Psychotropic drug use among older people in general practice: discrepancies between opinion and practice

Characteristics of GP and study populations

Questionnaires were returned by 350 GPs, which represents a response rate of 36.1% (350/967). Among the non-responders, the reason for non-participation was a lack of time to answer (90.1%, 128/142) or lack of interest in the objective of the study (8.9%, 16/142). Responders practised in all 22 regions of the country, had been practising for an average of 16 years, were predominantly male (84.8%), and had a mean age of 44 years. Participating GPs were significantly younger than non-responding GPs (44 years versus 55 years, P<0.001); they did not significantly differ in terms of sex or location of practice (rural or urban areas).

On their last working day, responder GPs saw 2498 patients aged ≥65 years. GPs declared that these older patients were consulting for a physical problem, a psychological problem, or both, in 55.8% (1394/2498), 37% (924/2498), and 7.2% (180/2498) of cases respectively. These patients were taking an anxiolytic/hypnotic in 32.1% (803/2498) of cases, antidepressants in 17.5% (438/2498) of cases, and antipsychotic treatment in 8.1% (202/2498) of cases.

GPs' opinions about psychotropic use for individuals aged ≥65 years

When asked if they knew the six national guidelines for managing people with anxiety and/or insomnia, 22% (191/349) of GPs declared that they did, while 82% knew at least one of these guidelines. One of the guidelines, ‘How to stop benzodiazepine and benzodiazepine-related drugs (Z-drugs) among older patients’,18 was reported to be the best known (70% of GPs).

Pressure by patients to initiate or renew prescription of anxiolytics/hypnotics had previously been felt by 97.1% of GPs (Table 1). However, 90.5% declared that it was possible to reduce or stop treatment for their patients. GPs felt that more information should be distributed to the general population (84%) as well as to physicians (80%). Lastly, GPs agreed that greater access to psychiatrists could help to reduce prescription of psychotropic drugs (Figure 1).

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Figure 1

GPs' general opinions on ways to reduce anxiolytic/hypnotic prescriptions among patients aged ≥65 years.

Psychotropic consumption: patient-based data

Psychotropic consumption of 339 patients is described in Table 2. Patients were aged a mean of 77.3 years (SD = 7.5), mostly female (70.8%, 240/339), and were living alone (46.5%, 157/338), with their family (40.8%, 138/338), or in an institution (12.8%, 43/338).

Overall, 195 of the 339 patients were taking at least one anxiolytic, 140 patients were taking at least one hypnotic, and 193 patients were taking at least one antidepressant. Anxiolytics were the most commonly used drugs (57.5%, 195/339), with a proportion of exclusive users of 22.1% (75/339).

The anxiolytics most frequently prescribed were lorazepam (22.6%, 44/195), bromazepam (21.0%, 41/195), and alprazolam (13.3%, 26/195). Hypnotics were used by 41.3% of patients (140/339), with a proportion of exclusive users of 15.9% (54/339). The most frequently prescribed hypnotics were zolpidem (57.1%, 80/140) and zopiclone (27.8%, 39/140). Antidepressants were used by 56.9% of patients receiving a psychotropic drug (193/339), with a proportion of exclusive users of 14.7% (50/339). The types of antidepressants reported were specific serotonin reuptake inhibitors (52.8%, 102/193), specific noradrenaline (norepinephrine) reuptake inhibitors (15.5%, 30/193), tianeptine (12.9%, 25/193), mianserine (11.4%, 22/193), and tricyclics (7.3%, 14/193).

The most frequent drug combinations were anxiolytics with antidepressants (12.6%, 74/339), followed by antidepressants combined with hypnotics (11.8%, 40/339). Among the 291 patients who were under an anxiolytic or hypnotic drug, the treatment duration was over 1 year in 68.4% of cases (199/291). The main indication for anxiolytics or hypnotics was anxiety (71.8%, 209/291), chronic insomnia (60.1%, 175/291), and/or depression (31.9%, 93/291). Among the 193 patients who were taking antidepressants, the treatment duration was over 1 year in 43.5% of cases (84/193; Table 2). They were prescribed for depression (93.3%, 180/193) and/or anxiety (45.1%, 87/193).

Psychotropic drug use was inappropriate in 84.3% (285/339) of cases, owing to long-acting benzodiazepine use (7.6%, 26/339), concomitant use of three or more psychotropic drugs (8.6%, 29/339), or the use of benzodiazepines or Z-drugs for more than 3 months (84.2%, 285/339).

GPs stated that it was impossible to reduce or stop anxiolytic or hypnotic treatment for 57% of patients (166/291), whereas 27.1% (79/291) agreed that it could be possible. Forty-six GPs had no opinion. GPs rated that 68.1% (199/291) of the patients were physically dependent on their anxiolytics/hypnotics, 32.9% (96/291) were psychologically dependent, and 30.4% (198/291) physically and psychologically dependent. Dependence on antidepressants was estimated to be 20.7% (40/193), 32.4% (41/193), and 15.5% (30/193) for physical, psychological, or both types of dependence respectively.

Barriers to reducing the dosage or to stopping anxiolytics/hypnotics for these patients are presented in Figure 2. The principal barriers reported were patients' refusal (79%), absence of reimbursement of psychotherapy (79%), or no local offer of psychotherapy available (73%), and absence of any other alternative therapy (70%).

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Figure 2

Barriers to reduce or stop anxiolytic or hypnotic drugs in patients aged ≥65 years.

Summary of main findings

This study confirmed the high rate of very long-term prescription (defined as >2 years in duration), and combined use of psychotropic medication among older patients seen in general practice. While 90.5% of GPs stated that it was possible to reduce or stop psychotropic drugs in most older patients, only 27.1% reported the feasibility of doing so when facing their patients. These findings illustrate a mismatch between GPs' opinions about psychotropic prescription and the reality of practice. According to GPs, the principal barriers to reducing or stopping anxiolytic/hypnotic drugs were patient refusal and the unavailability of psychotherapy or alternative therapies. GPs agreed that more information must be provided to educate the public as well as physicians on this matter.

Strengths and limitations of the study

The participation rate of 36.1% is within the range of results from most surveys conducted in general practice.8^,24^–26 There may be a selection bias because GPs in the Sentinelles network are younger than the overall population of GPs in France. Moreover, GPs who participated in this study might be more concerned about mental health problems that non-responders and their practices may, therefore, differ. However, the daily number of patients seen by the participating GPs is not different from the number seen daily by all French GPs,27 and the rate of psychotropic use reported here is similar to the rates previously described in other general practice settings in France.1^,2^,4^,28

An additional limitation may have been introduced by only offering the GPs closed questions. Some GPs spontaneously made comments pointing out other reasons for overprescription of psychotropics. In addition, GPs rated their knowledge of the French guidelines for treating older individuals with psychotropic drugs using ‘yes/no’ answers, so this information must be interpreted with some caution because no check was done on whether the stated knowledge was accurate. Finally, the survey does not present data about diagnosis (and the adequacy of treatment according to the diagnosis) or patients' opinions.

Comparison with existing literature

The present study confirms that almost one of three patients aged ≥65 years and seen in French general practice receives an anxiolytic or hypnotic prescription, and one of five patients receives an antidepressant prescription. These results are in accordance with the results of previous studies conducted in France.1^–4^,6^,12^,28^–34

In France, benzodiazepines are somewhat more frequently prescribed than Z-drugs, compared to other countries. In Sweden and in the UK, Z-drugs are more frequently prescribed than the conventional benzodiazepines.35 However, both treatments (benzodiazepines and Z-drugs) should be used with caution.36^,37

The prevalence of inappropriate psychotropic drug use is comparable to the percentages found in Sweden, specifically regarding the use of long-acting benzodiazepines or the concomitant use of three or more psychotropic drugs.35 The present study highlights the excessive duration of psychotropic treatments, particularly for benzodiazepines and Z-drugs. Although antidepressants can be indicated for long-term treatment,38 hypnotics are not recommended for longer than 1 month, and anxiolytics are recommended for no longer than 3 months.16^,21^,39^–42

GPs' opinions and knowledge about psychotropic drug prescription in older patients have rarely been explored. In the present study, 91% of GPs were optimistic about the possibility of reducing or stopping anxiolytics and hypnotics. In reality, only 27% of GPs admitted it was possible when facing their patients. This mismatch between ‘theoretical’ and ‘real-world’ practice reveals that knowledge of the guidelines is insufficient, as reported in the literature.41^–43

Several factors have been identified to explain inappropriate prescribing of psychotropics in older people: (i) GP-related barriers, including lack of knowledge; (ii) confusion due to the lack of a consensus defining inappropriate psychotropic use; (iii) difficulties in re-addressing inappropriate medication started by a previous provider; (iv) the number of prescribers and pharmacies involved in patient care; (v) inappropriate attitudes towards ageing (ageism); and (vi) cost issues.44 Patients may also contribute to the problem by insistently demanding an inappropriate medication.45^–47

In the present study, some GPs offered additional comments about prescription barriers that were different from those proposed in the questionnaire; these included: ‘The best way to avoid withdrawal problems is to avoid initial prescription!’, ‘Incentives for psychotropic prescription through pharmaceutical marketing should be stopped’, and ‘Psychotropics are impossible to stop mainly for patients with a difficult social life (loneliness, poverty, living in a deprived neighbourhood)’. These last comments confirm that current management of psychological and physical troubles deserves more attention,44^,45 and that psychotropic consumption is probably not simply a consequence of a GP prescription, but is also a social issue.

Implications for future research and clinical practice

More appropriate use of psychotropic prescription drugs is a key element in improving disease management for older patients in general practice. GPs suggested three areas that should be targeted: (i) implementing educational programmes to increase patients' awareness of the risks related to long-term use of psychotropics; (ii) creating work groups to support drug withdrawal in primary care; and (iii) applying behavioural treatments, such as cognitive therapy, sleep education, sleep hygiene, and muscle relaxation.45^–48 The effectiveness and acceptance of these psychological interventions for mental health problems in older people have been recently evidenced, even if not widely promoted in daily practice.49^–51

Collaborative care between GPs and psychiatrists could also encourage appropriate prescriptions. Another area that could probably be targeted is the difference between whether the medication could be stopped or whether there is clinical evidence that it should be stopped. Although there is clear evidence of the risks associated with long-term use of hypnotic/anxiolytic drugs, stopping these treatments may also expose patients to rebound anxiety, withdrawal syndrome, and the social consequences of untreated anxiety disorders.52^–54 Thus, efforts to reduce the risks associated with long-term use of psychotropics should be balanced with the risks associated with psychotropic withdrawal.

This study has evidenced an important mismatch between GPs' opinions about psychotropic prescription and the reality of practice. Reconciliation of theory and practice is needed and should be further examined. To help GPs to reduce psychotropic consumption and prescription, specific education of the general public and physicians is needed, and increased access to non-pharmacological treatment and collaborative care with a psychiatrist could be evaluated.