|Year : 2018 | Volume
| Issue : 2 | Page : 107-114
Prevalence of physical comorbidity and prescription patterns in elderly patients with depression: A multicentric study under the aegis of IAGMH
Sandeep Grover1, Ajit Avasthi1, Swapnajeet Sahoo1, Bhavesh Lakdawala2, Amitava Dan3, Naresh Nebhinani4, Alakananda Dutt5, Sarvada C Tiwari6, Ab Majid Gania7, Alka A Subramanyam8, Jahnavi Kedare4
1 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Psychiatry, GMERS Medical College, Gandhi Nagar, Gujarat, India
3 Department of Psychiatry, Calcutta National Medical College, Kolkata, West Bengal, India
4 Department of Psychiatry, AIIMS, Jodhpur, Rajasthan, India
5 Department of Psychiatry, Advanced Medical Research Institute, Kolkata, West Bengal, India
6 Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh, India
7 Department of Psychiatry, Skims Medical College, Srinagar, Jammu and Kashmir, India
8 Department of Psychiatry, Topiwala National Medical College and Byl Nair Charitable Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||27-Dec-2018|
Dr. Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Aim of the Study: This study aims to evaluate the prevalence of physical comorbidities and prescription patterns in elderly patients with depression. Materials and Methods: This study included 488 elderly patients (aged ≥60 years) with depression recruited across eight centers. A self-designed physical comorbidity checklist was used to assess for the presence of various physical comorbidities and prescription of psychotropic medications was recorded. Results: More than three-fourth of the study sample (n = 384; 78.7%) had at least one physical comorbidities and one-third (36.7%) of the samples had at least three physical illnesses. About half of the study samples had hypertension (47.3%) and slightly more than one-fourth had diabetes mellitus (29%). The most common physical illness involved the cardiovascular system (51.5%), followed by endocrinological system (39.3%), orthopedic and joint-related diseases (35%), and ophthalmological problems (22.3%). Those with physical comorbidity had higher severity of depression, anxiety, and somatic symptom. Sertraline was the most preferred antidepressant followed by escitalopram and mirtazapine. Only 12.7% of the sample was prescribed antipsychotics of which quetiapine and olanzapine were the most commonly used agents. Benzodiazepines were prescribed to more than half of the study samples (56.55%), with clonazepam being the most preferred benzodiazepine followed by lorazepam. Compared to those without hypertension, those with hypertension were more commonly prescribed sertraline and escitalopram and less commonly prescribed fluoxetine. Similarly, compared to those without diabetes mellitus, those with diabetes mellitus were more commonly prescribed sertraline and less commonly prescribed fluoxetine. Conclusion: Comorbid physical illnesses are highly prevalent in elderly participants with depression with hypertension being the most common physical comorbidity followed by diabetes mellitus and osteoarthritis. The presence of physical comorbidity is associated with more frequent prescription of sertraline and escitalopram.
Keywords: Depression, elderly, physical comorbidity, prescription pattern
|How to cite this article:|
Grover S, Avasthi A, Sahoo S, Lakdawala B, Dan A, Nebhinani N, Dutt A, Tiwari SC, Gania AM, Subramanyam AA, Kedare J. Prevalence of physical comorbidity and prescription patterns in elderly patients with depression: A multicentric study under the aegis of IAGMH. J Geriatr Ment Health 2018;5:107-14
|How to cite this URL:|
Grover S, Avasthi A, Sahoo S, Lakdawala B, Dan A, Nebhinani N, Dutt A, Tiwari SC, Gania AM, Subramanyam AA, Kedare J. Prevalence of physical comorbidity and prescription patterns in elderly patients with depression: A multicentric study under the aegis of IAGMH. J Geriatr Ment Health [serial online] 2018 [cited 2019 Jan 23];5:107-14. Available from: http://www.jgmh.org/text.asp?2018/5/2/107/248624
| Introduction|| |
Depression in the elderly is a rising problem worldwide. The prevalence rate of depression in the elderly participants across the Indian studies is in the range of 8.9-62 per 1,000 in the community surveys and 42%–72% in the clinic-based studies. The presence of a physical illness in an elderly individual is almost a universal phenomena and the majority of the elderly participants have at least one physical comorbidity such as Parkinson's disease, hypertension, coronary heart disease, diabetes mellitus, chronic kidney disease, benign hypertrophy of prostate, and malignancies.,,, It is also now a well-known fact that there is a bidirectional relationship between physical/medical comorbidities and depression, and more particularly in the elderly, presence of a medical comorbidity can affect the symptom profile, course, and outcome of depression., The presence of multiple physical comorbidities in late-life depression can further complicate the selection of medications due to the risks of drug interactions and decreased physiological and cognitive reserve in the elderly.,, Undiagnosed physical illness in elderly with depression is also not uncommon which further add on the morbidity.,, Thereby, it becomes highly essential and complex to manage both depression and medical comorbidities in the elderly together, and many a times, it becomes a clinical challenge to the practitioners.
Although there are many studies from India- and other parts of the world, which have estimated the prevalence of depression across different physical illnesses,,,,,,, there is limited data on the prevalence of physical illnesses in elderly with depression. Data from the developed countries are also limited in this area.,, Few previous studies from India have evaluated prevalence of physical comorbidities in elderly with depression,,, and these suggest that hypertension, diabetes mellitus, osteoarthritis, cataract, cardiovascular illness, and cerebrovascular disorders are among the most commonly encountered diseases. However, these studies have varied regarding the prevalence of most common diseases in elderly with depression. In addition, it has been seen that a large number of elderly with depression have undiagnosed physical illnesses.,, A recent study focusing on the symptom profile of elderly with depression with medical comorbidities revealed that presence of any physical comorbidity did not influence the manifestations of depression.
Prescription pattern studies from the West among elderly with depression suggest that over the years there is increase in the use of selective serotonin reuptake inhibitors (SSRIs) and decrease in the use of tricyclic antidepressants (TCAs).,, Although reasonable data is available on the prescription patterns of antidepressants and psychotropics from India for adult population,,,,,, but data with respect to prescription patterns of psychotropics in the elderly participants is limited to a handful of studies., Although there is some data on the antidepressant prescription pattern in the presence of medical comorbidity among adults, there is lack of data on the prescription pattern among elderly with depression with physical comorbidities. Accordingly, the present multicentric study aimed to evaluate the prevalence of physical comorbidities and prescription patterns in the elderly with depression.
| Materials and Methods|| |
This was a multicentric study, conducted in 8 centers across the country, under the aegis of the Indian Association for Geriatric Mental Health, detailed methodology of which is already published. The study was approved by all the local Institutional Ethics Committees of the institutes in which this study was conducted. All the participants were explained about the study and were recruited after obtaining written informed consent.
The study followed a cross-sectional design in which participants were assessed only once. To be included in the study, patients of either gender, aged ≥60 years, fulfilling the criteria of major depressive disorder as per Diagnostic and Statistical Manual of Mental Disorders-IV Edition criteria (DSM-IV) and confirmed by MINI Plus were recruited and those with mental retardation and those too ill to be assessed were excluded from the study. A self-designed physical morbidity checklist was used to assess for the presence of various physical comorbidities. This included names of the commonly seen chronic physical morbidities from all systems of the body (neurological, endocrinological, cardiovascular, renal, hepatic, gastrointestinal, dermatological, infections, malignancies, gynecological, etc., along with an option to record “any other” physical comorbidities, not listed in the checklist. Physical comorbidity was assessed by taking detailed history, physical examination, and reviewing the treatment records. No specific investigations were done as part of the study. All the patients were also rated on Geriatric Depression Rating Scale (GDS-30), Generalized Anxiety Disorder Questionnaire (GAD-7), and Patient Health Questionnaire (PHQ-15).
Analysis was done using the Statistical Package for Social Sciences-version 14 (SPSS for Windows, SPSS Inc., Chicago, IL, USA). Descriptive analysis involved calculation of mean and standard deviation (SD) with a range for continuous variables and frequency and percentages for ordinal or nominal variables. Comparisons were done using the Chi-square test, t-test, and Mann–Whitney test.
| Results|| |
The study included 488 patients diagnosed with depression. Slightly more than half of the study participants were males (53.7%; n = 262), were on paid employment (53.3%, n = 260), and from urban locality (53.1%, n = 259). The mean age of the study sample was 66.55 (SD 5.83) years, and the mean years of formal education was 7.63 (SD 5.85) years. About one-fourth of the samples (25.4%; n = 124) were currently single (unmarried, widowed, separated, and divorced). More than two-thirds of the participants were living in nonnuclear family setup (69.9%, n = 341).
Three-fifths of the sample was diagnosed with first episode depression (60.9%; n = 297) and the rest were diagnosed with recurrent depressive disorder (39.1%; n = 191). More than three-fourth of the samples had at least one comorbid physical illness (78.7%, n = 384) [Table 1]. Comorbid substance abuse disorders were found in about one-third (37.9%) of the participants and a small proportion of the participants had comorbid psychiatric disorders (3.1%). The mean age of onset of depression was 60.2 (SD 10.5) years, and the mean total duration of illness was 65.68 (SD 91.80) months.
|Table 1: Physical comorbidity in elderly patients with depression (n=488)|
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Physical comorbidities in elderly patients with depression
More than three-fourth of the study samples had at least one physical comorbidities (n = 384; 78.7%). About half of the study samples had hypertension (47.3%) and slightly more than one-fourth had diabetes mellitus (29%). More than one-third (36.7%) of the study samples had 3 or more physical illnesses. The most common physical illness involved the cardiovascular system (51.5%), and this was followed by endocrinological system (39.3%), orthopedic and joint-related diseases (35%), and ophthalmological problems (22.3%). Details of involvement of other systems are given in [Table 1].
Relationship of physical comorbidity with severity of depression, anxiety, and somatic symptoms in the elderly
When patients with and without physical comorbidity were compared, those with physical comorbidity had higher severity of depression, anxiety, and somatic symptom [Table 2].
|Table 2: Symptom profile as per Generalized Anxiety Disorder Questionnaire-7, Geriatric Depression Rating Scale-30, Patient Health Questionnaire-15 scales|
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Relationship of physical comorbidity with demographic and clinical variables
When compared with those without any physical illness, significant differences were noted in relation to gender (males > females, χ2 = 5.799; P = 0.016*), marital status (single > married, χ2 = 17.802; P < 0.001***), and family type (non-nuclear > nuclear; χ2 = 5.024, P = 0.025*). No significant difference was noted with regard to locality (rural/urban), type of depression (single/multiple episodes) or presence/absence of comorbid psychiatric illness/substance abuse. In addition, those with comorbid physical illness were more older (t-test = 3.216; P = 0.001***), more educated (t-test = 7.173, P < 0.001***) and were depressed for a longer duration in months (t-test = 2.446, P = 0.015*).
Psychotropic prescription patterns
Majority (91.8%) of the participants were prescribed antidepressants while they were assessed for the study. Among the various antidepressants, sertraline was the most preferred antidepressant followed by escitalopram and mirtazapine. All the patients were on single antidepressant. With regard to antipsychotics, only 12.7% of the sample was prescribed antipsychotics of which quetiapine and olanzapine were the most commonly used agents. Benzodiazepines were prescribed to more than half of the study samples (56.55%), with clonazepam being the most preferred benzodiazepine followed by lorazepam [Table 3].
Comparison of prescription patterns across different centers
As is evident from [Table 4], across three centers (Lucknow, Ahmedabad, and Kolkata-1) sertraline was the most commonly prescribed agent. In two centers (Chandigarh and Mumbai), escitalopram was the most preferred agent and in one center (Srinagar), both sertraline and escitalopram were prescribed to an equal number of patients. In one center (Kolkata-2), mirtazapine was the most commonly used agent. In one center (Jodhpur), although sertraline was the most commonly used antidepressant; however, the most common strategy was not to prescribe antidepressant. Tricyclic antidepressants were prescribed to very few patients across the different centers, except for Mumbai center, where these formed about one-fifth (22.2%) of the prescribed antidepressants.
Across different centers, antipsychotics were prescribed to very few patients, with quetiapine being the most preferred antipsychotic in three centers (Chandigarh, Ahmedabad and Kolkatta-2), whereas olanzapine was the most preferred antipsychotic in 2 centers (Kolkatta-1 and Mumbai) and aripiprazole emerged as the most preferred agent in one center (Lucknow). None of the participants in Srinagar center were prescribed any antipsychotics [Table 4].
Clonazepam was the most preferred benzodiazepine across six centers (Chandigarh, Lucknow, Ahmedabad, Kolkata 1 and 2, and Jodhpur) and lorazepam emerged as the most preferred agent in other two centers (Srinagar and Mumbai) [Table 4].
Mood stabilizers were used in very few patients in only two centers, i.e., Chandigarh and Kolkata-1 [Table 4].
Influence of physical comorbidity on the prescription patterns
As hypertension and diabetes mellitus emerged as the most common comorbidities, prescription patterns were compared between those with hypertension and those without any physical comorbidity. Similarly, prescription patterns were compared between those with diabetes mellitus and those without any physical comorbidity.
Comparison of patients with Hypertension (n = 231) and with those with no physical comorbidity (n = 104)
As is evident from [Table 5], sertraline was the most preferred antidepressant and compared to those without any physical comorbidity, patients with hypertension were more commonly prescribed sertraline and escitalopram and less commonly prescribed fluoxetine. Further compared to those with hypertension, significantly higher proportion of patients with no physical comorbidity were not prescribed antidepressants.
|Table 5: Antidepressant prescription patterns in patients with hypertension (n=231) and diabetes mellitus (n=142) and those without any physical illness (n=104)|
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Comparison of patients with diabetes mellitus (n = 142) and with those with no physical comorbidity (n = 104)
Again, compared to those without any physical comorbidity, patients with diabetes mellitus were more commonly prescribed sertraline and less commonly prescribed fluoxetine. As in the hypertension group, compared to those with diabetes mellitus, significantly higher proportions of patients with no physical comorbidity were not prescribed antidepressants.
| Discussion|| |
The present multicentric study suggests that more than three-fourths of elderly patients with depression have at least one comorbid physical illness (76.4%), which is similar to the prevalence figures reported in the previous studies from India.,, The findings are also comparable to the data (prevalence of 76%–92%) from the Western countries.,,,, Regarding specific physical illnesses, hypertension was the most common diagnosis, seen in about half of the patients (47.3%) and this was followed by diabetes mellitus (28.1%) and osteoarthritis (21.7%). Previous clinic-based studies and a community-based study from India have reported osteoarthritis, hypertension, and cataract as the most common physical comorbidities.,,, However, these clinic-based studies had very small sample size (n = 40) and the community-based study was limited to a specific area (Visakhapatnam, n = 1200). Studies from the West in elderly with depression also report diabetes mellitus and hypertension as the two most common physical comorbidities.,, Findings of the present study are in concurrence with existing Indian (with regard to prevalence of hypertension; 18%–55%) and Western (with regard to the prevalence of both hypertension; 18%–55% and diabetes mellitus; 7.6%–70%) literature irrespective of methodological differences in the assessment of physical comorbidity in these studies. The high level of physical comorbidity in elderly suggests that psychiatrist should focus on physical health of elderly too, and similarly, clinicians managing different physical illness should assess their patients for depression. Further, this fact must be taken into account for prescribing various psychotropics regarding evaluating drug interactions and synergistic side effects of medications used for different disorders.
With regard to impact of presence of physical comorbidity on the severity of depression, anxiety and somatic symptoms in elderly depressed participants, it was quite evident that those with comorbid physical illness had greater severity of depression (as assessed by GDS-30), of somatization (as assessed by PHQ-15) and anxiety (as assessed by GAD-7). Only one study from India had previously evaluated the impact of physical comorbidity on the symptom profile of geriatric depression, and this study reported no influence of presence of any physical comorbidity on the symptom profile and severity of depression in the elderly. However, the present study findings are in contrast to the findings of the previous study. The possible reason for this difference could be due to the higher proportion of the patients in the previous study to be having severe depression. However, it is important to understand that a cause and effect relationship cannot be determined from the present study, as this was cross-sectional in nature. Many putative hypotheses can be provided for this association. First, disabling physical morbidities possibly delay the help seeking for depression. Second, it is quite possible that the higher severity noted could be due to overlap of symptoms between the physical illnesses and depression. It would be interesting to evaluate these hypotheses in future by carrying out longitudinal studies.
With regard to prescription patterns of antidepressants, the present study suggests that sertraline was the most preferred antidepressant and this was followed by escitalopram and TCAs are the least preferred drug in the elderly. Similarly, quetiapine was the most preferred antipsychotic in the elderly participants with depression and clonazepam being the most preferred benzodiazepine to be used in the majority of centers. There is a lack of data on prescription patterns for elderly. A previous study from Chandigarh evaluated the first prescription of elderly patients attending the psychiatry outpatient services and suggested that escitalopram followed by sertraline was the most commonly prescribed antidepressant among elderly. Olanzapine followed by quetiapine emerged as the most commonly prescribed antipsychotics. Clonazepam followed by lorazepam were the most commonly prescribed benzodiazepines. Findings of the present study echo almost the similar trends with minor differences. In contrast to escitalopram, sertraline emerged as the most commonly prescribed agent in the present study. The most likely reason for this could be significantly higher prevalence of hypertension and coronary artery disease and presence of efficacy data for sertraline in this group of patients., A multicentric, multicountry study from South-East Asia, which evaluated the prescription pattern among patients with physical comorbidity reported escitalopram and mirtazapine to be the most commonly prescribed agents, followed by sertraline in patients with medical comorbidity, with SSRIs being the most commonly prescribed class of antidepressants. SSRIs being most commonly prescribed agents is in sync with the prescription guidelines for management of depression in elderly (Indian Psychiatric Society guidelines for management of elderly depression) and prescription guidelines for the use of antidepressants in the medically ill adult's patients with depression.,
In the present study, there was no polypharmacy which is also in concurrence with the previous studies and guidelines advocating use of single antidepressant/fewer drugs in elderly depression.,, Similarly, with regard to antipsychotics, those with less potential to cause extrapyramidal side effects (second-generation antipsychotics, more preferably quetiapine/olanzapine) were most commonly used medications across the 8 centers and typical antipsychotics were less preferred. There has been a recent upsurge in the use of quetiapine in low doses in elderly participants with depression as well as psychosis because of its sedative, relaxing/calming and anti-anxiety effects.,,,, The present study finding of higher prescription of quetiapine in elderly participants could be influenced by this data. The previous study from India reported olanzapine to be the most commonly used antipsychotic in the elderly participants. However, the study included elderly participants with any psychiatric diagnosis, and hence, the present study could not be compared with the same, though olanzapine was the 2nd most preferred drug in the present study.
In the present study, sedative-hypnotic medications were prescribed in more than half of the elderly participants with depression with clonazepam being the most preferred followed by lorazepam. In the previous Indian study on prescription patterns in the elderly participants with any psychiatric diagnosis, benzodiazepines were mostly prescribed to elderly participants with psychotic disorders (43%) with clonazepam being the most preferred, similar to the present study findings. Studies from West also report the use of benzodiazepines in about one-third of the elderly with depression, with clonazepam and lorazepam being the commonly used agents.,,, However, the general consensus is that there should be a limitation to the use of benzodiazepines in the elderly because their several potential side effects such as falls, cognitive decline, osteoporosis, etc., among elderly.,, The high prevalence of use of benzodiazepine could be possibly be due to presence of high level of anxiety in the study sample.
The present study has certain limitations. For the present study, participants were recruited from psychiatry outpatient clinics attached to general hospital settings, and hence, the findings may not be generalizable to community-dwelling population or those attending other treatment setting. The physical comorbidities were determined on the basis of history, review of treatment records, and physical examination. No specific investigations were done as part of this study. It is quite possible that lack of detailed investigations could have possibly led to underestimation of the prevalence of physical comorbidities.
| Conclusion|| |
To conclude, the present study shows that more than three-fourth of the elderly patients with depression have at least one physical illness with hypertension being the most common physical comorbidity followed by diabetes mellitus and osteoarthritis. The presence of a physical illness is associated with more severe depression, anxiety, and somatization. Regarding prescription patterns, sertraline was the most preferred antidepressant in elderly with depression, both among those with and without physical comorbidity. Quetiapine was the most commonly used antipsychotic and clonazepam being the most commonly prescribed benzodiazepine in the elderly participants with depression.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]