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PCPs tend to prescribe antidepressants despite lack of scientific backing for their use
There is a lack of strong scientific evidence to support most off-label antidepressant prescription writing, suggesting a need for better education for physicians, according to research recently published in BMJ.
“[Our results] highlight an urgent need to produce more evidence on the risks and benefits of off-label antidepressant use and to provide physicians with this evidence at the point of prescribing,” Jenna Wong, MSc, department of epidemiology, biostatistics and occupational health, McGill University, Montreal, said in a press release.
Wong and colleagues studied 106,850 antidepressant prescriptions written by 174 physicians for 20,920 adults aged 18 years or older who visited a physician in Canada between Jan. 1, 2003, and Sept. 30, 2015. The prescriptions were written using an electronic prescribing system. Drugs with fewer than 150 prescriptions written for them during the study period were excluded.
They found that for only 15.9% (95% CI, 13-19.3) of all off-label antidepressant prescriptions, there was strong scientific evidence to support its use for the indication being treated. For 39.6% (95% CI, 35.7-43.2) of such off-label prescriptions, there was not strong evidence to support the use of the prescribed drug, but there was for another antidepressant in the same class . For the remaining 44.6% (95% CI, 40.2-49) of these off-label prescriptions, neither the prescribed drug nor any other drugs in the class had strong evidence for the indication.
Researchers found that, by class, tricyclic antidepressants had the highest prevalence of off-label indications at 81.4% (95% CI, 77.3-85.5), largely due to a high off-label prescribing rate for amitriptyline (93%; 95% CI, 89.6-95.7). Trazodone use for insomnia was the most common off-label use for antidepressants, accounting for 26.2% (21.9-30.4) of all off-label prescriptions.
Wong told Healio Family Medicine how the scenario studied could be improved.
“Ideally, we would have electronic prescribing systems in place that notify physicians when they are prescribing drugs for indications that lack scientific evidence. These systems would be linked to drug knowledge databases or compendiums that continually search the literature and boil down the latest state of evidence into a concise summary that physicians can quickly and easily read at the point of prescribing,” she said. “However, in the absence of such systems, I think physicians could start by going to the packaging labels of antidepressants they usually prescribe and familiarize themselves with which indications are on-label. If the indications they often prescribe these drugs for are not on the list of approved indications, I would encourage physicians to search databases of indexed citations and abstracts such as PubMed for articles on the issue, where systematic reviews or meta-analyses would be the preferred type of article. If few articles are found on the issue, then it’s a good indication that the use is likely not evidence-based. Obviously, this suggestion requires time and a proactive attitude on the part of physicians, since it cannot be done at the point of prescribing with the patient present.”
In a related editorial, Daniel R Morales, PhD, general practitioner and discovery fellow, and Bruce Guthrie, PhD, professor of primary medicine, University of Dundee, United Kingdom reiterated the need for awareness when prescribing off-label medications. They also said the results Wong’s team observed are not limited to these types of drugs.
“Off-label prescribing matters because it is usually, but not always, associated with substantial uncertainty about the balance of benefit and harm. Prescribers should therefore be cautious when they prescribe an off-label medicine on the basis of an extrapolation of evidence for a different indication, in a different patient group, or for a substantially different dose or formulation,” Morales and Guthrie wrote. “These pitfalls are not confined to off-label drugs, however. Patients and prescribers should be cautious about all extrapolations of evidence whether the proposed treatment is ‘on-label’ or ‘off-label,’” they wrote. – by Janel Miller
Disclosure: The researchers report no relevant financial disclosures.