Weissman_GerPsych

Demographic, Clinical, and Functional Factors Associated With
Antidepressant Use in the Home Healthcare Elderly
Judith Weissman, Ph.D., J.D., M.P.H., Barnett S. Meyers, M.D., Samiran Ghosh, Ph.D., and
Martha L. Bruce, Ph.D., M.P.H.
Department of Psychiatry, Weill Cornell Medical College, White Plains, NY.
Abstract
Objectives—Determine rates and demographic, clinical, and functional correlates of
antidepressants (ADs) in home healthcare patients.
Methods—Year 2007 cross-sectional National Home Health and Hospice Care Survey (N =
3,226) of patients 65 years or older (mean 80.11, confidence interval [CI] = 79.65–80.57).
Results—Overall 33.50% used ADs. Among the 6.76% with depression, 70.84% used ADs
compared with 29.15% who used ADs without a documented depression diagnosis. In a
regression, controlling for depression, blacks used less ADs than whites (odds ratio [OR] = 0.41,
CI = 0.24–0.70). Younger age (OR = 0.96, CI = 0.94–0.98), activities of daily living impairments
(OR = 1.15, CI = 1.05–1.26), benzodiazepines (OR = 2.63, CI = 1.88–3.69), antipsychotics (OR =
2.08, CI = 1.29–3.36), and nonpsychotropics (OR = 1.07, CI = 1.04–1.10) were related to AD use.
Conclusion—Among home healthcare patients, more than one-third took ADs including patients
without depression. Blacks used fewer ADs than whites. Increased use was associated with
younger age, disability, and nonpsychotropics.
Keywords
Antidepressant; elderly; home health-care
Home healthcare (HHC) is primarily interim care for homebound postacute ill or injured
patients. Because care is provided in the home, HHC offers the opportunity to identify the
unmet patient needs before transitioning to the next stage of care. HHC nurses provide, on
average, 22 visits to the patient's home. The Medicare requirement that HHC nurses assess
the mental status of new admissions, and every 60 days thereafter during HHC, provides a
setting for intervening to improve depression detection and management.
A decade ago, research found high rates of depression among HHC patients but low rates of
antidepressant (AD) use. Since that time, rates of AD use have increased greatly among
older adults generally.1,2 We do not know, however, the extent to which such changes
applied to the most medically compromised and disabled older adults, such as HHC patients,
or if they are equally distributed across sociodemographic groups. Among Medicare patients
generally, African Americans received disproportionately fewer ADs than whites even when
diagnosed as depressed, and African Americans and Latinos received less good mental
healthcare compared with whites.3–5
© 2011 American Association for Geriatric Psychiatry
Send correspondence and reprint requests to Judith Weissman, Ph.D., J.D., M.P.H., Department of Psychiatry, Weill Cornell Medical
College, White Plains, NY 10601. juw7002@med.cornell.edu or Martha L. Bruce, Ph.D., M.P.H. judithweissman@yahoo.com.
The authors thank Yuhua Bao, Ph.D. for her contributions.
NIH Public Access
Author Manuscript
Am J Geriatr Psychiatry. Author manuscript; available in PMC 2013 June 17.
Published in final edited form as:
Am J Geriatr Psychiatry. 2011 December ; 19(12): 1042–1045. doi:10.1097/JGP.0b013e318235b743.
NIH-PAAuthorManuscriptNIH-PAAuthorManuscriptNIH-PAAuthorManuscript

This study used data from the 2007 National Home and Hospice Care Survey (NHHCS) to
estimate rates of AD use in HHC patients and identify demographic, functional, and clinical
factors associated with AD use in this vulnerable patient population.
METHODS
Sample and Measures
The NHHCS sampled HHC patients who were scheduled for assessment interviews. Patient
data were collected through agency interviews and medical records. Our sample included
HHC patients aged 65 years or older; receiving Medicare postacute care for medical and
surgical reasons. We excluded hospice patients because of their different medical and
service needs.6
We classified medications as psychotropic if approved for psychiatric disorders treatment.
ADs included selective serotonin reuptake inhibitor, serotonin-norepinephrine reuptake
inhibitor, tricyclic antidepressant, and “Others,” which included bupropion, mirtazapine.
We classified psychotropic medications besides ADs into antipsychotics, including
phenothiazene antipsychotics, atypical antipsychotics, and miscellaneous antipsychotics;
mood stabilizers including lithium, valproate, lamotrigine, and carbamazepine; and other
psychotropic medications (other psychotropics) including benzodiazepines, miscellaneous
anxiolytics, sedatives, and hypnotics.
The NHHCS reported International Classification of Disease, 9th Revision, diagnoses (1
primary and up to 15 secondary) per patient. Diagnoses were included as part of the
physician referral. Among bipolar patients, only patients who had a depression episode were
included, and were grouped with the depressed. Medical comorbidity was represented by the
sum of International Classification of Diseases, Ninth Revision, Clinical Modification
categories and functional status was measured as total activities of daily living (ADL)
impairments. Sociodemographic factors included age, gender, race, Hispanic ethnicity,
marital status (married, divorced, single—never married), and living arrangements (lives
alone, lives with spouse, lives with other family members/children/parents, or nonfamily
members).
Statistical Analysis
We used a survey data analytic procedure (SAS Institute Inc., Cary, NC), which adjusted for
variance estimation using Taylor series. Rao-Scott χ2 for weighted survey data was used to
test categorical variables. Student's t-tests were conducted for continuous variables. A
multivariate logistic regression with AD use as the dependent variable included factors
significantly associated with AD use (p < 0.10) in the bivariate analysis.
RESULTS
Sample Characteristics
Analyses included 3,226 patients, representing 1,003,390 national patients. The study
population was predominately women (68.37%), average age 80.11 years (range: 65–100,
CI = 79.65–80.57). The sample included whites (82.45%), blacks (14.98%), Asians (1.62%),
Pacific Islanders, and American Indians (0.95% combined). Hispanic participants were
8.15%. Patients were primarily widowed (46.45%) or married (38.68%). Most patients lived
alone (35.09%) or with a spouse (32.00%).
The most common psychiatric diagnoses were depression (6.76%), dementia (4.00%), and
anxiety (3.18%). Psychotic disorders comprised the smallest portion of the overall sample
Weissman et al. Page 2

(0.29%), and neither dementia, anxiety nor psychotic disorders were associated with AD
use. Total number of psychiatric disorders ranged from 0 to 3 with a mean of 0.14 (CI =
0.12–0.17). Number of nonpsychiatric conditions ranged from 0 to 9 per patient with a mean
of 2.17 (2.09–2.25). Mean number of ADL impairments was 2.85 (CI = 2.76–2.94). Overall,
33.50% of patients used ADs and 3.40% were taking more than one AD. Among patients
taking ADs, the most commonly used was selective serotonin reuptake inhibitors (65.14%),
followed by tricyclic antidepressants (14.67%), serotonin-norepinephrine reuptake inhibitors
(11.34%), and other ADs (22.41%). The most common group of psychotropic medications,
besides ADs, was other psychotropics (30.15%). A small fraction received antipsychotics or
mood stabilizers. The total mean number of prescriptions was 10.67 (CI = 10.39–10.96) and
total mean number of nonpsychotropic medications was 11.09 (CI = 10.77–11.41)
suggesting that patients were taking medications without a reported prescription.
Factors Associated With AD Use
AD use was higher among patients with depression than those without (70.34% versus
28.71%). Sociodemographic factors that were significantly correlated with AD used
included black race with white (OR = 0.38, CI = 0.24–0.59) and younger age (t-test = –4.12,
df = 1, p < 0.0001). Clinical correlates included depression (OR = 5.45, CI = 3.20–9.30),
total psychiatric and nonpsychiatric disorders (t-test = 5.83, df = 1, p < 0.0001; t-test = 2.43,
df = 1, p = 0.01, respectively), and number of ADL impairments (t-test = 2.77, df = 1, p =
0.005) (mean number ADL impairments; AD users versus non-AD users: 3.03, SE = 0.07
and 2.75, SE = 0.05). AD use was associated with other psychotropic use (3.56, CI = 2.69–
4.72). Total number of prescriptions was higher among AD users (AD users 12.92, SE =
0.26 versus non-AD users 9.49, SE = 0.15). Total number of psychotropic medications and
nonpsychotropic medications were associated with AD use (t-test = 8.91, df = 1, p < 0.0001;
t-test = 7.23, df = 1, p < 0.0001, respectively).
The multivariate logistic regression found that black race and advanced age remained
significantly inversely associated with AD use. Other significant factors included
depression, ADL impairments, use of antipsychotrics and other psychotropics, and the total
number of nonpsychotropic medications (Table 1).
CONCLUSIONS
The major finding was that more than one-third of geriatric HHC patient used ADs. Use of
ADs varied systematically be sociodemographic and clinical factors even after controlling
for depression diagnoses. Among the subset with a chart diagnosis of depression, about 70%
were taking ADs. In contrast, earlier findings in the geriatric HHC population reported that
only 22% of patients who met a research depression diagnosis1 were receiving an AD. Rates
of AD use were also high (28.71%) among patients without a depression diagnosis. Whether
the high use of ADs among patients without a depression diagnosis represented the under-
reporting of depression, the initiation of ADs for past depressions that were not carried
forward or ADs prescribed for subthreshold symptoms or for indications other than
depression, cannot be ascertained.
Among sociodemographic factors, the higher use of ADs in whites compared with blacks,
after controlling for depression and other clinical factors, may reflect patient preferences,
differential access to care, provider differences.7 This racial difference in AD use may
reflect disparities in quality of mental healthcare, although the design cannot assess clinical
appropriateness. Regarding age, its inverse relationship between AD use may reflect a
tendency not to treat subthreshold depressive symptoms in the older adults.8

Among clinical factors, the positive relationship between total medications for
nonpsychiatric conditions and AD use, after controlling for depression diagnosis, may
reflect AD prescriptions for symptoms related to medical burden (e.g., fatigue, diminished
interest) that imitate clinical depression. Alternatively, providers who prescribe ADs may
tend to prescribe more medications overall. The association between ADs and
benzodiazepines may result from prescriptions written to reduce anxiety or sleep
disturbances frequently accompanying depression.
The NHHCS was limited by the reliance on medical records, which may fail to include
diagnoses because of transcription errors. Diagnoses may also get lost during patient
transitions.9 As with cross-sectional studies, causation and timing cannot be established.
Further investigation in longitudinal data could determine the timing and the circumstances
under which a physician writes the prescription.
Our study strength was the examination of the HHC population. HHC provides a window of
time in which patients are observed by HHC nurses, and in which the unmet healthcare
needs of the HHC patient can be addressed. HHC is also a service used by a broad sample of
the national population and represents an opportunity to address disparities in mental
healthcare. The use of the newly released NHHCS offered data from a broad population
sample of the HHC elderly, necessary to update the national patterns in AD use. These new
data indicated that AD use has become highly common in HHC patients, regardless of
depression diagnoses, and varied by sociodemographic, clinical, and functional factors. The
extent to which AD use in clinically appropriate is a question that needs to be addressed by
future research. Its importance is underscored by the sys tematic variation in ADs by
sociodemographic and clinical factors, even after controlling for documented depression.
Acknowledgments
Judith Weissman received support from the National Institute of Mental Health funded Tri-Site Collaborative
Training Program in geriatric mental health services research (T32 MH073553). Additional funding came from
NIMH (P30MH085943), Cornell ACISR in Late-Life Depression.
References
1. Bruce M, McAvay G, Raue P, et al. Major Depression in Elderly Home Healthcare Patients. Am J
Psychiatry. 2002; 159:1367–1374. [PubMed: 12153830]
2. Bao Y, Shao H, Peng T, et al. Diagnosed depression among Medicare home healthcare patients:
national estimates of prevalence and key profiles. Psych Services. 2011; 62:538–540.
3. Strothers HS III, Rust G, Minor P, et al. Disparities in antidepressant treatment in Medicaid elderly
diagnosed with depression. J Am Geriatr Soc. 2005; 53:456–461. [PubMed: 15743289]
4. Gonzalez HM, Croghan T, West B, et al. Antidepressant use in black and white populations in the
United States. Psychiatr Serv. 2008; 59:1131–1138. [PubMed: 18832498]
5. Melfi CA, Croghan TW, Hanna MP, et al. Racial variation in antidepressant treatment in a Med
icaid population. J Clin Psychiatry. 2000; 61:16–21. [PubMed: 10695640]
6. National Center for Health Statistics. 2007 National Home and Hospice Care Survey and National
Home Health Aide Survey Documentation. Hyattsville, MD: 2009.
7. Katz J. Patient preferences and health disparities. JAMA. 2001; 286(12):1506–1509. [PubMed:
11572745]
8. Gottfries CG. Is there a difference between elderly and younger patients with regard to the
symptomology and aetiology of depression? Int Clin Psychopharmacol. 1998; 13:13–18.
9. Brown EL, Raue PJ, Lodzanowski ME, et al. Transition to home care, quality of mental health,
pharmacy, and medical history information. Int J Psychiatry Med. 2006; 36:339–340. [PubMed:
17236701]

TABLE 1
Logistic Regression Modeling Any AD as a Dependent Variable and Black Race, Age, Total Number of ADL
Impairments, Depression, Other Psychotropics, Antipsychotic Use, and Total Number of Nonpsychotropic
Medications as Independent Variables
Independent Variables OR (CI) Wald χ2 (df) (p)a
Black race 0.41 (0.24-0.70) 10.26 (1) (0.0014)
Age 0.96 (0.94-0.98) 14.98 (1) (0.0001)
Total ADL impairments 1.15 (1.05-1.26) 10.01 (1) (0.0016)
Depression 4.78 (2.65-8.60) 27.20 (1) (<0.0001)
Other psychotropics use 2.63 (1.88-3.69) 31.85 (1) (<0.0001)
Antipsychotic use 2.08 (1.29-3.36) 9.05 (1) (0.0026)
Total number of nonpsychotropic medications 1.07 (1.04-1.10) 28.64 (1) (<0.0001)
a
Wald χ2 test for significance of independent variables in the logistic regression model.

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