The last decade has seen an overall increase in the use of psychotropic medications among adults of all ages. In the National Ambulatory Medical Care Surveys, from 1985 to 1994, the number of visits during which a psychotropic medication was prescribed increased from 32.73 million to 45.64 million, and the proportion of visits during which a psychotropic medication was prescribed increased from 5.1% to 6.5% (p£0.01) (Pincus et al., 1998). This increase may impact older adults, who are substantial users of all types of medications. During 1995, an estimated 12.02 million visits were made to office-based physicians by individuals 65 years or older during which psychotropic medications were prescribed -- most frequently antianxiety agents and antidepressants (Aparasu et al., 1998).

Changes in the type of psychotropic medications prescribed have also been noted over the last decade, with a decrease in use of hypnotic and antianxiety medications -- previously the largest category of psychotropic medications prescribed -- and an increase in the use of antidepressants (Pincus et al., 1998). The investigators hypothesized that this increase is due, in part, to the introduction in the 1980s of the selective serotonin reuptake inhibitors (SSRIs), which can be prescribed for both depression and anxiety symptoms. Whether this trend is observed in older adults is less known.

Sedatives, hypnotics and antianxiety medications are among the psychotropic medications most frequently prescribed to older adults (Morgan et al., 1988; Stewart et al., 1994). The appropriateness of their use in this population has been questioned (Taylor et al., 1998), due in part to their side effects. For example, cognitive impairment is a common side effect (Hanlon et al., 1998), and benzodiazepine use has been associated with an increased risk of motor vehicle accidents (Hemmelgarn et al., 1997).

Although the prevalence of major depression is lower in older adults compared to middle-aged adults (1% to 3% versus 3% to 5%, respectively), symptoms of depression are prevalent in late life (Beekman et al., 1995; Blazer et al., 1987; Weissman et al., 1991). The prevalence of antidepressant use in older adults has been shown in a Canadian sample to vary with age, gender and time of assessment (Mamdani et al., 1999). Specifically, the prevalence of antidepressant use was higher with older patients, females and with increasing year of assessment. The prevalence was estimated to range from a low of 5.6% in 65- to 69-year-old men in 1993 to a high of 17.2% among 85- to 89-year-old women in 1997.

Using data from Duke University's Established Populations for Epidemiologic Studies of the Elderly (EPESE), a longitudinal study of 4,162 community-dwelling individuals 65 years or older (Cornoni-Huntley et al., 1990, as cited in Blazer et al., 2000b), we investigated the use of psychotropic medications in our cohort from 1986 to 1996 and racial differences in patterns of use. Data on medication use were collected through in-person interviews with participants in 1986/1987, 1989/1990, 1992/1993 and 1996/1997. Participants were asked to report any medications taken within the two weeks prior to the interview. Other than attrition due to death, few sample members were lost to follow-up or refused further participation during the 10 years (Blazer et al., 2000a, 2000b).

A total of 75% of our sample reported using one or more prescription medications. While cardiovascular drugs were the therapeutic category of medication most frequently mentioned, psychotropic medications were second, comprising 12.5% of all medications reported in 1986 (Hanlon et al., 1992). Racial differences in medication use were noted, with whites taking an average of 2.35 medications compared to an average of 2.02 taken by African Americans (p<0.001).

These results led to our recent reporting of racial differences in patterns of psychotropic medication use during the 10 years of our study (Blazer et al., 2000a, 2000b). At the time of the baseline survey in 1986, a total of 17.3% of the sample were taking one or more psychotropic medications, while by the time of the 10-year follow-up in 1996/1997, a total of 20.6% of our sample reported psychotropic medication use. A total of 13.3% of the sample were taking a sedative, hypnotic or antianxiety medication and 3.8% were taking an antidepressant in 1986/1987. In 1996/1997, when the cohort was 10 years older, a total of 11.8% of the sample were taking a sedative, hypnotic or antianxiety medication, and 11.0% were taking an antidepressant. The use of these psychotropic medications by race is shown in the Table. Across all categories, whites were more likely to be taking a psychotropic medication than African Americans.

Sedatives, hypnotics and antianxiety agents were used frequently by this cohort and, despite efforts to decrease the use of these medications in older adults, the use of antianxiety medications declined only slightly during our 10-year follow-up period. While benzodiazepines accounted for the majority of these medications prescribed, whites were two to three times more likely than African Americans to be taking non-benzodiazepines as well as benzodiazepines across all 10 study years. In controlled analyses, use of sedatives, hypnotics and antianxiety medications was associated with white race, female gender, depression, a higher number of visits to health care professionals, some impairment in physical functioning, and perceived health as fair or poor.

The threefold increase in our sample's use of antidepressants over 10 years is more striking. Since we did not observe a significant decline in the use of antianxiety medications, it is not likely that the increased use in antidepressants is due to replacement of antianxiety medications with antidepressants. In addition, the prevalence of depression remained fairly constant across all 10 years -- around 9% -- so the increased use is not due to an increase in the prevalence of depression in our cohort. At the time of our baseline survey in 1986/1987, 4.5% of those 75 years old to 84 years old were taking an antidepressant. When the individuals in our cohort who were 65 years to 74 years at baseline aged to that point 10 years later, a total of 10.6% were taking antidepressants. Similarly, 3.8% of those 85 or older at the time of the baseline survey were taking an antidepressant. When the baseline cohort who were 75 years to 84 years aged to be 85 or older 10 years later, 13.1% were taking an antidepressant. Also, racial differences in the use of antidepressants were evident and became more pronounced over time. While whites were twice as likely as African Americans to be taking an antidepressant in 1986/1987, they were three times more likely to be taking an antidepressant than African Americans in 1996/1997. And, while African Americans doubled their use of antidepressants over 10 years, white respondents tripled their use in the same time period. When examined by category of antidepressant, the increase in antidepressant use was due primarily to increased use of the SSRIs, and few older African Americans were taking these medications.

White race was a significant predictor of both antianxiety and antidepressant use when other factors such as gender, education, health service use, physical and cognitive health status, self-perceived health, income, and health insurance were simultaneously controlled. These results suggested the differences in use are not due to access to care or similar factors. These racial differences are surprising in that landmark community studies in psychiatric epidemiology such as the Epidemiologic Catchment Area (ECA) Survey (Regier et al., 1984), in which older adults were surveyed, failed to find racial differences in the prevalence of depressive and anxiety disorders -- with the possible exception of phobic disorder for which medications are rarely prescribed (Blazer et al., 1991; Eaton et al., 1991; Weissman et al., 1991). Additionally, since respondents in our study were asked to bring all their medications for the interviewer to record, we feel it is unlikely there would be racial differences in reporting.

These results suggested the changing patterns observed in a national survey (Pincus et al., 1998) of decreased use of antianxiety medications and increased antidepressant use were observed in our sample in whites but not in African Americans. Reasons for these racial differences remain unknown. Possible explanations include: physicians may be more likely to prescribe psychotropic medications to whites than to African Americans; African Americans may be less likely to request psychotropic medications from their physician; or racial concordance between physician and patient may affect prescribing of psychotropic medications. Now that additional SSRIs are on the market and their prescription has become more common than in 1996/1997, it would be useful to see if these trends continue in older adults.

Dr. Hybels is assistant research professor in the department of psychiatry and behavioral sciences and a postdoctoral fellow in the Center for the Study of Aging and Human Development at Duke University Medical Center.

Dr. Blazer is J.P. Gibbons Professor of Psychiatry in the department of psychiatry and behavioral sciences at Duke University Medical Center and adjunct professor of epidemiology at University of North Carolina School of Public Health. He is also chair of the University Council on Aging and Human Development at Duke University.

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Racial Differences in the Increased Use of Psychotropic Medications