National trends of psychotropic medication use among patients diagnosed with anxiety disorders: Results from Medical Expenditure Panel Survey 2004–2009

Journal of Anxiety Disorders 27 (2013) 163–170

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Journal of Anxiety Disorders

National trends of psychotropic medication use among patients diagnosed with anxiety disorders: Results from Medical Expenditure Panel Survey 2004–2009 Chung-Hsuen Wu a,∗ , Chi-Chuan Wang b,c , Aaron Jacob Katz d , Joel Farley d a

School of Pharmacy, College of Pharmacy, Taipei Medical University, Taiwan Research Triangle Institution Health Solutions, Research Triangle Park, NC, United States School of Pharmacy, National Taiwan University, Taipei, Taiwan d Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, United States b c

a r t i c l e

i n f o

Article history: Received 15 May 2012 Received in revised form 13 October 2012 Accepted 23 November 2012 Keywords: Anxiety disorders Psychotropic medication use Medical Expenditure Panel Survey (MEPS) Antidepressants Benzodiazepines National trends

a b s t r a c t Data from the 2004 to 2009 Medical Expenditure Panel Survey (MEPS) were used to: (1) characterize changes in utilization and (2) identify factors associated with the use of psychotropic medication among patients with anxiety disorders. We calculated the prevalence, compared the use patterns for each year and drug class, and used logistic regression to identify the factors associated with psychotropic medication use. Patients ever using a psychotropic medication for anxiety grew from 57.4% in 2004 to 63.8% in 2009 (p < 0.01). From 2004 to 2009, use of benzodiazepines (22.7–30.5%, p < 0.01) and atypical antipsychotics (2.3–3.9%, p < 0.01) increased. A high prevalence in the use of benzodiazepines (41.8% in 2004 to 48.8% in 2009) was observed among older adults. Older age, having insurance coverage, and poor health status were significantly associated with self-reported psychotropic medication use. An increase of psychotropic medication use from 2004 to 2009 was observed. A high prevalence and increasing trend in the use of benzodiazepines may warrant further attention given safety concerns in older adults. © 2013 Elsevier Ltd. All rights reserved.

1. Introduction Anxiety disorders are a common psychiatric condition affecting approximately 18.1% of the United States population each year (Kessler, Berglund, et al., 2005; Kessler, Chiu, Demler, Merikangas, & Walters, 2005) and nearly 28.1% of the U.S. population over their lifetime (Kessler, Berglund, et al., 2005; Kessler, Chiu, et al., 2005). Anxiety disorders frequently co-exist with other chronic physical and mental illnesses including irritable bowel syndrome (IBS), chronic pain, asthma, cardiovascular diseases, and depression (Kessler et al., 2002; Otte, 2008; Roy-Byrne et al., 2008; Ruscio et al., 2007; Strine et al., 2008; Todaro, Shen, Raffa, Tilkemeier, & Niaura, 2007). A significant amount of productivity and economic loss is attributable to anxiety disorders and related comorbidity. Studies have shown anxiety disorders that have a deleterious effect on functional well-being and health related qualify of life (Revicki et al., 2011) and can increase medical expenditures and the use of different health resources among patients (Bereza, Machado, & Einarson, 2009; Revicki et al., 2011). Symptoms of anxiety disorders can be well controlled by pharmacologic and psychological treatments. Clinical guidelines

∗ Corresponding author at: No. 250, Wu-Hsing St., Taipei 11031, Taiwan. Tel.: +886 2 2736 1661x6180; fax: +886 2 2739 0671. E-mail address: [email protected] (C.-H. Wu). 0887-6185/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.janxdis.2012.11.004

recommend pharmacologic treatments as first-line therapy for anxiety disorders (American Psychiatric Association, 2004, 2007, 2009). With relatively few side effects, medications such as selective serotonin reuptake inhibitors (SSRIs) or serotonin–norepinephrine reuptake inhibitors (SNRIs) can effectively provide symptom relief for patients with anxiety disorders (American Psychiatric Association, 2004, 2007, 2009; Karsnitz & Ward, 2011; Sable & Jeste, 2001). Although anxiety disorders can be successfully managed with medications, previous research shows that patients are frequently untreated (Young, Klap, Sherbourne, & Wells, 2001). In a nationally representative telephone survey, less than one-third of patients with anxiety received appropriate treatment (Young et al., 2001). As a consequence, untreated anxiety can result in higher health resource utilization such as increased emergency room visits for anxiety-related mental health conditions (Smith, Larkin, & Southwick, 2008). Major pharmacologic treatment for anxiety disorders includes antidepressants (SSRIs, SNRIs, and tricyclic antidepressants (TCAs]), and benzodiazepines. Regarding the under treatment reported in the previous study (Young et al., 2001) and newer treatment available such as SSRIs and SNRIs, it is important to understand the use pattern of psychotropic medications as well as predictors of the use patterns given the benefits and risks of using these medications. For example, although taking benzodiazepines can quickly reduce anxious symptoms, it may also increase the risk of addiction among users and can potentially increase the risk of falls

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and cognitive impairment among older users (Leipzig, Cumming, & Tinetti, 1999; Ravindran & Stein, 2010; Takkouche, MontesMartinez, Gill, & Etminan, 2007). These adverse effects are less prevalent among users of SSRIs or SNRIs, which may shift treatment patterns to these agents. Furthermore, benzodiazepines were excluded from coverage under Medicare part D in the U.S. which may have shifted the prescribing in older adults to other agents. Previous studies have documented an increasing trend in outpatient visits for the treatment of anxiety disorders and the use of psychotropic medications to manage these conditions (Olfson, Marcus, Wan, & Geissler, 2004; Smith et al., 2008). A prior study by Olfson et al. (2004) using Medical Expenditure Panel Survey (MEPS) data showed that the proportion of patients with anxiety disorders using psychotropic medications increased from 52.1% to 69.9% between 1987 and 1999. To our knowledge, the Olfson study represents the only nationally generalizable investigation of treatment patterns for anxiety disorders and given the timing of these data, the results are not likely generalizable to current practice patterns for anxiety disorders. It is essential to update the use pattern and better understand factors associated with psychotropic medication among patients with anxiety disorders. The current study seeks to fill this gap in the literature to better understand psychotropic medication use in the U.S. The purpose of this study is to: (1) characterize changes in utilization and (2) identify factors associated with the use of psychotropic medication among patients with anxiety disorders over a 6 year-period from 2004 to 2009. With new agents available, we expect to see a decreased trend of benzodiazepine use and an increased trend of newer agents (e.g., SSRIs, SNRIs). In addition, we also expect to observe a decreased trend of benzodiazepine use among older adults with anxiety disorders due to the exclusion of benzodiazepines from Medicare Part D prescription drug coverage in older adults in the U.S.

2. Methods 2.1. Data sources We used data from the Medical Expenditure Panel Survey (MEPS), which is a nationally representative survey of the U.S. civilian non-institutionalized population (Agency for Healthcare Research and Quality (AHRQ), 2006, 2011c; Ezzati-Rice, Rohde, & Greenblatt, 2008). MEPS is commonly used to evaluate national estimates of medication use and expenditures. It is designed as a longitudinal survey comprised of five rounds of interviews over two and half consecutive years (Ezzati-Rice et al., 2008). The sampling frame of MEPS HC is selected from the National Health Interview Survey, a survey conducted by National Center for Health Statistics (Agency for Healthcare Research and Quality (AHRQ), 2011c). Approximately 35,000 respondents are interviewed each year and the population represents a nationally generalizable estimate of health care use in the U.S. after accounting for complex survey weighting. The response rate of each survey year in this study is 63.1% (2004), 61.3% (2005), 58.3% (2006), 56.9% (2007), 59.3% (2008), and 57.2% (2009), respectively (Agency for Healthcare Research and Quality (AHRQ), 2006, 2007, 2008, 2009, 2010, 2011c). MEPS is considered as a comprehensive and reliable data source to study medication use from a national perspective. The data set for this study was derived by combining data for each patient in the MEPS survey across the Full Year Consolidated Data File, Medical Conditions File, and Prescribed Medicines File (Agency for Healthcare Research and Quality (AHRQ), 2011a).

2.2. Study population We use the MEPS data from 2004 through 2009. Patients diagnosed with anxiety disorder using Clinical Classification Codes (CCC) (Agency for Healthcare Research and Quality (AHRQ), 2011b) were identified from the Medical Conditions File and defined as the study population. To ensure confidentiality of survey respondents, CCC aggregates clinically homogeneous conditions listed in the ICD-9CM codes using Clinical Classification Software (Agency for Healthcare Research and Quality (AHRQ), 2011b) to provide valid clinical diagnostic categories for a respondent’s health conditions (Agency for Healthcare Research and Quality (AHRQ), 2011b). In our study, the anxiety disorders CCC comprised conditions including generalized anxiety disorder, panic disorder, social anxiety disorder, obsessive–compulsive disorder, post-traumatic stress disorder, stress related anxiety, overanxious disorder, and mixed emotional disturbances. The ICD-9CM codes of these conditions are 293.84, 300.00, 300.01, 300.02, 300.09, 300.10, 300.20, 300.21, 300.22, 300.23, 300.29, 300.3, 300.5, 300.89, 300.9, 308.0, 308.1, 308.2, 308.3, 308.4, 308.9, 309.81, 313.0, 313.1, 313.21, 313.22, 313.3, 313.82, and 313.83. 2.3. Medication identification We identified psychotropic medication use from the Prescribed Medicines File. In MEPS, survey respondents were asked to report prescribed medicines associated with certain medical conditions to allow for national estimates of prescription utilization (Agency for Healthcare Research and Quality (AHRQ), 2011a). In the questionnaires, interviewers first asked respondents whether the medicine was used for a specific health condition. For respondents who answered yes to this question, a following question was asked for which health condition was the medicine prescribed for. Psychotropic medications identified in our study were for anxiety disorders. After identifying the study population, we used a medication chart provided by the Anxiety Disorders Association of America to categorize each subclass of psychotropic medications among users (Anxiety Disorders Association of America (ADAA), 2009) and categorized medications into five major groups including: antidepressants, anxiolytics, anticonvulsants, noradrenergic agents, and atypical antipsychotics (ADAA, 2009Anxiety Disorders Association of America (ADAA), 2009). Antidepressants were further classified into four categories: SSRIs (citalopram, escitalopram, fluvoxamine, paroxetine, fluoxetine, and sertraline), TCAs (doxepin, clomipramine, nortriptyline, amitriptyline, maprotiline, desipramine, nortriptyline, doxepin, trimipramine, imipramine, and protriptyline), monoamine oxidase inhibitors [MAOIs] (isocarboxazid, phenelzine, and tranylcypromine), and other antidepressants which included SNRIs (duloxetine and venlafaxine), serotonin modulators (trazodone), norepindphrine serotonin modulator (mirtazapine), and bupropion. Anxiolytics were classified into three categories: azapirones (buspirone), benzodiazepines (lorazepam, flurazepam, clonazepam, triazolam, chlordiazepoxide, temazepam, oxazepam, clorazepate, diazepam, and alprazolam), and antihistamines (hydroxyzine). Anticonvulsants included tiagabine, gabapentin, valproate, lamotrigine and topiramate. Noradrenergic agents include alpha blockers (prazosin, clonidine, and guanfacine) and beta blockers (propranolol and atenolol). Atypical antipsychotics included aripiprazole, ziprasidone, risperidone, quetiepine, and olanzapine. 2.4. Covariates We used Andersen’s Behavioral Model of Health Services Use to identify covariates associated with psychotropic medication use among patients with anxiety disorders (Andersen, 1995, 2008;

C.-H. Wu et al. / Journal of Anxiety Disorders 27 (2013) 163–170

Andersen & Newman, 1973). The Andersen’s model is a theoretical framework that is often used to predict factors associated with health behaviors and health resource utilization. In the model, factors are categorized into three groups. They are predisposing, enabling, and need factors that are used to predict health behaviors or health resource utilization (Andersen, 1995, 2008; Andersen & Newman, 1973). In this study, we chose the covariates based on the Andersen’s model assumption that medication use (i.e. psychotropic medication use in our study) is associated with a number of predisposing, enabling, and need factors. Predisposing factors included in our study were age (18–64 years and ≥65 years), gender, race (white, black, and others: including American Indians/Alaska Natives, Asians, Native Hawaiians/Pacific Islanders, and people with multiple races), ethnicity (Hispanic and not Hispanic), years of education (≥13, 12, and 0–11), and geographic region of residence (Northwest, Midwest, South, and West). Enabling factors included household income and insurance coverage. Income was categorized according to the federal poverty limit (FPL) and classified as high income greater than or equal to 400% FPL, middle income: 200% to less than 400% FPL, low income: 125% to less than 200% FPL, near poor: 100% to less than 125% FPL, and poor: less than 100% FPL. Insurance was classified as any private, public insurance only, and uninsured. Need factors included perceived health status (excellent, very good, good, fair, and poor), and comorbid mental conditions. Comorbid mental conditions were defined if respondents were diagnosed with a mental illness in addition to anxiety disorders during the survey year. The comorbid mental conditions included attention deficit or conduct disorder, dementia or cognitive disorders, mood disorders, and schizophrenia or psychotic disorders. 2.5. Statistical analysis All analyses were adjusted for design elements including weights, clustering, and stratification provided by National Center for Health Statistics to obtain national estimates (Agency for Healthcare Research and Quality (AHRQ), 2011c). After the adjustment, the relative sample size of our study becomes weighted estimates representing the U.S. population (Agency for Healthcare Research and Quality (AHRQ), 2011c). Analyses were conducted in two major steps. First, we used descriptive statistics to characterize and evaluate changes in medication use patterns. Weighted annual prevalence estimates for each drug class were presented in the year of 2004 and 2009. We compared 2004 and 2009 annual prevalence estimates of the drugs to evaluate changes in medication use. We also examined trends in medication use from 2004 to 2009 on five major drug classes including SSRIs, SNRIs, TCAs, benzodiazepines, and atypical antipsychotics. These therapeutic classes were selected because they represent the most commonly used categories to treat anxiety disorders in daily clinics (Davidson, 2009; Karsnitz & Ward, 2011; Lauderdale & Sheikh, 2003). We present changes among the overall population as well as older respondents aged 65 years and older. Wald Chi-squared tests, that provide a more conservative statistical hypothesis test than a regular Chi-squared test, were used to evaluate changes from 2004 and 2009. Second, we used an adjusted multivariate logistic regression model to evaluate factors associated with the use of psychotropic medications among the study population in 2009 while simultaneously controlling for covariates. The dependent variable of the logistic regression was the use of any psychotropic medication previously identified above in 2009. All data management and statistical analyses were performed using SAS v.9.2 (SAS Institute, Cary, NC) (SAS Institute Inc., 2008). The sampling design of MEPS is not from a simple random sampling process but from a complex sampling design. All analyses were

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adjusted for the complex sample survey design including stratification, clustering and weighting in the MEPS data to obtain national level estimates. In our study, all results were adjusted by variables of sample design elements that were provided in the MEPS data. Two-tailed tests with a 0.05 level of significance were used to determine statistical significance. The study protocol had exemption by the Institutional Review Board (IRB) at the University of North Carolina at Chapel Hill.

3. Results Table 1 shows the characteristics of the 2004 and 2009 study population. The number of respondents in the U.S. diagnosed with anxiety disorders grew from 18.9 million in 2004 to 21.4 million in 2009. Table 1 also compared proportions of key population characteristics between 2004 and 2009. Slight growth between 2004 and 2009 can be seen among respondents with anxiety disorders aged 18–64 (83.0% vs. 83.5%, p = 0.75), women (64.5% vs. 65.6%, p = 0.51), Whites (88.5% vs. 88.8%, p = 0.98), patients with more than 13 years of education (45.3% vs. 49.6%, p < 0.05), and patients with public insurance (20.2% vs. 23.7%, p = 0.06). Despite this growth, only respondents with 13 or more years of education were found to have a statistically significant increase over this time period. Table 2 presents the estimates of psychotropic medication use for anxiety disorders and compares the difference in use between the 2004 and 2009 study populations. The number of respondents with anxiety disorders using psychotropic medications significantly increased from 10.9 million in 2004 to 13.7 million in 2009 (57.4% vs. 63.8%, p < 0.01). Specifically, the use of benzodiazepines (22.7% vs. 30.5%, p < 0.01), antihistamines (0.5% vs. 1.1%, p < 0.05), and atypical antipsychotics (2.3% vs. 3.9%, p < 0.01) for anxiety disorders significantly grew from 2004 to 2009. Although there was an increase in the use of SSRIs (26.5% vs. 28.3%) and SNRIs (4.7% vs. 6.4%), the increase between 2004 and 2009 was not large enough to make the increase become statistically significant. Fig. 1 details change in the use of SSRIs, SNRIs, TCAs, benzodiazepines, and atypical antipsychotics among respondents with anxiety disorders from 2004 to 2009 among the overall U.S. population with anxiety disorders. SSRIs and benzodiazepines are the two most prevalent medications used for anxiety disorders. Beginning in 2007, the use of benzodiazepines exceeded the use of SSRIs. Although the use of SNRIs and antipsychotics were low when compared with SSRIs or benzodiazepines, the use of both agents constantly increased from 2004 to 2009. Fig. 2 details change in the use of SSRIs, SNRIs, TCAs, benzodiazepines, and atypical antipsychotics among older respondents aged ≥65 years with anxiety disorders from 2004 to 2009. Approximately three million older respondents had anxiety disorders in each year. Benzodiazepines represented the most prevalent pharmacologic treatment used for anxiety disorders. A high prevalence in the use of benzodiazepines (41.8% in 2004 to 48.8% in 2009, p = 0.09) was observed. Use of benzodiazepines reached 50.4% in 2005 and then sharply dropped to 39.1% in 2007 before it increased back to 48.8% in 2009. SSRIs were commonly used for anxiety disorders among older respondents and the use rate significantly increased from 2004 to 2009 (22.0% vs. 33.5%, respectively, p < 0.01). Table 3 shows the factors associated with psychotropic medication use among respondents with anxiety disorders in 2009. Unadjusted and adjusted odds ratios (OR) were reported from logistic regression models. Unadjusted models evaluated the association between individual characteristics and psychotropic medication use without adjustment for other model characteristics. Age, gender, race, ethnicity, education, region, household income, insurance coverage, perceived health status, and mood disorder were found to be significantly associated with psychotropic medication use.

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Table 1 Characteristics of the study populations in 2004 and 2009. Patients diagnosed with anxiety disorders 2004 (18.9 million)

Age 18–64 ≥65 Gender Female Male Race White Black Others Ethnicity Hispanic Not Hispanic Education 0–11 12 ≥13 Region Northwest Midwest South West Household income High income Middle income Low income Near poor Poor Insurance Any private Public only Uninsured Perceived health status Excellent Very good Good Fair Poor

2009 (21.4 million) a

Est. N

%

Est. N

%a

14,672,586 3,008,187

83.0% 17.0%

16,837,363 3,330,124

83.5% 16.5%

12,198,007 6,711,484

64.5% 35.5%

14,043,056 7,355,431

65.6% 34.4%

16,734,582 1,315,978 858,930

88.5% 7.0% 4.5%

18,992,736 1,456,355 949,395

88.8% 6.8% 4.4%

1,656,758 17,252,732

8.8% 91.2%

1,949,745 19,448,741

9.1% 90.9%

4,300,031 5,957,636 8,504,357

22.9% 31.8% 45.3%

4,156,401 6,554,492 10,538,252

19.6% 30.8% 49.6%

3,544,675 4,886,580 6,030,075 4,285,752

18.9% 26.1% 32.2% 22.9%

3,875,106 5,289,651 6,852,025 5,233,331

18.2% 24.9% 32.2% 24.6%

6,976,141 5,463,414 2,591,567 1,061,243 2,817,125

36.9% 28.9% 13.7% 5.6% 14.9%

7,117,018 7,182,816 2,887,091 936,169 3,275,392

33.3% 33.6% 13.5% 4.4% 15.3%

13,281,149 3,821,624 1,806,718

70.2% 20.2% 9.6%

14,195,378 5,075,054 2,128,054

66.3% 23.7% 9.9%

2,744,759 5,316,381 5,888,630 3,151,681 1,565,254

14.7% 28.5% 31.5% 16.9% 8.4%

3,108,752 5,744,811 6,335,145 4,110,895 1,819,071

14.7% 27.2% 30.0% 19.5% 8.6%

p-Valueb 0.75

0.51

0.98

0.75

<0.05

0.82

0.07

0.06

0.43

Source: 2004 and 2009 Medical Expenditure Panel Survey (MEPS). a Weighted estimate of the column percentage. b Wald Chi-square test between 2004 and 2009.

Results from the multivariate logistic regression controlling for all model covariates shows that older age (OR = 2.15, 95% confidence interval [CI] = 1.42–3.24), having insurance coverage (private insurance: OR = 2.06, 95% CI = 1.43–2.98, public insurance:

OR = 3.58, 95% CI = 2.43–5.27), and a poor health status (poor health status: OR = 2.09, 95% CI = 1.12–3.93, fair health status: OR = 1.75, 95% CI = 1.11–2.77) were associated with a higher probability of psychotropic medication use. Minority including Black race and

24.0

Annual rates of sub-class medicaon use

60.0%

22.0 20.0

50.0%

18.0 16.0

40.0%

14.0 12.0

30.0%

10.0 8.0

20.0%

6.0 4.0

10.0%

2.0 0.0

0.0% 2004 Paents with anxiety

2005

2006 SSRIs

SNRIs

2007 TCAs

2008 Benzodiazepines

Naonal prevalence of paents with anxiety disorders (in millions)

26.0

70.0%

2009 Anpsychocs

Fig. 1. The trend of psychotropic drug use among patients with anxiety disorders from 2004 to 2009.

C.-H. Wu et al. / Journal of Anxiety Disorders 27 (2013) 163–170

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Table 2 The estimate trend change of psychotic drug use for treating anxiety disorders between 2004 and 2009.f 2004

2009

Difference

p-Value

Est. N

Row %a

Est. N

Row %a

18,909,490 10,862,949

100.0 57.4

21,398,486 13,658,729

100.0 63.8

6.4

<0.01

Antidepressants SSRIsb SNRIsc TCAsd Other antidepressantse

5,013,756 896,928 311,205 780,854

26.5 4.7 1.6 4.1

6,057,271 1,369,137 325,376 771,355

28.3 6.4 1.5 3.6

1.8 1.7 −0.1 −0.5

0.32 0.07 0.76 0.47

Anxiolytics Azapirones Benzodiazepines Antihistamines Anticonvulsants

394,367 4,300,065 103,606 328,404

2.1 22.7 0.5 1.7

476,549 6,518,625 242,730 426,697

2.2 30.5 1.1 2.0

0.1 7.7 0.6 0.3

0.78 <0.01 <0.05 0.60

66,353 92,111 440,078

0.4 0.5 2.3

64,763 93,766 838,336

0.3 0.4 3.9

0.0 0.0 1.6

0.82 0.84 <0.01

Patients diagnosed with anxiety disorders Psychotropic medications for anxiety disorders

Noradrenergic agents Alpha blockers Beta blockers Atypical antipsychotics

Source: 2004 and 2009 Medical Expenditure Panel Survey (MEPS). a Weighted estimate of the row percentage. b Selective serotonin reuptake inhibitors. c Serotonin–norepinephrine reuptake inhibitors. d Tricyclic antidepressants. e Other antidepressants include trazodone, mirtazapine, and bupropion. f The estimated U.S. population was 293,527,003 in 2004. Among them, 6.4% (18,909,490) were diagnosed with anxiety disorders. The estimated U.S. population was 306,660,588 in 2009. Among them, 7.0% (21,398,486) were diagnosed with anxiety disorders. The increase of prevalence was not statistically significant (p = 0.07).

Hispanic ethnicity were less likely to report psychotropic medication use.

4. Discussion To our knowledge, this is the most comprehensive study to have examined psychotropic medication use among a nationally representative population of patients with anxiety disorders in the U.S. to date. The results show a significant increase in psychotropic medication use among respondents with anxiety disorders between 2004 and 2009. More specifically, our results also show that the use of benzodiazepines and antipsychotics increased substantially among patients with anxiety disorders during this time period. In contrast, the use of SSRIs and SNRIs also grew during between 2004 and 2009, but not significantly in our study. Our findings are consistent with prior estimates from the study by Olfson et al. that showed an increase in the use of psychotropic medication use

among patients with anxiety disorders in the 1990s (Olfson et al., 2004). The increased use of atypical antipsychotics among patients with anxiety disorders is interesting and deserves particular attention. These results are consistent with a recent study by Comer, Mojtabai, and Olfson (2011) which showed an increase in antipsychotic prescribing in visits for anxiety from10.6% to 21.3% between 1996 and 2007 using data from the National Ambulatory Care Survey. The U.S. Food and Drug Administration (FDA) has not approved any antipsychotics for anxiety disorders (Maglione et al., 2011). However, an augmentation of atypical antipsychotics with antidepressants is a common treatment strategy in daily clinics (Ravindran & Stein, 2010). The increased use of atypical antipsychotics documented in our study may point to an increased number of patients with non-response to traditional approved anxiety medications, or it may point to an increased number of patients with more severe anxiety disorders who need a more complicated treatment regimen. Although off-label prescribing of these medications

24.0

Annual rates of sub-class drug use

60.0%

22.0 20.0

50.0%

18.0 16.0

40.0%

14.0 12.0

30.0%

10.0 8.0

20.0%

6.0 4.0

10.0%

2.0 0.0%

0.0 2004 Paents with anxiety

2005

2006 SSRIs

SNRIs

2007 TCAs

2008 Benzodiazepines

2009

Naonal prevalence of paents with anxiety disorders (in millions)

26.0

70.0%

Anpsychocs

Fig. 2. The trend of psychotropic drug use among older patients (age ≥ 65) with anxiety disorder from 2004 to 2009.

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Table 3 Factors associated with psychotropic drug use for anxiety among patients with anxiety disorders in 2009 (N = 21.4 million patients). Variables Predisposing factors Age 0–17 18–64 ≥65 Gender Female Male Race White Black Others Ethnicity Hispanic Not Hispanic Education 0–11 12 ≥13 Region Northwest Midwest South West

Unadjusted odds ratio

95% CIa

Adjusted odds ratio

95% CIa

0.29 Reference 3.06

(0.18–0.48) Reference (2.11–4.45)

0.25 Reference 2.15

(0.13–0.47) Reference (1.42–3.24)

1.31 Reference

(1.05–1.64) Reference

1.23 Reference

(0.96–1.57) Reference

Reference 0.66 0.51

Reference (0.50–0.88) (0.33–0.78)

Reference 0.50 0.46

Reference (0.37–0.67) (0.29–0.74)

0.44 Reference

(0.32–0.60) Reference

0.48 Reference

(0.34–0.67) Reference

0.86 1.59 Reference

(0.66–1.14) (1.20–2.11) Reference

0.97 1.39 Reference

(0.68–1.37) (1.02–1.90) Reference

1.81 2.39 1.84 Reference

(1.23–2.68) (1.67–3.41) (1.31–2.58) Reference

1.64 2.20 1.83 Reference

(1.11–2.41) (1.52–3.20) (1.25–2.67) Reference

(1.04–1.90) (0.98–3.03) (0.91–1.90) (1.00–1.78) Reference

1.13 1.05 1.09 1.22 Reference

(0.75–1.70) (0.57–1.92) (0.71–1.66) (0.92–1.64) Reference

(1.40–2.58) (2.76–5.77) Reference

2.06 3.58 Reference

(1.43–2.98) (2.43–5.27) Reference

Reference (0.94–2.00) (1.05–2.14) (1.67–3.57) (2.14–6.06)

Reference 1.14 1.17 1.75 2.09

Reference (0.75–1.73) (0.79–1.73) (1.11–2.77) (1.12–3.93)

(0.57–1.44) Reference

1.66 Reference

(0.86–3.22) Reference

(1.05–9.71) Reference

1.30 Reference

(0.31–5.44) Reference

(1.21–1.94) Reference

1.26 Reference

(0.99–1.65) Reference

(0.79–5.24) Reference

1.27 Reference

(0.46–3.49) Reference

Enabling factors Household income 1.41 Poor 1.72 Near poor 1.31 Low income 1.34 Middle income Reference High income Insurance 1.90 Any private Public only 4.00 Reference Uninsured Need factors Perceived health status Excellent Reference Very good 1.37 Good 1.50 Fair 2.44 3.60 Poor Attention deficit or conductive disorder Yes 0.90 No Reference Dementia or cognitive disorders 3.19 Yes Reference No Mood disorders 1.53 Yes Reference No Schizophrenia or psychotic disorders 2.03 Yes Reference No Source: 2009 Medical Expenditure Panel Survey (MEPS). a 95% CI: 95% confidence interval.

may be common in clinical practice, the safety and effectiveness of these medications for anxiety has not been proven. It should be noted that the reason for using psychotropic medication is not differentiated in our study and antipsychotic medications may be used for conditions comorbid to anxiety. More research is needed to evaluate the risks and benefits of using atypical antipsychotics for anxiety disorders using well-designed clinical trial protocols. The increase in the use of benzodiazepines found in our study is of interest given recent estimates, which suggested a decrease in the use of these agents during the 1990s (Olfson et al., 2004). Among older respondents with anxiety disorders, benzodiazepines were the most prevalent agent that patients self-reported using for anxiety disorders in our study. In clinics, benzodiazepines are recommended for anxiety due to a higher tolerability, fast onset,

and sedative actions (Nutt, 2005; Ravindran & Stein, 2010). However, these agents also have considerable side effects which have been noted as particularly problematic in older adults including excessive sedation, cognitive impairment and a risk for falls (Madhusoodanan & Bogunovic, 2004; Salzman, 1991). Given the increase in utilization, clinicians should consider the safety of benzodiazepines when prescribing them for older adults. We found a sharp decrease in benzodiazepine use from 2005 to 2007 among older adults, which is likely due to the implementation of Medicare Part D in 2006 that excluded benzodiazepine medications from inclusion on formulary (Bambauer, Sabin, & Soumerai, 2005). Our finding of decreased use is similar to a study conducted by Chen et al., which found a reduction in utilization and an increase in out-of-pocket costs for benzodiazepines following

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the implementation of Medicare Part D (Chen et al., 2008). It is interesting to note that the use of benzodiazepines has returned back to pre-Medicare Part D levels in this population from 2007 to 2009. The trend of benzodiazepine use among older adults suggests a short term effect of Part D on benzodiazepine use despite the sustained financial burden of paying for benzodiazepines among older adults with anxiety disorders. A significant increase in the use of SSRIs among older respondents was observed between 2004 and 2009 in our study. However, although there was a significant increase in the use of these agents between 2005 and 2007, there was a decrease in their use in 2007 and 2008. This contrasts the increase in benzodiazepine use during this period. Whether the opposite trend direction implies the use of SSRIs represented a temporary alternative for benzodiazepine use during the implementation of Part D necessitates further evaluation. From our findings, the use of SSRIs and SNRIs increased among the overall population but the increase was not significant between 2004 and 2009. SSRIs and SNRIs are recommended as first pharmacologic treatment options for anxiety disorder due to their efficacy and tolerability (American Psychiatric Association, 2007, 2009; Ravindran & Stein, 2010). A better awareness of the use of these agents for anxiety disorders by physicians and patients may explain part of the increase in the use of these agents found during the years addressed in our study. Our results also showed that older respondents with insurance coverage and poor overall health status were more likely to report psychotropic medication use for anxiety disorders. Since patients with poor health can have higher need of treatment, it is not surprising to find that those patients were more likely to use psychotropic medication. As we expected, patients with insurance coverage were more likely to report medication use for anxiety disorders given that patients with insurance coverage usually have better access to health care. Anxiety disorders have been reported to be associated with a greater risk of mortality among older patients (van Hout et al., 2004). The treatment of older adults with anxiety disorders may become increasingly important over time as the prevalence of anxiety increases and the population ages (Devane, Chiao, Franklin, & Kruep, 2005). Side effects and tolerance needs to be carefully considered when clinicians treat older patients with anxiety disorders. Several limitations must be considered in interpreting our study results. MEPS results are based on respondents’ self-reported outcomes and are subject to recall bias among respondents. A number of steps are taken to reduce recall bias in MEPS including limiting recall periods typically to 6 months for survey questions. Regarding prescription data, MEPS interviewers seek permission from respondents to obtain a computerized record of all prescriptions filled to validate prescription histories (Agency for Healthcare Research and Quality (AHRQ), 2011a). One limitation of MEPS is that it does not allow for the capture of the severity of anxiety or the capture of a specific type of anxiety disorders since Clinical Classification Codes group all sub types of anxiety disorders together. As a result, the psychotropic medication use pattern reported in our study is a general use pattern among patients with anxiety disorders. Furthermore, we used Andersen’s model to select factors that may associate with psychotropic medication use in our study. However, factors that associated different sub types of psychotropic medication use may be different. Finally, the findings from our study are generalizable only to the U.S. population. Differences in treatment patterns and diagnoses of mental health conditions such as anxiety may differ in other countries. Future research may want to examine rates of treatment in other countries to examine for differences in the prevalence of anxiety and treatment. Despite all the limitations, the results of our study still provided the most updated patterns and trend of psychotropic medication use for treating anxiety among patients diagnosed with anxiety disorders in the U.S.

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