysis included medications that are sometimes used as mood stabilizers but are of unproved efficacy (such as gabapentin, ox-cabazepine, and topiramate), approximately 40% of patients treated by psychiatrists and 13% of those treated by other physicians received these drugs along with antidepressants.

"Only a small minority" of patients who took antidepressants were treated by mental health professionals; most received their prescriptions from primary care physicians. This indicates "the extent to which antidepressant treatment has become broadly accepted in the general medical sector," the investigators said. The trends for antidepressant use among children and adolescents closely paralleled those in young adults.

The study was supported by the Agency for Healthcare Research and Quality and NARSAD (previously known as the National Alliance for Research on Schizophrenia and Depression).

Dr. Olfson has received research support from the National Institutes of Health, the Agency for Healthcare Research, the American Foundation for Suicide Prevention, the National Association for Research on Schizophrenia and Affective Disorders, the New York State Office of Mental Health, AstraZeneca PLC, Bristol-Myers Squibb Co., Eli Lilly & Co., and Ortho-McNeil Janssen Scientific Affairs LLC. Dr. Marcus has received research support the NIH, Bristol-Myers Squibb, Eli Lilly, AstraZeneca, and Ortho-McNeil.