Multimorbidity and use of hypnotic and anxiolytic drugs: cross-sectional and follow-up study in primary healthcare in Iceland

Abstract

Background: The prevalence of multimorbidity is increasing worldwide, presumably leading to an increased use of medicines. During the last decades the use of hypnotic and anxiolytic benzodiazepine derivatives and related drugs has increased dramatically. These drugs are frequently prescribed for people with a sleep disorder often merely designated as "insomnia" in the medical records and lacking a clear connection with the roots of the patients' problems. Our aim was to analyse the prevalence of multimorbidity in primary healthcare in Iceland, while concurrently investigating a possible association with the prevalence and incidence of hypnotic/anxiolytic prescriptions, short-term versus chronic use.

Methods: Data were retrieved from a comprehensive database of medical records from primary healthcare in Iceland to find multimorbid patients and prescriptions for hypnotics and anxiolytics, linking diagnoses (ICD-10) and prescriptions (2009-2012) to examine a possible association. Nearly 222,000 patients, 83 % being local residents in the capital area, who contacted 16 healthcare centres served in total by 140 general practitioners, were set as a reference to find the prevalence of multimorbidity as well as the prevalence and incidence of hypnotic/anxiolytic prescriptions.

Results: The prevalence of multimorbidity in the primary care population was 35 %, lowest in the young, increasing with age up to the 80+ group where it dropped somewhat. The prevalence of hypnotic/anxiolytic prescriptions was 13.9 %. The incidence rate was 19.4 per 1000 persons per year in 2011, and 85 % of the patients prescribed hypnotics/anxiolytics were multimorbid. Compared to patients without multimorbidity, multimorbid patients were far more likely to be prescribed a hypnotic and/or an anxiolytic, OR = 14.9 (95 % CI = 14.4-15.4).

Conclusions: Patients with multiple chronic conditions are common in the primary care setting, and prevalence and incidence of hypnotic/anxiolytic prescriptions are high. Solely explaining use of these drugs by linear thinking, i.e. that "insomnia" leads to their prescription is probably simplistic, since the majority of patients prescribed these drugs are multimorbid having several chronic conditions which could lead to sleeping problems. However, multimorbidity as such is not an indication for hypnotics, and doctors should be urged to greater caution in their prescribing, bearing in mind non-pharmacological therapy options.

Keywords: Anxiolytics; Chronic health problems; Hypnotics; ICD-10; Insomnia; Multimorbidity; Multiple chronic conditions; Primary care.

Fig. 1

Proportion of incident patients issued one, 2–4 or 5+ prescriptions. The proportion of incident patients in the primary healthcare stratified by age who were prescribed hypnotics/anxiolytics for the first time in 2011 (no prior prescriptions for 24 months) grouped according to number of prescriptions during a 12 month period

Fig. 2

Diagnostic patterns among multimorbid incident patients. Distribution of mental diagnoses, pain related diagnoses and other diagnoses in multimorbid patients who initiated use of hypnotics/anxiolytics in 2011, orderd by diagnoses and either one time use (1), intermittent use (2–4) or regular use (5+)

Fig. 3

Number of patients prescribed hypnotics and/or anxiolytics. Patients prescribed hypnotics/anxiolytics according to age and number of chronic conditions

Fig. 4

Odds ratios for being prescribed hypnotics and/or anxiolytics. The ORs with 95 % CIs for the likelihood of a hypnotic and/or an anxiolytic being prescribed for patients with multimorbidity according to age and sex