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Psychotropic Medications Often Prescribed Without a Diagnosis

A new study published in the online journal Psychiatric Services suggests that more than half of the people who receive prescriptions for psychotropic medications have not received a formal diagnosis of a mental illness.

The study examined the MarketScan claims of more than 5 million patients, and found that 58.2 percent of patients on at least one psychotropic medication had no recorded diagnosis of a psychiatric disorder.

The lead investigator for the study was Ilse Wiechers, M.D. Dr. Wiechers is a Robert Wood Johnson foundation clinical scholar at the Yale School of Medicine, and also works with the U.S. Department of Veterans Affairs. In an interview with Medscape Medical News, Dr. Wiechers says that she was inspired to research the topic because of her personal experience as a geriatric psychiatrist. In her work, Dr. Wiechers encountered many patients on psychiatric medications without diagnoses, and even found that in many cases, the patients themselves were not certain why they were taking the medications.

Examining a Variety of Psychotropic Medications

Previous research has established that the practice of prescribing antidepressant medications without a mental illness diagnosis is fairly common, but there was little information about other classes of psychotropic medications. Dr. Wiechers’ study looked at a wide variety of psychiatric drugs, dividing them into six groups: antidepressants, antipsychotics, benzodiazepines (commonly prescribed for anxiety and panic disorders), stimulants (commonly prescribed for ADHD), anticonvulsant mood stabilizers, and lithium (used to treat mania in patients with bipolar disorder).

The study found that benzodiazepines are the class of drug most frequently prescribed without a diagnosis. Sixty-one percent of the patients on these medications had no recorded diagnosis of mental illness. The next most likely drug class was mood stabilizers (58 percent), followed by antidepressants (52 percent), antipsychotics (31 percent), stimulants (26 percent) and lithium (12 percent).

A Larger Problem Among Older Patients

The researchers divided patient data into three subgroups by age in order to examine trends among different age groups. Of the 5,132,789 patient records used, 37 percent were for patients 18-39 years of age, 23 percent were for patients 40-49 years of age, and 40 percent were for patients 50-64 years of age.

Of the three age subgroups, the oldest group reported the largest number of prescriptions without a psychiatric diagnosis by far. Of the patients between 50 and 64 years of age, 69 percent had no recorded diagnosis for their psychotropic medications. They were 2.9 times as likely to receive a prescription without a diagnosis than the 18-39 years age group. The study also found that the 40-49 years age group was 1.8 times more likely to receive a psychiatric prescription without a diagnosis than the youngest group, showing that the phenomenon seems to steadily increase with age.

Understanding the Data

The study also looked at the ways in which mental health specialty care affected the connection between diagnosis and prescription. The results suggested that patients who seek specialty care for a mental health concern are much less likely to receive a prescription for psychotropic drugs without a formal diagnosis. Only 14 percent of the people in Dr. Wiechers’ study who filed a claim in the preceding year for services at a mental health or substance abuse clinic did not receive a diagnosis before receiving a prescription. This suggests that a large majority of the people who receive a psychiatric prescription without a diagnosis of mental illness do so in a general medicine, primary care or surgical setting.

Dr. Wiechers notes that there are a variety of possible explanations for her findings other than inappropriate use of medications. Poor documentation may be part of the problem, particularly for patients who have been taking a medication for many years, and who may have no recent diagnostic record relating to the medication. It may also be that in some cases patients are taking appropriate medication for an illness that should have been formally diagnosed, but was not.

Nevertheless, the results do indicate that further research is needed to better understand the reasons for this phenomenon, and that a change in prescription practices may be needed if inappropriate prescription is found to be widespread.

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