by Elisa Cascade; Amir H. Kalali, MD; and Uriel Halbreich, MD
Ms. Cascade is Vice President, Quintiles Inc./iGuard, Falls Church, Virginia; Dr. Kalali is Vice President, Global Therapeutic Group Leader CNS, Quintiles Inc., San Diego, California, and Professor of Psychiatry, University of California, San Diego; and Dr. Halbreich is Director, Biobehavior Research, Professor of Psychiatry and OB/GYN, SUNY, WPA Section on Interdisciplinary Collaboration, Buffalo, New York.
Psychiatry (Edgemont) 2008;5(12):14–15
Because of limitations in diagnosis coding, it is difficult to determine which products are used to treat premenstrual dysphoric disorder. To better understand treatment of premenstrual dysphoric disorder, we examined the antidepressant prescribing behavior of obstetrician/gynecologists as a marker for premenstrual dysphoric disorder treatment and compare these use patterns to psychiatrists and primary care physicians. Over the past quarter, only three percent of antidepressants were prescribed by obstetrician/ gynecologists as compared to 51 percent by primary care physicians and 20 percent by psychiatrists. Obstetrician/ gynecologists more frequently use selective serotonin reuptake inhibitors (69% compared to 58% in primary care and 48% in psychiatry) and are more likely to choose an selective serotonin reuptake inhibitors agent indicated for the treatment of premenstrual dysphoric disorder (e.g., fluoxetine, paroxetine, sertraline): 66 percent versus 59 percent for both primary care physicians and psychiatrists. Use of desvenlafaxine was slightly elevated in obstetrician/ gynecologists as compared to primary care physicians (0.3% vs. 0.1% of total antidepressants, respectively); however, psychiatrists prescribed more desvenlafaxine than either group: 0.4 percent of total antidepressant prescriptions. Discussion of this data is provided.
premenstrual dysphoric disorder, PMDD, SSRI, SNRI, antidepressant, psychiatry, OB/GYN, PCP
Because of limitations in diagnosis coding, it is difficult to determine which products are currently used to treat premenstrual dysphoric disorder (PMDD). To date, the selective serotonin reuptake inhibitor (SSRI) antidepressants (e.g., fluoxetine, paroxetine, sertraline) are the only products indicated for PMDD treatment. However, the serotonin-norepinephrine reuptake inhibitor (SNRI) desvenlafaxine is currently being studied in the treatment of hot flashes. To better understand treatment of PMDD, we examined the antidepressant prescribing behavior of obstetrician/ gynecologists (OB/GYNs) as a marker for PMDD treatment and compare these use patterns to psychiatrists and primary care physicians (PCPs).
We obtained data on total retail prescriptions for antidepressant medications in June, July, and August of 2008 from SDI/Verispan’s Vector One National (VONA), which captures nearly half of all prescription activity in the US.
Over the past quarter, only three percent of antidepressants were prescribed by OB/GYNs FIGURE 1. PCPs account for 51 percent of antidepressants prescribed and psychiatrists for an additional 20 percent.
FIGURE 2 displays the mix of therapeutic classes prescribed by physician specialty. As seen in FIGURE 2, OB/GYNs more frequently prescribe SSRIs (69%) relative to PCPs (58%) and psychiatrists (48%). With respect to individual SSRI selection, OB/GYNs are more likely to prescribe an agent indicated for the treatment of PMDD (e.g., fluoxetine, paroxetine, sertraline): 66 percent versus 59 percent for both PCPs and psychiatrists. Use of desvenlafaxine was slightly elevated in OB/GYNs as compared to PCPs (0.3% vs. 0.1% of total antidepressants, respectively); however, psychiatrists prescribed more desvenlafaxine than either group: 0.4 percent of total antidepressant prescriptions.
Premenstrual syndromes (PMS) and PMDD are interdisciplinary disorders that present with diversified clusters of symptoms. Women sufferers may seek treatment with their PCP, OB/GYN, or psychiatrist. Not surprisingly, the data from SDI/Verispan’s VONA confirm that the woman-patient’s entry point to the medical healthcare system substantially influenced the treatment prescribed to her. While a psychiatrist and a PCP would probably prescribe an antidepressant as the first line of treatment for PMDD, an OB/GYN would very rarely prescribe antidepressants.
Though the VONA data presented here do not specify it, it is plausible that OB/GYNs would prescribe more hormonal interventions, mostly oral contraceptives (OC), which are widely used, with at least one OC having an indication for PMDD.
So far, none of the medications indicated for PMDD have been shown to be effective for more than 60 percent of women sufferers. The reasons for this efficacy ceiling are intriguing and should be addressed. The main reason for the relatively weak response rate is probably the lack of precise, widely accepted, multidisciplinary, diagnostic criteria. This leaves much flexibility to the practitioner to prescribe according to his or her clinical orientation, beliefs, and traditions, as opposed to prescribing based on evidence. The lack of accepted knowledge on syndromal subgroups of PMS further contributes to imprecise treatments. Hopefully these issues will be rectified in the near future.