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Group and individual academic detailing for clinicians influenced prescribing of antidepressants for the elderly
  1. Robert C Baldwin, DM, FRCP, FRCPsych
  1. Manchester Royal Infirmary; Manchester, UK

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QUESTION: In treating elderly people with depression, can academic detailing in group or individual educational visits increase prescriptions of less anticholinergic antidepressants and reduce prescriptions of highly anticholinergic antidepressants?

Design

Cluster randomised {allocation concealed*}, unblinded*, controlled trial with 8 months of follow up.

Setting

The South Holland islands, southwest Netherlands.

Participants

21 peer review groups of healthcare professionals (190 general practitioners [GPs] [93% men] and 36 pharmacists [81% men]) who met regularly to exchange information, advise on policy, agree on guidelines, and use feedback methods to measure adherence to guidelines. Patients were 60–96 years of age (n=46 078, mean age 71 y, 58% women).

Intervention

Block randomisation was used to assign 3 blocks of 7 peer review groups to 1 of 3 conditions: individual educational visits (n=84 professionals, 17 143 patients), group educational visits for the peer review group as a whole (n=61 professionals, 12 734 patients), or no visits (n=81 professionals, 16 201 patients).

Main outcome measures

Incident use of highly anticholinergic antidepressants and less anticholinergic antidepressants.

Main results

Results were adjusted for sex and baseline rates of incident antidepressant prescriptions. At 8 months, patients whose healthcare providers received group visits had fewer prescriptions for highly anticholinergic antidepressants than those whose healthcare providers received no visits (p=0.023) (table). Prescriptions for less anticholinergic antidepressants were given more often in the individual visit condition than in the no visit condition (p=0.016) (table). Prescription rates did not differ between the group and individual visit conditions.

Individual or group educational visits v no visits for influencing incident prescription rates for elderly people with depression at 8 months‡

Conclusions

In elderly people with depression, group academic detailing for health professionals reduced prescriptions of highly anticholinergic antidepressants and individual academic detailing increased prescriptions of less anticholinergic antidepressants. Prescription rates for both types of antidepressants did not differ between group and individual visit conditions.

Commentary

In all age groups, newer antidepressants are used increasingly.1 Concerns have been expressed that insufficient evidence exists to support this trend in older people.2 When faced with a choice between dosage titration with an older tricyclic agent (TCA) or the simpler regimens afforded by many of the newer drugs, practitioners will often choose the latter. Furthermore, although older antidepressants are effective, they have some extremely unpleasant side effects to which the elderly in particular are prone. An intervention designed to lead to safer prescribing seems worthwhile.

The study by van Eijk et al investigates academic detailing, which is a university based educational outreach activity designed to improve practice in healthcare professionals, particularly prescribing practices.3 It is based on theories and techniques used in adult learning and marketing.

To categorise antidepressants as safer or less safe according to their anticholinergic properties risks overlooking other dimensions of safety; effects such as postural hypotension, sedation, falls, and lethality in overdose may also be found among drugs in the authors' “safer” group. For example, in the UK dothiepin (dosulepin) is still frequently prescribed but has been criticised because relatively few tablets in overdose may be lethal, while lofepramine, another tricyclic, is not listed but is widely used.4

Therefore, whatever yardstick is used to define safer or better is best left to locally agreed protocols. In the UK, this is a necessary part of implementing the National Service Framework for Older People (NSFOP). The NSFOP also charges specialist psychiatric services with providing educational support and training to primary care clinicians. Thus, it is important that new technology of this kind be examined closely by psychiatrists who treat older people.

References

View Abstract
  • Classification of drugs used in study

    Highly anticholinergic antidepressants

    Tricyclic derivatives
    Amitriptyline
    Clomipramine
    Doxepin
    Imipramine
    Maprotiline (polycyclic derivative)

    Less or non-anticholinergic antidepressants

    Tricyclic derivatives
    Desipramine
    Opipramol
    Nortriptyline
    Dosulepin
    Dibenzepine
    Trimipramine

    Selective serotonin reuptake inhibitors

    Sertraline
    Fluoxetine
    Fluvoxamine
    Paroxetine

    Monoamine oxidase inhibitors

    Tranylcypromine
    Moclobemide
    Nialamide

    Others

    Trazodone
    Venlafaxine
    Mianserine
    Mirtazapine

    See also:

    Pharmacist medication review decreased death, and number and cost of drugs prescribed for residents in nursing homes. Evidence-Based Mental Health 2001;4:63.

    Caregiver teamwork improved psychotropic drug prescribing in nursing homes. Evidence-Based Mental Health 1998;1:96.

Footnotes

  • * See glossary.

  • Information provided by author.

  • Source of funding: OZ zorgverzekeringen (health insurance company).

  • For correspondence: Dr A de Boer, Department of Pharmaco-epidemiology and Pharmacotherapy, Utrecht Institute of Pharmaceutical Sciences, Faculty of Pharmacy, PO Box 80082, 3508 TB Utrecht, the Netherlands. Fax +31 30 253 9166.

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