Initiation of psychotropic medication after partner bereavement: a matched cohort study

Abstract

Background: Recent changes to diagnostic criteria for depression in DSM-5 remove the bereavement exclusion, allowing earlier diagnosis following bereavement. Evaluation of the potential effect of this change requires an understanding of existing psychotropic medication prescribing by non-specialists after bereavement.

Aims: To describe initiation of psychotropic medication in the first year after partner bereavement.

Methods: In a UK primary care database, we identified 21,122 individuals aged 60 and over with partner bereavement and no psychotropic drug use in the previous year. Prescribing (anxiolytic/hypnotic, antidepressant, antipsychotic) after bereavement was compared to age, sex and practice matched controls.

Results: The risks of receiving a new psychotropic prescription within two and twelve months of bereavement were 9.5% (95% CI 9.1 to 9.9%) and 17.9% (17.3 to 18.4%) respectively; an excess risk of initiation in the first year of 12.4% compared to non-bereaved controls. Anxiolytic/hypnotic and antidepressant initiation rates were highest in the first two months. In this period, the hazard ratio for initiation of anxiolytics/hypnotics was 16.7 (95% CI 14.7 to 18.9) and for antidepressants was 5.6 (4.7 to 6.7) compared to non-bereaved controls. 13.3% of those started on anxiolytics/hypnotics within two months continued to receive this drug class at one year. The marked variation in background family practice prescribing of anxiolytics/hypnotics was the strongest determinant of their initiation in the first two months after bereavement.

Conclusion: Almost one in five older people received a new psychotropic drug prescription in the year after bereavement. The early increase and trend in antidepressant use after bereavement suggests some clinicians did not adhere to the bereavement exclusion, with implications for its recent removal in DSM-5. Family practice variation in use of anxiolytics/hypnotics suggests uncertainty over their role in bereavement with the potential for inappropriate long term use.

Figure 1. Proportion of Patients in Receipt of Psychotropic Medication in the Year Before and After Bereavement.

Blue: All Bereaved (n = 29,548) Green: All Non-Bereaved (n = 80,471) Red: Bereaved without psychotropic medication in year before bereavement (n = 21,122) Purple: Non-Bereaved without psychotropic medication in year before bereavement (n = 59,280) Daily percentages are based on a denominator of patients still registered on that day.

Figure 2. Probability of Initiation (%) of Psychotropic Drugs in the Year after Bereavement in Bereaved (B) and Non Bereaved (NB) Patients.

Initiation probabilities during the first year after bereavement are derived from Kaplan Meier estimates and divided into the following periods Light Grey: 6–12 months Medium Grey: 2–6 months Dark Grey: 0–2 months.