First prescription of new elderly patients attending the psychiatry outpatient of a tertiary care institute in North India

ORIGINAL ARTICLE: EPIDEMIOLOGY,CLINICAL PRACTICE AND HEALTH

First prescription of new elderlypatients attending the psychiatry

outpatient of a tertiary careinstitute in North Indiaggi_767 284..291

Sandeep Grover, Vineet Kumar, Ajit Avasthi and Parmanand Kulhara

Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Aim: There is lack of data on prescription patterns in elderly patients from developingcountries. The aim of this study is to examine the first prescription given to elderly patients(age >60 years) attending the psychiatry outpatient clinic of a tertiary care hospital.

Methods: In this retrospective study, data on patients older than 60 years attending thepsychiatric outpatient clinic of a tertiary care hospital between 1 January 2009 and 30November 2010 were extracted from the computer-based registry and analyzed.

Results: During the study period, 1192 new patients older than and equal to 60 yearsregistered with the psychiatric outpatient clinic. Exact prescription data was available for975 patients. The most common major diagnostic group was mood disorders (33.9%),followed by neurotic, stress-related and somatoform disorders (23.1%). Across all diag-nostic groups, olanzapine was the most commonly prescribed antipsychotic medication(20.7% of patients with an organic mental disorder, 40.8% with psychotic disorder, 30.2%with bipolar disorder); quetiapine and risperidone were the other commonly prescribedantipsychotics. Across all diagnostic groups, escitalopram was the most commonly pre-scribed antidepressant, and sertraline was the second most frequently prescribed SSRI.Among mood stabilizers, valproate was preferred over lithium (25.4% vs.12.7%). Sedative-hypnotic medications were frequently prescribed across all diagnostic groups. Clonazepamand lorazepam were the most often prescribed benzodiazepines. The mean number ofpsychotropic medications was highest among bipolar disorder patients (1.84) and leastamong the patients with an organic mental disorder (1.25).

Conclusions: Olanzapine, SSRI and clonazepam were the most commonly prescribedantipsychotic, antidepressant, and benzodiazepine, respectively, and valproate was pre-ferred over lithium among elderly patients with bipolar disorder. Geriatr Gerontol Int2012; 12: 284–291.

Keywords: old age, prescription, psychotropics.

Introduction

The aging population is a global phenomenon, a phe-nomenon that is more remarkable in developing coun-

tries compared to developed ones. It is projected that by2060 approximately 80% of persons over age 60 will beliving in developing countries.1

The elderly (aged >60 years) accounted for 5.6% ofIndia’s total population in 1961, and this increased to7.5% in 2001.2 In absolute numbers, over the last fourdecades the elderly population has increased from24 million (1961 census) to 77 million (2001 census),and it is expected to increase to 136 million by 2021.Hence, the health care system in India will have to cope

Accepted for publication 15 September 2011.

Correspondence: Dr Sandeep Grover MD, Department ofPsychiatry, Postgraduate Institute of Medical Education andResearch, Chandigarh 160012, India. Email:[email protected]

Geriatr Gerontol Int 2012; 12: 284–291

284 � © 2011 Japan Geriatrics Societydoi: 10.1111/j.1447-0594.2011.00767.x

with the needs of a huge number of elderly in thecoming years.

However, research on psychiatric morbidity in elderlyin India is meager. Only one study has presented infor-mation about the prescription patterns of anti-dementiadrugs and antipsychotics in 51 elderly patients.3

Most of the available studies have evaluated theuse of psychotropic medications in elderly populationsin developed countries. Some studies have reportedincreased use of antidepressant prescriptions among theelderly,4,5 with an increasing trend for SSRI and a moveaway from tricyclic antidepressants (TCA).6,7 Similarlyfor bipolar disorders, literature suggests that lithium isbeing replaced by newer mood stabilizers.8,9 With regardto antipsychotics, data suggest that risperidone andolanzapine are the most commonly prescribed medica-tions in this group.10

Almost all psychotropic medications available world-wide are readily available at affordable prices in India,although it is a developing nation. However, researchwith a focus on prescription patterns in elderly in Indiais somewhat rare.3 The present study aims to evaluatethe first prescription given to elderly patients (aged�60 years) attending the psychiatry outpatient clinic ofa tertiary care hospital.

Methods

Setting

This study was carried out at the outpatient clinic of atertiary care multispecialty hospital in North India.The outpatient service is open 6 days a week, Mondayto Saturday. The psychiatry outpatient clinic acceptswalk-in patients as well as ones referred by doctorsfrom other specialties in the hospital or by psychiatristswith private practices or from other government settings.Eight faculty members in clinical psychiatry with varyingamounts of clinical experience and 12 senior residents(qualified psychiatrists), with at least 3 years of clinicalexperience in psychiatry, run the services. At any giventime, three senior residents are posted on a rotationalbasis for a period of at least 6 months at the walk-in-clinic. Any new elderly patient attending the psychiatrywalk-in clinic will be seen by one of the three seniorresidents (two for general psychiatry patients and one forpsychosexual disorders and marital problems) or afaculty member. In many cases, the senior resident dis-cusses the case with one of the faculty members afterinitial evaluation, and case management is formulatedthereafter. All diagnoses are made according to theICD-10 Classification of Mental and Behavioural Disor-ders (Clinical Descriptions and Diagnostic Guidelines).11

Clinicians choose the appropriate medication forpatients, but work with them and their family membersto determine the best course, as very few medica-

tions (trifluperazine, chlorpromazine and fluphenazinedecanoate for psychosis, imipramine for depression, andlithium) are available free of cost from the hospital dis-pensary. Most patients and their families prefer thenewer psychotropics with better side-effect profiles forwhich they must pay out of pocket. Freedom to prescribeany medication coupled with easy availability of mostpsychotropics offers a unique opportunity to prescribeany antipsychotic, antidepressant, mood stabilizer orbenzodiazepine.

After the evaluation, information regarding eachpatient’s initial clinical evaluation and sociodemo-graphic data are coded and entered into a computer-based registry. Since 1 January 2009, information onmedications prescribed has been included, and thesedata were used for the present study. The ethical issuesinvolved in the study were evaluated by the ResearchReview Committee of the Department of Psychiatry atthe Postgraduate Institute of Medical Education andResearch (Chandigarh, India).

Procedure

Data of all newly registered patients, aged 60 years orabove, between 1 January 2009 and 30 November 2010were extracted from the computer-based registry andanalyzed. Data analysis was done using SPSS v. 14.0 forWindows (Chicago, IL, USA).

Results

During the nearly 2-year study period, a total of 15 136new patients registered in the psychiatry outpatientclinic. Of these patients, a total of 1192 (7.9%) wereaged over 60 years.

Sociodemographic profile

The sociodemographic profile of the subjects includedin the study is shown in Table 1. More than half of thepatients were Hindu men from an urban backgroundwho lived in a joint family. Approximately one-fourth ofthe sample was illiterate, and slightly less than half of thesample was educated up to or beyond matriculation(10 years of formal school education). Approximatelythree-fourths of patients were married.

Diagnosis

Table 2 shows the diagnostic breakdown of the sample.The most common major diagnostic group was mooddisorders (33.9%), followed by neurotic, stress-relatedand somatoform disorders (23.1%) and organic mentaldisorders (19.5%), including symptomatic disorders.

Prescription patterns

We extracted prescription data for 975 patients havingone of the diagnoses among four major diagnostic

Prescriptions for elderly

© 2011 Japan Geriatrics Society � 285

groups: (i) organic mental disorders, including symp-tomatic mental disorders; (ii) schizophrenia and otherpsychotic disorders; (iii) mood (affective) disorders; and(iv) neurotic, stress-related and somatoform disorders.

Antipsychotics. Almost all patients with a psychotic dis-order received an antipsychotic medication (89.8%). Asignificant proportion of patients with organic mentaldisorders and mania/bipolar disorder received antipsy-chotics (48.7% and 44.4% respectively). Very fewpatients with unipolar depressive disorders (7.6%) and anegligible proportion of patients with neurotic, stress-related and somatoform disorders (1.1%) receivedantipsychotic medications (see Table 3). In all diagnos-tic groups, olanzapine was the most commonlyprescribed antipsychotic medication. In the psychoticdisorder group, olanzapine comprised almost half of allantipsychotic prescriptions (45.5%, 40 out of 88); thiswas followed by quetiapine (20.5%) and risperidone(15.9%). In the bipolar disorder group, olanzapine(67.9%, 19 out of 28) was the most commonly pre-scribed medication, followed by risperidone (14.3%). Inthe organic mental disorder group, olanzapine (42.5%,

48 out of 113) was most commonly prescribed medica-tion, closely followed by quetiapine (35.4%). Very fewpatients across all the diagnostic groups received typicalantipsychotics.

Antidepressants. Across all diagnostic groups, SSRI werethe most commonly prescribed antidepressants, andescitalopram was the most commonly prescribed agent.Antidepressants were mostly prescribed to patients withunipolar depressive disorder or neurotic, stress-relatedand somatoform disorder (85.3% and 79.3%, respec-tively). In these two groups, escitalopram comprisednearly one-third of all antidepressant prescriptions(30.9%, 90 out of 291; 32.0%, 70 out of 219) (Table 3).It was very closely followed by sertraline in both theunipolar depressive disorder and neurotic, stress-relatedand somatoform disorder groups.

Mood stabilizers. Among the mood stabilizers, valproatewas preferred over lithium (25.4% vs. 12.7%).

Benzodiazepines and other hypnotic-sedative medications.Clonazepam was the most often prescribed benzodiaz-epine across all the groups except the organic mentaldisorder group, for which lorazepam was more fre-quently prescribed. More than half of the patients wereprescribed benzodiazepines or some other sedatives forbipolar disorder, unipolar depression, and neurotic,stress-related and somatoform disorder; 43% ofpatients with a psychotic disorder were prescribed asedative. In the organic mental disorder group, onlyone-fourth of the patients received benzodiazepines orother sedatives (Table 3).

Other group of medications. Some patients also receivedother medications, such as trihexyphenidyl and vitaminsupplements, as part of their prescription.

Mean number of psychotropic medications. The meannumber of psychotropic medications was highest in thebipolar disorder group and the least in organic mentaldisorders (Table 3).

Discussion

The present study evaluated the first prescription for975 patients older than 60 years of age visiting a psy-chiatry outpatient clinic in North India.

Across all diagnostic groups, olanzapine was the mostfrequently prescribed antipsychotic. In the psychoticgroup and affective disorders group, almost all antipsy-chotic prescriptions were atypical; typical antipsychoticprescriptions comprised approximately 1% of total pre-scriptions in psychotic disorders, and none of thebipolar disorder patient received typical antipsychotics.The preference for atypical antipsychotic prescriptions

Table 1 Socio-demographic profile of elderlypatients attending the Walk-in-clinic (n = 1192)

Variables Number (%)

SexMen 689 (57.8)Women 503 (42.2)

Marital statusSingle 23 (1.9)Married 880 (73.8)Other (widow or widower,remarried, separated, divorced)

289 (24.2)

EducationIlliterate 271 (22.7)Primary/middle passed 332 (27.9)Matriculate or beyond 589 (49.4)

ReligionHinduism 781 (65.5)Sikhism 375 (31.5)Islam 26 (2.2)Christianity 9 (0.8)Other 1 (0.1)

Family typeJoint 736 (61.7)Nuclear 376 (31.5)Extended 65 (5.5)Others 15 (1.3)

LocalityUrban 727 (61.0)Rural 465 (39.0)

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for patients with affective disorders possibly reflects theusefulness of these medications as mood stabilizers, asreported in some of the recent trials.12 Data from devel-oped countries suggest that 72% and 88.6% of patientsreceive an atypical antipsychotic as a monotherapy forpsychotic disorders and affective disorders, respectively;the rest received monotherapy with typical antipsy-chotics.13 When we compare our findings with thesestudies, the prescription rate of typical antipsychoticsis significantly less in our study. Furthermore, in thepresent study none of the psychotic disorder or bipolardisorder patients received more than one antipsychotic

medication, whereas, in developed countries, the use ofmultiple antipsychotics is more common.13,14

A study from Canada that evaluated prescriptions for2002 suggested that risperidone and olanzapine are themost commonly prescribed second generation antipsy-chotics, respectively accounting for 56.4% and 29.6%of second generation prescriptions.13 In contrast, ourstudy found that olanzapine was the most commonlyprescribed antipsychotic across all diagnostic groups.A preference for olanzapine over risperidone possiblyreflects clinicians’ awareness of risperidone’s higherrates of extrapyramidal side effects. However, use of

Table 2 Diagnostic profile of elderly patients attending the walk-in-clinic (n = 1192)

Diagnoses Number (%)

Organic, including symptomatic, mental disorders 232 (19.5)F00 Dementia in Alzheimer’s disease 154 (12.9)F05 Delirium, not induced by alcohol and other psychoactive substances 47 (3.9)F06 Other mental disorders due to brain damage and dysfunction and to physical disease 25 (2.1)F01,02,03,04,07,09 Other 6 (0.5)

Mental and behavioral disorders due to psychoactive substance use 14 (1.2)F10-Alcohol dependence 13 (1.1)F11-Opioid dependence 1 (0.1)

Schizophrenia, and other psychotic disorders 98 (8.2)F20-Schizophrenia 30 (2.5)F29-Psychosis NOS 58 (4.9)F23-Acute and transient psychoses 7 (0.6)F21,22,24,25,28 Other 3 (0.3)

Mood (affective) disorders 404 (33.9)F30-Manic episode 4 (0.3)F31-Bipolar depression 10 (0.8)Bipolar affective disorder, current episode manic/hypomanic/mixed 49 (4.1)F32-First episode depression 220 (18.5)F33-Recurrent depressive disorder 67 (5.6)F34-Dysthymia 54 (4.5)

Neurotic, stress-related and somatoform disorders 276 (23.2)F40-Phobic anxiety disorders 15 (1.3)F41-Other anxiety disorders 138 (11.6)F42-Obsessive-compulsive disorder 19 (1.6)F43-Reaction to severe stress and adjustment disorders 61 (5.1)F44-Dissociative disorders 7 (0.6)F45-Somatoform disorders 36 (3.0)

Behavioral syndromes associated with physiological disturbances and physical factors 34 (2.9)F51-Nonorganic sleep disorders 33 (2.8)F52-Sexual dysfunction, not caused by organic disorder or disease 1 (0.1)F60-Disorders of adult personality and behavior 2 (0.2)F63-Habit and impulse disorders 3 (0.3)Mild cognitive impairment 2 (0.2)Seizure disorder 16 (1.3)Nil psychiatry 22 (1.8)Diagnosis deferred 62 (5.2)Absent (registered but did not see the psychiatrist) 27 (2.3)

NOS, not otherwise specified.



Table 3 Prescription of psychotropic medications

Antipsychotics Organic mentaldisorders*(n = 232)n (%)

Psychoticdisorders(n = 98)n (%)

Manic episode/bipolar disorder(n = 63)n (%)

Unipolardepressive(n = 341)n (%)

Neurotic, stress-relatedand somatoformdisorders (n = 276)n (%)

AntipsychoticsMissing data 14 (6.0) 2 (2.0) 2 (3.2) 13 (3.8) 4 (1.4)No antipsychotic prescribed 105 (45.3) 8 (8.2) 33 (52.4) 302 (88.6) 269 (78.9)Data available for antipsychotics

recommendations113 (48.7) 88 (89.8 ) 28 (44.4) 26 (7.6) 3 (1.1)

Olanzapine 48 (20.7) 40 (40.8) 19 (30.2) 9 (2.6) 1 (0.4)Risperidone 8 (3.4) 14 (14.3) 4 (6.3) 6 (1.8) 1 (0.4)Paliperidone 2 (0.9) 8 (8.2) – 1 (0.3) –Quetiapine 40 (17.2) 18 (18.4) 3 (4.8) 9 (2.6) 1 (0.4)Amisulpiride 2 (0.9) 5 (5.1) – 1 (0.3) –Aripiprazole 3 (1.3) 1 (1.0) 1 (1.6) – –Clozapine – 1 (1.0) – – –Risperidone (injectable) (depot) – – 1 (1.6) – –Trifluperazine – 1 (1.0) – – –Haloperidol 9 (3.9) – – – –Chlorpromazine – – – – –Haloperidol (injectable) 1 (0.4) – – – –

AntidepressantsMissing data 14 (6.0) 2 (2.0) 2 (3.2) 13 (3.8) 4 (1.4)No antidepressant prescribed 189 (81.4) 89 (90.8) 50 (79.3) 37 (10.8) 53 (15.5)Data available for antidepressants

recommendations29 (12.5) 7 (7.1) 11 (17.5) 291 (85.3) 219 (79.3)

Escitalopram 15 (6.4) 2 (2.0) 5 (7.9) 90 (26.4) 70 (25.4)Sertraline 6 (2.6) 1 (1.0) 1 (1.6) 87 (25.5) 63 (22.8)Venlafaxine 2 (0.9) 1 (1.0) 1 (1.6) 33 (9.7) 2 (0.7)Fluoxetine 1 (0.4) 2 (2.0) – 2 (0.6) 15 (5.4)Mirtazapine 2 (0.9) – 1 (1.6) 29 (8.5) 16 (5.8)Paroxetine 1 (0.4) – 1 (1.6) 8 (2.3) 10 (3.6)Clomipramine – – 1 (1.6) – 1 (0.4)Fluvoxamine – – 1 (1.6) 1 (0.3) 3 (1.1)Imipramine – – – 9 (2.6) 5 (1.8)Amitriptyline – 1 (1.0) – 3 (0.9) 16 (5.8)Desvenlafaxine – – – 9 (2.6) 2 (0.7)Duloxetine 1 (0.4) – – 2 (0.6) 12 (4.3)Milnacipran 1 (0.4) – – 14 (4.1) 2 (0.7)Trazodone – – – 3 (0.9) 1 (0.4)Dothiepin – – – 1 (0.3) 1 (0.4)

Mood stabilizersMissing data 14 (6.0) 2 (2.0) 2 (3.2) 13 (3.8) 4 (1.4)No mood stabilizer prescribed 215 (92.7) 95 (96.9) 37 (58.7) 325 (95.3) 270 (97.8)Data available for mood stabilizers


Valproate 2 (0.9) 1 (1.0) 16 (25.4) 1 (0.3) 0Lithium 1 (0.4) – 8 (12.7) 1 (0.3) 1 (0.4)Carbamazepine – – – 1 (0.3) –Oxcarbazepine – – – – 1 (0.4)

BenzodiazepinesMissing data 14 (6.0) 2 (2.0) 2 (3.2) 13 (3.8) 4 (1.4)No benzodiazepine prescribed 163 (70.3) 54 (55.1) 23 (36.5) 107 (31.4) 117 (42.4)Data available for benzodiazepines


Clonazepam 15 (6.5) 27 (27.5) 27 (42.9) 159 (46.6) 120 (43.5)Lorazepam 27 (11.6) 11 (11.2) 9 (14.3) 26 (7.6) 15 (5.4)Zolpidem 9 (3.9) 4 (4.1) 1 (1.6) 19 (5.6) 10 (3.6)Alprazolam 1 (0.4) – – 8 (2.3) 4 (1.4)Nitrazepam – – 3 (0.9) 4 (1.4)Diazepam 3 (1.3) – 1 (1.6) – 1 (0.4)Etizolam – – – 3 (0.9) 1 (0.4)Eszopiclone – – – 3 (0.9) –Other medications 73 7 11 37 32Mean number of psychotropic medications 1.25 1.48 1.84 1.76 1.51

*Among patients with an organic mental disorders, 63 patients with dementia received donepezil/donepezil plus mementine; 10 received other medications.

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olanzapine and risperidone as the two most commonlyprescribed antipsychotics is in line with Indian psychi-atric prescription trends reported earlier.15

In the organic mental disorder group, which con-sisted mostly of patients with Alzheimer’s disease(66.4%), nearly half of the patients were prescribed anantipsychotic medication. A previous study from Indiawith 53 subjects reported that 53% of the dementiapatients were prescribed antipsychotic medications.3

Findings from this study are similar, but the rate ofantipsychotic prescriptions we found is much higherthan that in some recent studies from developed coun-tries.16,17 Over the years, the prescription of atypicalantipsychotic prescriptions for dementia patients hasdeclined in developed countries because of elderlypatients’ increased risk of sudden cardiac death.18 As aresult, the USA’s Food and Drug Administration issueda black box warning for prescribing these drugs to theelderly.19 A study by Kales et al. also suggested that afterthe issue of black box warning, prescription rates foratypical antipsychotics declined.16 The higher prescrip-tion rates for antipsychotics in the Indian setting in thisand previous studies possibly reflect the poor facilitiesfor these patients, specifically the lack of old age homesand infrequent use of non-pharmacological measures tomanage these patients.3 Hence, there is a need in Indiato develop better rehabilitation facilities so patients arenot as dependent on prescriptions.

In the present study, out of the 154 dementia patients,only 73 (47.4%) of patients were prescribed anti-dementia drugs, with over 40% receiving donepezil (ofthe 154 patients, 37.7% received donepezil and 3.2%combination of donepezil and memantine). This con-trasts with the findings from another center in India,where donepezil was prescribed for more than half ofthe patients (52.9%, 27 out of 51); memantine (18%)and a combination of donepezil and memantine (10%)were the next most common prescriptions.3 These dif-ferences could be due to varying degrees of illness orcenter-specific practice patterns with respect to manag-ing dementia. Dementia in a multi-specialty center suchas ours is managed by both psychiatrists and neurolo-gists. Therefore, it is quite possible that patients whopresent with mild to moderate dementia are managed byneurologists with anti-dementia drugs, whereas thosepatients who have more severe behavioral and psycho-logical symptoms associated with dementia are referredto psychiatrists. This also explains the higher prescrip-tion rates of antipsychotics.

Across all diagnostic groups, SSRI were the mostoften prescribed group of antidepressants, with escitalo-pram followed by sertraline being the most frequentlyprescribed medications from this group. Among newergeneration antidepressants, venlafaxine and mirtazapinecontributed significantly to antidepressant prescriptionsin elderly. As in the case of antipsychotics, older

generation antidepressants were negligibly prescribed.This finding is in line with reports of an increasing trendtowards SSRI and a decreasing trend towards TCA.6,7

However, the percentage of patients who were pre-scribed TCA in the present study was much lower thanthat reported in developed countries.20 In the presentstudy, escitalopram and sertraline were the two mostcommonly prescribed antidepressants, which is in con-trast to findings from developed nations, where citalo-pram and fluoxetine have been reported to be the twomost commonly prescribed antidepressants.20 A smallproportion of patients in the organic mental disordergroup received antidepressants (12.5%). These rates aremuch lower than the prescription rate of antidepres-sants reported in developed countries for Alzheimer’spatients, which ranges from 32.3% to 40.5%.17 Thereasons for these varying trends must be understood.One such reason for varying antidepressant prescriptionrates could be the greater reliance on antipsychotics inthe Indian setting, whereas, in developed countries,doctors shy away from these prescriptions because ofblack box warnings.

In the present study, valproate was prescribed almosttwice as often as lithium (25.4% vs. 12.7%). This is inline with present trend of prescribing mood stabilizers.9

A possible reason for this preference for valproate couldstem from the notion that it is more useful in managingacute manic episodes.19 Other reason for the decrease inlithium prescriptions could relate to safety concerns andthe lack of promotion by pharmaceutical companies.Some authors feel that this preference for valproate overlithium is not justified.8,9

Sedative-hypnotic medications were frequently pre-scribed across all diagnostic groups. Studies from devel-oped countries have noted that benzodiazepines areused in one-third to half of elderly patients, especiallythose with depression.21–23 In the present study, as indeveloped countries, clonazepam and lorazepam werethe most often prescribed benzodiazepines. This higherpercentage of patients receiving benzodiazepines is par-ticularly important as guidelines classify them as inap-propriate, and some authors suggest limited use for theelderly given the potential side effect.24

Almost all patients included in our study were pre-scribed a single medication from a particular group,which is understandable as the first prescription was thefocus of this study. Still, most of the patients were pre-scribed more than one medication, with the highestmedication load in the bipolar disorder group and theleast in organic mental disorder group. This practice ofprescribing a single agent from a particular group ofdrugs suggests that recommended treatment guidelinesare broadly followed, meaning that one medication isstarted at a time.

To conclude, the present study’s findings have bothsome similarities to and differences from prescription



patterns observed in studies from developed countries.Findings of the present study suggest that atypicalantipsychotics are more commonly prescribed thantypical antipsychotics. This is similar to the findingsfrom developed countries, but the proportion of typicalantipsychotic prescriptions in the present study is sig-nificantly smaller. In contrast to developed countries,the use of multiple antipsychotics occurs less fre-quently. Additionally, in contrast to developed coun-tries, in India, olanzapine is preferred over risperidone.With regard to antidepressants, SSRI are the most com-monly prescribed antidepressant class, as in developedcountries, but the prescription rates of TCA in thepresent study are significantly lower than in developedcountries. In the present study, the two most commonlyprescribed antidepressants were escitalopram and ser-traline, which contrasts to the findings from developedcountries, where citalopram and fluoxetine are report-edly the two most commonly prescribed antidepres-sants.25 The prescription rate and use of benzodiazepineare quite frequent, which is similar to findings fromdeveloped countries.

Our study had several limitations. We focused onlyon the first prescription, which does not necessarilyreflect the true clinical situation for all patients, particu-larly those who attend the psychiatry services in the longterm. Depending on patients’ response to treatment,medications such benzodiazepines are tapered off aftersome time in many patients, and others may requireother medications to achieve clinical improvement. Inthe present study, patients’ dose and dosing scheduleswere not documented nor was information on non-psychotropic medications. Other factors such ascost, treatment adherence, availability of supervision,concerns about side effects and guideline adherencewhen prescribing were also not studied. Moreover, thepresent study was limited to a tertiary care, multi-specialty, postgraduate teaching center that may notreflect national trends. Since the analysis is based onprescription data, it reflects physicians’ prescribingbehavior but not necessarily clinical benefits. Wecould not control for clinical variables, including dura-tion of treatment, which likely affect prescribing behav-ior. Future studies should try to overcome theselimitations.

Disclosure statement

No authors report any conflict of interest.

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Documents

First prescription of new elderly patients attending the psychiatry outpatient of a tertiary care institute in North India