Pharmacological treatment of major depressive disorder according to severity in psychiatric inpatients: results from the AMSP pharmacovigilance program from 2001–2017

Abstract

The International Classification of Diseases (10th Version) categorizes major depressive disorder (MDD) according to severity. Guidelines provide recommendations for the treatment of MDD according to severity. Aim of this study was to assess real-life utilization of psychotropic drugs based on severity of MDD in psychiatric inpatients. Drug utilization data from the program “Drug Safety in Psychiatry” (German: Arzneimittelsicherheit in der Psychiatrie, AMSP) were analyzed according to the severity of MDD. From 2001 to 2017, 43,868 psychiatric inpatients with MDD were treated in participating hospitals. Most patients were treated with ≥ 1 antidepressant drug (ADD; 85.8% of patients with moderate MDD, 89.8% of patients with severe MDD, and 87.9% of patients with psychotic MDD). More severely depressed patients were more often treated with selective serotonin–norepinephrine reuptake inhibitors and mirtazapine and less often with selective serotonin reuptake inhibitors (p < 0.001 each). Use of antipsychotic drugs (APDs), especially second-generation APDs, increased significantly with severity (37.0%, 47.9%, 84.1%; p < 0.001 each). APD + ADD was the most used combination (32.8%, 43.6%, 74.4%), followed by two ADDs (26.3%, 29.3%, 24.9%). Use of lithium was minimal (3.3%, 6.1% ,7.1%). The number of psychotropic drugs increased with severity of MDD—patients with psychotic MDD had the highest utilization of psychotropic drugs (93.4%, 96.5%, 98.7%; p < 0.001). ADD monotherapy was observed to a lesser extent, even in patients with non-severe MDD (23.2%, 17.1%, 4.4%). Findings reveal substantial discrepancies between guideline recommendations and real-life drug utilization, indicating that guidelines may insufficiently consider clinical needs within the psychiatric inpatient setting.

Change of prescription for patients with schizophrenia or major depressive disorder during admission: Real-world evidence from the Effectiveness of Guidelines for Dissemination and Education psychiatric treatment project

“…The relationship between the main drug and the other aforementioned psychotropics was not observed for patients with MDD, while the number of antipsychotics, especially atypical antipsychotics, increased more often in the poly_mono group than in the poly_poly group. This result is consistent with the results of a recent study of 43,868 MDD inpatients, which showed that more patients were treated with combination therapy of one antidepressant plus atypical antipsychotics (23.8-74.8%, according to severity) than with polypharmacy of antidepressants (26.3-24.9%) [11]. Because the treatment guidelines recommended augmentation by mood stabilizers or atypical antipsychotics before prescribing polypharmacy of antidepressants [8,9], switching from antidepressant polypharmacy to antidepressant monotherapy and augmentation with atypical antipsychotics may be appropriate.…”

“…In our study, the percentages of antidepressant polypharmacy, concomitant anxiolytic and hypnotic use, and concomitant second generation antipsychotic use by patients with MDD were 25.4%, 74.4%, and 54.5%, respectively [6]. These ndings highlight that in line with recent studies from western countries [10,11], most patients need antidepressant polypharmacy or concomitant use of other psychotropics. Notably, anxiolytics and hypnotics are not evidence-based augmentation options [9] The large difference in prescriptions among institutions is another challenge, as the rate of antidepressant monotherapy ranged from less than 20-100% [12].…”

Effect of education regarding treatment guidelines for schizophrenia and depression on the treatment behavior of psychiatrists: A multicenter study

“…National mental health policies based on hospitals and financing systems might be obstacles to reducing polypharmacy in Japan. The severity of major depressive disorder and polypharmacy in 44 000 patients in Europe from 2001 to 2017 suggests a trend toward polypharmacy depending on severity; however, changes in polypharmacy over time were not reported 44 . Changes in psychotropic polypharmacy in patients with schizophrenia or major depressive disorder have not been reported from 2016 to 2019.…”

“…The severity of major depressive disorder and polypharmacy in 44 000 patients in Europe from 2001 to 2017 suggests a trend toward polypharmacy depending on severity; however, changes in polypharmacy over time were not reported. 44 Changes in psychotropic polypharmacy in patients with schizophrenia or major depressive disorder have not been reported from 2016 to 2019. A more recent study reported no statistically significant effect of the new Japanese policies for appropriate hypnotic use on long-term prescriptions of hypnotics.…”

Psychiatric Psychobiological Treatment Versus Exclusive Psychological Treatment in Depressive Disorders

“…In any case, relatively little is known about which particular groups of patients may respond better to psychiatric treatment -using drugs and psychotherapy, which is generally informal-combined with psychological treatment -psychotherapy alone, either formal or informalversus exclusive treatment, either drug alone or psychological alone [9]. Furthermore, there are substantial discrepancies in real life between clinical guideline recommendations and the actual use of medication [10].…”