title: Potential underuse, overuse, and inappropriate use of antidepressants in older veteran nursing home residents.
abstract: OBJECTIVE
  To examine prevalence and resident- and site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants in older Veterans Affairs (VA) Community Living Center (CLC) residents.
  
  
  METHODS
  Longitudinal study.
  
  
  METHODS
  One hundred thirty-three VA CLCs.
  
  
  METHODS
  Three thousand six hundred ninety-two veterans aged 65 and older admitted between January 1, 2004, and June 3, 2005, with long stays (≥ 90 days).
  
  
  METHODS
  Prevalence of potential underuse, inappropriate use, and overuse of antidepressants in residents with and without depression (as documented according to International Classification of Diseases, Ninth Revision, Clinical Modification, codes or Depression Rating Scale).
  
  
  RESULTS
  Selective serotonin reuptake inhibitors were the most commonly prescribed antidepressant. Of the 877 residents with depression, 25.4% did not receive an antidepressant, suggesting potential underuse. Of residents with depression who received antidepressants, 57.5% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. Of the 2,815 residents who did not have depression, 1,190 (42.3%) were prescribed one or more antidepressants; only 48 (4.0%) of these had a Food and Drug Administration-approved labeled indication, suggesting potential overuse. Overall, only 17.6% of antidepressant use was appropriate (324/1,844). The only consistent resident factor associated with potential underuse and overuse use was taking an antipsychotic without evidence of schizophrenia (underuse: adjusted relative risk ratio (ARRR)=0.56, 95% confidence interval (CI)=0.33-0.94; overuse: adjusted odds ratio=1.52, 95% CI=1.21-1.91). Having moderate to severe pain (ARRR=1.54, 95% CI=1.08-2.20) and the prescribing of an anxiolytic or hypnotic (ARRR=1.33, 95% CI=1.02-1.74) increased the risk of potential inappropriate antidepressant use.
  
  
  CONCLUSIONS
  Potential problems with the use of antidepressants were frequently observed in older U.S. veteran CLC residents. Future studies are needed to examine the true risks and benefits of antidepressant use in CLC and non-VA nursing homes.
authors.affiliation: Geriatric Research, Education and Clinical Center, and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania, USA. jth14@pitt.edu
authors.forename: Joseph T
authors.initials: JT
authors.lastname: Hanlon
authors.forename: Xiaoqiang
authors.initials: X
authors.lastname: Wang
authors.forename: Nicholas G
authors.initials: NG
authors.lastname: Castle
authors.forename: Roslyn A
authors.initials: RA
authors.lastname: Stone
authors.forename: Steven M
authors.initials: SM
authors.lastname: Handler
authors.forename: Todd P
authors.initials: TP
authors.lastname: Semla
authors.forename: Mary Jo
authors.initials: MJ
authors.lastname: Pugh
authors.forename: Dan R
authors.initials: DR
authors.lastname: Berlowitz
authors.forename: Maurice W
authors.initials: MW
authors.lastname: Dysken
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000928:Antidepressive Agents / Q000009:adverse effects / Q000627:therapeutic use*; D015897:Comorbidity; D003430:Cross-Sectional Studies; D003866:Depressive Disorder / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology*; D004305:Dose-Response Relationship, Drug; D004347:Drug Interactions; D004359:Drug Therapy, Combination; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D015577:Geriatric Assessment / Q000706:statistics & numerical data; D006707:Homes for the Aged; D006801:Humans; D057970:Inappropriate Prescribing / Q000706:statistics & numerical data*; D008137:Longitudinal Studies; D008297:Male; D009735:Nursing Homes; D056687:Off-Label Use / Q000706:statistics & numerical data; D014481:United States; D014728:Veterans / Q000523:psychology*
chemical_list: D000928:Antidepressive Agents