There is a demand for prospective drug use surveies to adequately measure patient attention and installation indexs. Ordering wonts among head-shrinkers can be improved by making consciousness about taking drugs from the Essential Medicines List. Inclusion of a drug in the infirmary formulary requires consideration of both prescribers ' pick of a drug and its presence in the Essential Medicines List. Prescriber instruction can besides concentrate on decrease in prescription of attendant ataractic soporifics. Prescribers should besides be encouraged to look into for patients ' conformity with the prescribed medicines and to enter them in the instance sheets. Such steps will advance the rational usage of medical specialties and finally, the quality of health care.
The World Health Organisation ( WHO ) defines Drug use as the selling, distribution, prescription and usage of drugs in a society, with particular accent on the ensuing medical, societal and economic consequences.1 Often, drugs are non used maintaining in head their safety and efficacy.2 Rational drug prescribing is the usage of the least figure of drugs to obtain the best possible consequence in the shortest period and at a sensible cost.3 Irrational prescribing and disparity between prescription and ingestion of medical specialties may countervail the benefits demonstrated by randomized controlled tests on drug efficacy.4-7 Furthermore, optimistic outlooks of a drug, based on consequences of clinical tests may non happen when used outdoors controlled settings.8 The recent proliferation of new drugs, increasing acknowledgment of delayed inauspicious effects and concentrate on pharmacoeconomic considerations has stimulated involvement in ordering forms of physicians.5
Antidepressant prescribing forms have changed globally over the last few old ages, with conventional drugs like tricyclics and MAO inhibitors being bit by bit replaced by selective 5-hydroxytryptamines reuptake inhibitors ( SSRIS ) and fresh antidepressants. Prevalence of antidepressant use in the community is lifting in Western populations, with Iceland, Australia and Sweden holding the highest consumption.9
Therefore, our purpose was to analyze the drug use of antidepressant drugs in the psychiatric unit of a third attention infirmary in Pondicherry. Our aims were:
To detect the prescribing form of antidepressants among head-shrinkers in our infirmary
To measure the reason of the prescriptions
To measure the prevalence of antidepressant use in the community
MATERIALS AND METHODS
Type of survey: Retrospective and experimental.
Time period of survey: 1st January 2006 to 31st December 2006
Topographic point of survey: Psychiatric unit of a third attention infirmary in Pondicherry.
Inclusion standards:
1. All patients who attended the Psychiatry outpatient ( OP ) clinic of the infirmary from 1st January 2006 to 31st December 2006.
2. All patients diagnosed with depressive or adjustment upset ( diagnosed as per International Classification of Diseases - ICD 10 standards ) 10 or any status where antidepressants are indicated.
Exclusion standards:
Patients who did non have antidepressant drugs.
Patients go oning merely those antidepressant drugs prescribed outside the infirmary.
Data aggregation: Case records of Psychiatry outpatient clinic were taken from the medical records subdivision of the infirmary. Datas were entered in a pre-designed proforma ( Fig1 ) .
From the multiple prescriptions in the instance record with follow-up visits, we took all prescriptions incorporating at least one antidepressant as one prescription. Therefore, if the initial prescription was continued, it was regarded as the same prescription for the given continuance. Any dose alteration in that prescription was noted for ciphering drug ingestion. Addition of another antidepressant to or alteration of antidepressant from the bing regimen was regarded as a separate prescription. In both instances, the figure of drugs in the prescription included the added or changed antidepressant ( s ) , along with attendant medicines from the earlier prescription. However, prescriptions incorporating drugs for co-morbid conditions ( non-psychiatric ) which were non prescribed in the section of Psychiatry were excluded.
Sampling frame: All patients run intoing eligibility standards as given above.
Datas analysis: Datas were subjected to analysis for:
Demographic inside informations ( Age and gender )
Psychiatric diagnosing
Antidepressant drugs prescribed
4. Completeness of prescription, rightness of drug, dosage, frequence and continuance.
5. Rationality of prescription harmonizing to WHO ordering indexs.
6. Defined daily dose ( DDD ) of the antidepressants per 1000 dwellers per twenty-four hours ( DID )
7. Prescribed day-to-day dosage ( PDD ) of the antidepressants
8. PDD to DDD ratio of the antidepressants
Anatomical Therapeutic Chemical ( ATC ) categorization and Defined Daily Dose ( DDD ) per 1000 dwellers per twenty-four hours ( DID ) computations were used for gauging antidepressant usage in the community.
Following the methodological analysis outlined by WHO,11 we calculated DID as follows:
DID =Amount of antidepressant prescribed in 1 twelvemonth ( milligram ) Ten 1000 dwellers
DDD ( milligram ) X 365 yearss X Population of Pondicherry and Cuddalore
All patients belonged to either Pondicherry or Cuddalore territory of Tamil Nadu. So, for computation of DID, we used the population of Pondicherry every bit good as Cuddalore territory as per available statistics.
Entire figure of DIDs is calculated by adding up the DIDs for single antidepressants.
PDD was calculated as follows:
For each prescription, there were multiple doses of the antidepressants, due to dose titrations and we took the norm of the day-to-day doses for the antidepressant as the PDD. This procedure was repeated for all the indicants of each antidepressant and the concluding value was the norm of the PDDs therefore obtained.
PDD to DDD ratio was so calculated.
Statistical analysis: Descriptive statistical tools were used.
Ethical clearance: As it was a non-interventional survey, the institutional research commission granted waiver on the confidence that capable confidentiality would be maintained. We took the undermentioned stairss in this respect:
Designation of patients by the infirmary figure merely and non by name.
Case records to be accessed by research workers in the Medical records subdivision merely.
Patient inside informations non to be divulged to any party other than co-authors.
Proformas to be destroyed after decision of survey.
Consequence
Demographic inside informations: Out of 222 patients having psychoactive medical specialties during the survey period, 169 ( 76.58 % ) received one or more antidepressants. Among these 169 patients, 82 ( 48.52 % ) were males and 87 ( 51.48 % ) were females. Age distribution of patients having antidepressants is shown in Fig 2.
Psychiatric diagnosings: Distribution of primary psychiatric diagnosings of patients having antidepressants is shown in Table 1.
Antidepressant drugs prescribed: Entire figure of prescriptions given was 192 and a sum of 446 drugs were prescribed. Of them, 192 were antidepressant medicines of 8 types, as per ATC category. Table 2 and Fig 3 show different antidepressants prescribed. Number of antidepressant prescriptions along with their indicants is shown in Table 3.
Substitutions and Adjunctive antidepressants: Change of antidepressant was required on 18 occasions. Duloxetine was substituted on 10 occasions, escitalopram on 4, mirtazapine on 3 and imipramine on 1 juncture. Addition of a 2nd antidepressant was seen on 3 occasions because of hapless response with a individual drug. Of them, duloxetine was the first antidepressant on 2 occasions and mirtazapine on 1.
Attendant medicines prescribed in the section of Psychiatry: Table 4 shows attendant medicines prescribed in the section of Psychiatry.
Completeness of prescription, rightness of drug, dosage, frequence and continuance: Besides patient inside informations and outpatient designation figure, prescriptions contained the patient 's primary diagnosing, drug ( s ) prescribed, dose signifier, dosage, frequence of disposal and continuance of intervention along with the day of the months of followup. There was no incorrect dosage, frequence and continuance of intervention ; in some instances, inappropriate drug was prescribed for a incorrect diagnosing which was corrected when primary diagnosing was revised on follow up.
Table 5 shows the figure of drugs per prescription among the 192 prescriptions. More than 5 drugs were non prescribed to any patient.
Rationality of prescription harmonizing to WHO ordering indexs: As per WHO Prescribing indexs, we observed:
Average figure of drugs per prescription: 2.32 ( 446/192 )
Percentage of antidepressant drugs prescribed by generic name: 88.54 % ( 170/192 X 100 )
Percentage of Fixed dose combinations ( FDCs ) of antidepressants: Nothing
Percentage of brushs for ordering injections of antidepressants: Nothing
Percentage of antidepressant drugs prescribed from Essential Medicines List ( 16th EML of WHO ) : 1.56 % ( 3/192 X 100 )
Percentage of drugs prescribed from the National List of Essential Medicines ( NLEM, endorsed 2002 ) was 2.60 % ( 5/192 X 100 ) .
Percentage of drugs prescribed from the infirmary pharmacopeia was 96.35 % ( 185/192 X 100 ) .
Defined daily dose ( DDD ) of the antidepressants per 1000 dwellers per twenty-four hours ( DID ) : ATC cryptography, DDD and computation of DID are summarized in Table 6.
Entire figure of DIDs of antidepressants was 0.02.
Prescribed day-to-day dosage ( PDD ) of the antidepressants and PDD to DDD ratio of the antidepressants: PDD and PDD to DDD ratios are besides summarized in Table 6.
Discussion
Demographic inside informations: Antidepressants were prescribed more in females ( 51.48 % ) than in males ( 48.52 % ) . This is consistent with findings in other studies.12,13 This female preponderance might reflect the higher prevalence rate of psychiatric morbidity in adult females, peculiarly, depressive and anxiousness upsets and may besides be due to gender functions played by adult females in society, with more voicing of psychological jobs and seeking of professional help.13 The age distribution shows the bulk of patients, having antidepressants belonging to 21-30 old ages age group ( 36.69 % ) . In fact, 66.27 % were aged between 21 and 40 old ages. This is in contrast to the consequences of a survey of antidepressant usage in East Asia, wherein the average age of patients having antidepressant prescriptions was more than 40 years.14 In another survey in Europe, where antidepressants were the 2nd most normally prescribed psychotropic drugs, bulk of the users were between 35 and 49 old ages, with a average age greater than 40 years.13
Psychiatric diagnosings: Depressive upset was the most common psychiatric diagnosing among the population ( n=222 ) , with a prevalence of 47.75 % . It was besides the most common indicant for utilizing antidepressants ( 62.72 % ) , followed by Mixed Anxiety and Depressive upset and Schizophrenia with station schizophrenic depression among the top three diagnosings.
Antidepressant drugs prescribed: Antidepressants were the most common psychotropic drugs prescribed ( 76.58 % ) . Choice of antidepressant was based on ICD diagnosing, badness of disease/disorder, co-morbidity, drug efficaciousness and considerations for patients ' tolerability. Most common antidepressant prescribed was the Selective Noradrenaline re-uptake inhibitor ( SNRI ) duloxetine ( 50 % ) . The newer antidepressants - duloxetine, escitalopram, Zoloft and mirtazapine accounted for the majority of prescriptions. ( 96.36 % ) , which follows the planetary tendency towards antidepressant prescribing.14-18 In many surveies, Selective 5-hydroxytryptamine re-uptake inhibitors ( SSRIs ) accounted for the majority of the prescribed antidepressants, with high ordering rates.14-17 In our survey, SSRIs - escitalopram, Zoloft and Prozac were prescribed on 57 out of 192 occasions ( 29.69 % ) . Among the SSRIs, escitalopram was the preferable drug. Again, this is in contrast to findings in the East Asian survey on antidepressant usage, wherein Prozac and Zoloft were prescribed more often than escitalopram and its usage was lower than Desyrel, mirtazapine, impramine hydrochloride and amitryptiline. However, ordering rates of tricyclic antidepressants impramine hydrochloride and amitryptiline were lower than the prevalent norms.14 Doses of antidepressants were prescribed harmonizing to badness of disease/disorder, get downing with low doses and titrated upward or downward harmonizing to clinical response and patients were kept on regular followup.
Duloxetine was the most common antidepressant prescribed in Depressive upset ( 56.56 % ) , Mixed Anxiety and Depressive Disorder ( 41.38 % ) and in BPAD ( 62.50 % ) . Most common antidepressant prescribed in Schizophrenia with post-schizophrenic depression was escitalopram ( 44.44 % ) , and in OCD, Zoloft ( 80 % ) .
Substitutions and Adjunctive antidepressants: Prescription of a individual antidepressant was common and occurred in 98.44 % of instances. Reasons for altering an antidepressant were hapless curative response or unbearable inauspicious effects. Duloxetine was the most normally substituted antidepressant. It was besides the most common antidepressant to which adjunctive antidepressant drug was prescribed.
Attendant medicines prescribed in the section of Psychiatry: Ataractic soporifics were the most common group of drugs prescribed ( 65.10 % ) concomitantly with antidepressants, followed by major tranquilizers, temper stabilizers, trihexiphenidyl, acamprosate, propranolol and vitamin B1. Except for Vitamin B1, which was prescribed in Alcohol Dependence, and propranolol, which was prescribed for intervention of shudders, all others were psychoactive medicines. Trihexiphenidyl was prescribed to counter the extrapyramidal inauspicious effects of attendant major tranquilizers.
Completeness of prescription, rightness of drug, dosage, frequence and continuance: Rational prescribing was followed as per the rules of prescription order writing.19 Sing the definitions of polypharmacy which are most normally cited, there was no polypharmacy because there was no prescribing of antidepressant medicine which did non fit diagnosing and there was no prescription with more than 5 drugs.20 68.23 % of the prescriptions ( 131 out of 192 ) had 2 drugs or less, which is recommended. However, there were instances where wrong diagnosing led to ordering of inappropriate drug ab initio ; it was rectified when primary diagnosing was revised on follow up. Clinicians ' pick of drug was non based chiefly on affordability for the patient, so the cheapest drug was non ever prescribed.
Rationality of prescription harmonizing to WHO ordering indexs: The mean figure of drugs per prescription was more than 2, which is high. But, we had excluded all prescriptions where antidepressants were non prescribed. So, prescriptions where merely guidance was provided were non considered, in which instance the figure of prescriptions with less than 2 drugs would hold risen, thereby conveying down the mean figure of drugs per brush. Ordering by generic names was high ( 88.54 % ) and close to 100 % . There were no fixed dosage combinations ( FDCs ) or injectible readyings prescribed, which indicate rational prescribing patterns. The per centum of drugs prescribed from the 16th WHO Essential Medicines List and the National Essential Medicines List ( endorsed 2002 ) was low. However, per centum of drugs prescribed from the infirmary pharmacopeia was really high ( 96.35 % ) . This indicates the demand to convey about a balance between clinicians ' petitions for maintaining a drug in the infirmary pharmacopeia and the recommendations of WHO and National Essential Medicines Lists.
ATC Classification, Defined daily dose ( DDD ) and DDD of the antidepressants per 1000 dwellers per twenty-four hours ( DID ) : The anatomical curative chemical ( ATC ) categorization system divides drugs into different groups harmonizing to the organ or system on which they act and their chemical, pharmacological and curative properties.21,22 Each drug is assigned a peculiar combination of letters and Numberss. The defined day-to-day dosage ( DDD ) is the false mean care dose per twenty-four hours for a drug used for its chief indicant in adults.21 DDD was developed to get the better of expostulations against traditional units of measuring of drug ingestion and to guarantee comparison between drug use surveies carried out at different locations and different clip periods.
Entire DID of the antidepressants show low ingestion, in crisp contrast to the tendency of Western European states and the USA, particularly during the last decennary, with high rates of antidepressant prescribing and consumption.9,22,23
DID for duloxetine can be interpreted as 0.0025 out of 1000 patients or 0.025 % would hold used a dosage of 60mg. Similarly, DIDs of escitalopram, mirtazapine, Zoloft, impramine hydrochloride, Desyrel, amitryptiline and Prozac can be interpreted as ingestion of their several DDDs by a population of 0.019 % , 0.004 % , 1.007 % , 0.003 % , 0.019 % , 0.12 % and 0.00007 % .
Prescribed day-to-day dosage ( PDD ) of the antidepressants: The prescribed day-to-day dosage ( PDD ) is defined as the norm dosage prescribed harmonizing to a representative sample of prescriptions. It is of import to associate the PDD to the diagnosing on which the dose is based. The PDD will give the mean day-to-day sum of a drug that is really prescribed. PDD is particularly of import for drugs where the recommended dose differs from one indicant to another ( e.g. psychotropic drugs ) . When there is a significant disagreement between the PDD and the DDD, it is of import to take this into consideration when evaluating and construing drug use figures, peculiarly in footings of morbidity.24
PDD to DDD ratio of the antidepressants: Ratio of PDD to DDD is frequently used as an indicant of the adequateness of dosing. A ratio less than 1 as seen in instance of duloxetine and mirtazapine indicates under-dosing. A ratio greater than 1 was seen for Zoloft and amitryptiline. All other antidepressants showed a PDD to DDD ratio equal to 1, reflecting the adequateness of dosing in these cases.25
Restrictions of the survey: Our consequences should, nevertheless, be seen in the visible radiation of the little sample size, compared to the surveies with which they have been compared. Restrictions of the survey were the deficiency of patient attention indexs and some of the installation indexs like handiness of drugs and impact of cost on drug intervention, which increase the public-service corporation of the survey, but which can be derived prospectively merely. As with any drug use survey, existent usage or conformity with prescribed antidepressant was non possible to supervise, more so with a retrospective survey of instance records, where notes on conformity are missing. Furthermore, we could non quantify informations on comparative clinical effectivity of the antidepressants.
Strengths of the survey: Strengths of the survey are the usage of a structured proforma for informations aggregation with inside informations of drug prescriptions on follow up visits, and a comprehensive application of drug use tools like ATC/DDD categorization and computation of DID and PDD/DDD ratios to measure prevalence of antidepressant usage in the community of the survey population. Documentation of longitudinal follow-up informations gives a better thought of drug ingestion than transverse sectional informations. Data on drug permutations and augmentations every bit good as attendant psychotropic medicines are besides provided.
Decision: Our survey shows that depressive upset was the most common psychiatric diagnosing in the population and antidepressants were the most normally prescribed psychotropic medical specialties. There was a higher prevalence of antidepressant prescribing for adult females. Majority of antidepressants were prescribed to immature and older grownups between 21and 40 old ages. The SNRI Duloxetine, the SSRIs escitalopram and Zoloft and the untypical antidepressant mirtazapine were the most normally prescribed antidepressants, with or without other attendant psychotropic medical specialties. Most patients were treated by a individual antidepressant. However, hapless response and/or tolerability considerations made the prescribers change the antidepressant or add a 2nd antidepressant. Antidepressants were prescribed for many indicants other than depressive upset and head-shrinkers ' pick of drug was influenced by diagnosing, badness of disease/disorder, co-morbidity, drug efficaciousness, and considerations for patients ' tolerability, but non chiefly on the cost of medicine. Prescriptions were complete and polypharmacy was non seen. Favorable and unfavorable results were seen for 3 and 2 WHO ordering indexs severally. Consumption of antidepressants in the community was low. Adequate dosing was seen for all antidepressants, except for duloxetine and mirtazapine, for which under-dosing was prevailing.
Recommendations: There is a demand for prospective drug use surveies to get the better of some of the restrictions of our survey. Ordering wonts among head-shrinkers can be improved farther by making consciousness about taking drugs from the Essential Medicines List and cut down prescription of ataractic soporifics. Such steps can diminish the figure of drugs per prescription and besides the cost of therapy. Prescribers should besides be encouraged to look into for patients ' conformity with the prescribed medicines and to enter them in the instance sheets. Such steps will advance the rational usage of medical specialties and finally, the quality of health care.
