European Journal of Clinical Pharmacology @ by Springer-Verlag 1979

Europ. J. clin. Pharmacol. 15,249-256 (1979)

Why Are Psychotropic Drugs Prescribed to Out-Patients? A Methodological Study U. Bergman, M. Dahlstr6m, C. Gunnarsson, and B. Westerholm Department of Clinical Pharmacologyat the Karolinska Institute, Huddinge University Hospital, National Corporation of Swedish Pharmacies, and District Health Centre of Ornsk61dsvik, Sweden

Summary. The prescription of psychotropic drugs at a multidoctor district health centre in northern Sweden in 1973, was analysed by means of problemoriented medical records. Of the 22,000 inhabitants of the district 10,700 consulted the health centre. Psychotropic drugs were prescribed for 11.3% of the patients, corresponding to 5% of the inhabitants of the area. Sixty per cent of the patients received one psychotropic prescription and 90% not more than three. Two-thirds of prescriptions were for women. Hypnotics, sedatives and minor tranquillisers constituted 64% of all prescriptions, major tranquillisers 24% and antidepressants 12%. One fifth of the patients obtained drugs belonging to more than one of the major psychotropic groups during the year. Insomnia, psychoneurosis and depression made up two-thirds of the indications for psychotropic drug therapy. More than thirty different psychotropic drugs were prescribed for the two major indications. There was considerable variation in how the different doctors prescribed drugs for the same indication. Fifty-nine different drug products were prescribed, of which the commonest five constituted more than half of the total number. Individual doctors used from 22 to 38 different psychotropic drugs.

Thus, it seemed of interest to study the grounds on which psychotropic drugs are used by means of information available at the District Health Centre in Ornsk61dsvik, Sweden, where a problem-oriented medical record system has been in use since 1971 [3].

Material and Methods Ornsk61dsvik is a town in northern Sweden of 60,000 inhabitants (Fig. 1). It has mechanical industry and a centre for trade and education. A county hospital in which 9 specialties, including psychiatry, are rep-

Sweden

Key words: prescribing habits, psychotropics; drug utilization, methodology

Over the past ten years there has been much controversy about the use of psychotropic drugs [1]. Analyses of sales data and prescriptions (e. g. see [2]) have given information about the extent and to which age groups the drugs are being used, but they have told us nothing about why the drugs are prescribed.

Fig. 1. The district of Ornsk6ldsvik is indicated on the map of Sweden (top right). The District Health Centre serves the inhabitants in the area marked on the map (bottom left)

0031-6970/79/0015/0249/$01.60

250

U. Bergman et al.: Out-Patient Prescription of Psychotropic Drugs

Table 1. Percentages of medical problems in males and females in

Table 3. Number of prescriptions of psychotropic drugs per patient

relation to the age and sex structure of the population under study Inhabitants n = 22,000

Problems n = 15,817

Age

%Men

%Women

%Men

%Women

0 -14 15-44 45-64 65-

10 21 12 6

10 21 13 8

4 18 13 8

4 23 18 13

49

51

42

58

100

100

Table 2. Number of prescriptions of hypnotics, sedatives, minor

No. of

Men

prescriptions

No.

1 2 3 4 5 6 7 8 9 10 11 12 13 14

and major tranquiUisers and antidepressants issued at Ornsk61dsvik health care centre 1973 related to total number of consultations (30,199) Drug

Hypnotics, sedatives and minor tranquillisers Barbiturates 140 Benzodiazepines 782 Antihistamines with sedative effects 150 Compounds 264 Others 79

No. of prescriptions

Per cent % of the number of consultations

1415

4.7

64

II

Major tranquillisers Phenothiazines 518 Butyrophenones 4 Others (lithium) 7

529

1.8

24

III

Tricyclic antidepressants

257

0.9

12

2,201

7.4

100

r e s e n t e d h a n d l e s half of t h e o u t p a t i e n t visits in t h e town. T h e r e m a i n i n g visits a r e t a k e n c a r e of b y g e n eral p r a c t i t i o n e r s at the D i s t r i c t H e a l t h C e n t r e s . A l t o g e t h e r twelve d o c t o r s w o r k e d at this c e n t r e in 1973, giving service to a b o u t 2 2 , 0 0 0 i n h a b i t a n t s . At each consultation doctors recorded the patient's i d e n t i t y n u m b e r , d a t e of visit, c o d e of d o c t o r , laboratory data and the different diagnoses or problems t h a t w e r e h a n d l e d . A c c o r d i n g to t h e d o c t o r ' s instruction a secretary coded the drugs prescribed, i n c l u d i n g t h e a m o u n t a n d dose, a n d l i n k e d this inform a t i o n with t h e d i a g n o s e s o r p r o b l e m s for w h i c h t h e

Women

Total

%

No.

%

No.

259 78 38 20 7 2 1 3 2

21.5 6.4 3.2 1.6 0.6 0.2 0.1 0.3 0.2

473 163 73 38 13 15 2 5 5 1 1 2

39.3 13.5 6 3.2 1.1 1.2 0.2 0.4 0.4 0.1 0.1 0.2

1

0.1 1

0.1

792

65.8

411

34.2

732 241 111 58 26 17 3 8 7 1 1 2 1 1

% 60.8 19.9 9.2 4.8 1.7 1.4 0.3 0.7 0.6 0.1 0.1 0.2 0.1 0.1

1,203 100

drugs w e r e i n t e n d e d . T h e i n f o r m a t i o n was t h e n t r a n s f e r r e d to a c o m p u t e r - b a s e d s y s t e m for f u r t h e r analysis. Thus, e a c h p a t i e n t visit r e v e a l e d o n e o r m o r e p r o b l e m s , e a c h w i t h its o w n d r u g t r e a t m e n t . T e l e p h o n e c o n s u l t a t i o n s h a v e b e e n i n c l u d e d in t h e s t u d y b u t n o t visits for c e r t i f i c a t i o n of h e a l t h o r as p a r t of t h e p r e v e n t i v e h e a l t h service. R e c o r d i n g of t h e d i a g n o s e s a n d s y m p t o m s was d o n e with a s h o r t e n e d v e r s i o n of t h e I n t e r n a t i o n a l C l a s s i f i c a t i o n of D i s e a s e s ( I C D , 8th r e v i s i o n 1965), a l r e a d y t e s t e d b y g e n e r a l p r a c t i t i o n e r s in S w e d e n [4]. T h e list i n c l u d e s o n l y 280 d i f f e r e n t d i a g n o s i s n u m bers, since d i a g n o s e s u n c o m m o n in o u t p a t i e n t c a r e have been grouped together.

Results

Patient Population D u r i n g 1973, 10,689 p a t i e n t s m a d e 19,376 visits (1.8 v i s i t s / p a t i e n t ) a n d p r e s e n t e d 15,817 p r o b l e m s (1.5 p r o b l e m s / p a t i e n t ) ( T a b l e 1). W o m e n , e x c e p t for t h e y o u n g e s t age g r o u p , p r e s e n t e d m o r e m e d i c a l p r o b l e m s t h a n m e n . I n a d d i t i o n 4,481 t e l e p h o n e c o n s u l t a tions w e r e r e c o r d e d .

Prescriptions P s y c h o t r o p i c drugs w e r e p r e s c r i b e d to 1,203 p a t i e n t s ( 1 1 . 3 % ) . This c o r r e s p o n d s to 5 % of t h e i n h a b i t a n t s . T h e n u m b e r of p r e s c r i p t i o n s was 2,201; h y p n o t i c s , sedatives and minor tranquillisers constituted 64%, major tranquillisers 24% and antidepressants 12%

U. Bergman et al.: Out-Patient Prescription of Psychotropic Drugs

251

T.h.'.~.~.~m_~2.g2.!5.:2.4.

I.A.-2syc.hone ~. s. rosi

dixyrazine

k

-

I

I~

-

ar~itriptyline

-

[

I

r

........

~

B.-- Pjjch2s2mat~d~orders.

psychon.eum_~ -

comb.sedative-spasmoly tic nortriptyline

~--

diazepam

~--

nitrazepam

~

C~..psychoneurosis I

I

! t

.......

I

comb, meprobamate J pentobarbital I-

-

~

fluphenazine

i

~

i

,

I

-

,

'

=

jan feb rnar apr may jun jul 'aug~sep~oct 1973

-m .....

nov de

mar 1974

,

jun

T w o _w.ome.n and .o n.e_ m an .a.ge 6 5 . - : . .

.D.'_._Es..Y&h_o.n2uros2s., levomep romazine ~

di~'~zepam

barbiturates

~--

fluphenazine thioridazine

dixyrazine

L

I

nitrazepa

i

i

m

~:_~sc.h.emi.c he.art d.i222s_e.,_i..nso.mni2, P2~cho=neur°s_i..s. diazepam ~

nitrazepam pentobarbita

~__._~_~

T

]

~

i

~

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,

fluphenazine

:.L _P..sY.~_h_o.n_~.~.r2s2s. diazepam

fluphenazine levomepromazine

=

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oxazepam ~

_

- ~--

I : jan ' feb 'mar ' apr 'may ' jun ' jul ~' aug' sep' oct ' nov 1973

'

dec

'mar ' 1974

(Table 2). Twenty-five per cent of the hypnotics, sedatives and minor tranquillisers were prescribed by telephone; corresponding figures for the m a j o r tranquillisers were 3 0 % and for antidepressants 21%. The n u m b e r of prescriptions of psychotropic drugs per patient varied from one to fourteen, with an average of 1.8 per patient (Table 3). Sixty per cent of the patients obtained just one prescription and 9 0 % not m o r e than three during the year. Six patients (0.5%) with ten or m o r e psychotropic prescriptions (Fig. 2) were b u r d e n e d with serious medical, psychological or social problems. W o m e n were predominant, except in the youngest age group (Fig. 3).

jun

Fig. 2. Prescribed daily dose versus amount prescribed in six patients (A-E) with ten or more prescriptions for psychotropicsin 1973. Five of the six patients were well known psychotropic drug consumers. Four of them had a serious somatic diagnosis, e. g. cardiac anomaly, malignant tumour etc. The 6th patient, affected by religious brooding, was in her usual state after about one year of treatment, Apart from psychotropicsobtained during holidays (A, B), the same doctor in the district centre was responsible for all the prescriptions for each patient. In contrast to fluphenazine, the utilization of meprobamate/ pentobarbital was twice the prescribed daily dose in patient C. Patient E shared his hypnotic/sedatives with his housekeeper. D. E and F also obtained psychotropics from the hospital in 1973

Twenty-seven per cent (320/1,203) of the patients received a prescription for m o r e than one psychotropic drug during the year, 14% (168/1,203) at the same consultation. The most frequent combination was hypnotics, sedatives and minor tranquillisers with m a j o r tranquillisers (Table 4).

Indications for Psychotropic Drugs Fifty-one per cent of all psychotropics were prescribed for symptoms (according to I C D ) , 4 8 % for defined indications and 1% for " n o diagnosis". Insomnia and depressio mentis are both classified as symptoms. Of the defined indications mental disturb-

252

U. Bergman et al.: Out-Patient Prescription of PsychotropicDrugs

No prescriptions per 100 men and women ~ respectively

3O"

I

III

1oo

r

8o

eo

_1

4~

ee

0-14 15-44 45-64

65-

0"14 15-44 45-64

65-

0-14

4, Numberof patients who receivedpsychotropicdrugsfrom more than one of the followinggroups: hypnotics,sedatives, and minor tranquillisers (I), major tranquillisers (II) and antidepressants (III) during 1973a

Table

Combinations Numberof patients with of groups prescnptionsissued at The s a m e consultation

I + I + H + I +

II ~I III H + ~I

Toml

li

15-44 45-64

AGE

Total

Different consuItations

65-

Fig. 3. Number of prescriptionsof hypnotics,sedatives, and minor tranquillisers(I), major tranquillisers (includinglithium) (II), and tricyclicantidepressants (III) issuedper 100 men and women,respectively,in differentage groups at the districthealth centre of ~3rnsk61sdsvikin 1973 (hatchedbars). The data have been comparedwith informationobtained from a continuous nationwideprescriptionsurveyin 1976 [6] (open bars)

both hypnotics, sedatives and minor tranquillisers (Table 5) and major tranquillisers (Table 6). Depressio mentis and psychoneurosis were the principal indications for prescribing antidepressants (Table 7). For almost all indications women obtained more prescriptions (Tables 5, 6, 7). They also consulted the centre more often and presented more problems (Table 1).

Men Women Men Women Men Women

Prescribing Patterns of Doctors

19 18 1

46 25 2 10

15 8 1 t

39 14 8 7

34 26 1 2

85 39 10 17

38

83

25

68

63

151

Seventy-two per cent of the psychotropics was prescribed by four specialized permanent doctors, 26% by four junior doctors under training and 2% by four temporary junior locums. There was considerable variation in the prescribing pattern of the different doctors (Fig. 4). For the two major problems, insomnia and psychoneurosis, there were differences in preference for drugs such as benzodiazepines, antihistamines and major tranquillisers (Fig. 5). In all 33 and 35 different psychotropic drugs, respectively, were prescribed for these two major problems. The specialized doctors used about twice as much barbiturates, slightly more combinations and major tranquillisers and less benzodiazepines for sleeping disturbances (insomnia) than the junior doctors. On the other hand, the specialized doctors used more benzodiazepines and less major tranquillisers for psychoneurosis. On the whole, the latter used more combinations than their younger colleagues. Fiftynine different drugs (generics) were prescribed, of which the most common five constituted more than half of the total [5]. The individual doctors each prescribed from 22 to 38 different psychotropic drugs.

121

93

214

a Further I 0 6 patients obtained m o r e than one psychotropic drug from the same group, the most c o m m o n (97 patients) being hypnotics, sedatives and m i n o r tranquiltisers prescribed to 43 patients at t h e s a m e consultation.

ances (including psychoneurosis) comprised 29%, circulatory disorders 6%, and musculo-skeletal disorders and diseases in the nervous system 3%. Fourteen per cent of the problems resulted in prescription of a psychotropic, 9% in a hypnotic, sedative and minor tranquilliser, 3% in a major tranquiIliser and in less than 2% in an antidepressant. Insomnia, psychoneurosis and depressio mentis made up two-thirds of all (2,201) the psychotropics issued and were the main reasons for prescribing

U. Bergman et al.: Out-Patient Prescription of Psychotropic Drugs

Average Prescribed Daily Doses The average prescribed daily dose of the four major drugs has been analysed (Table 8). There was wide variation in dosage, both among those recommended by the manufacturers and those actually prescribed. The low levomepromazine dosage is in agreement with the high use of major tranquillisers in the treatment of psychoneurosis (Table 6).

Discussion

The population in this district of Ornsktldsvik is reasonably representative of Sweden in terms of age and sex. However, the use of psychotropic drugs, according to sales figures, was only about 55% of the Swedish average during 1975-1977, and 80% of sales in the northern region. Sales figures of psychotropics have been very stable in Sweden during the 1970s [6]. Although the prescribing figures are not entirely comparable with those obtained from a nationwide prescription survey [6], it is evident (Fig. 3) that this study represents an area with low prescribing of psychotropics. The low figures are not due to methodological errors. In 1972 the error rate in registration was found to be low; about 0.1% of the patient identifications and 0.5% of the diagnoses were missing [3]. In this study, sample tests of various drug-related parameters suggested an error rate of approximately 3%. Only about 10% of the telephone consultations were not recorded, as compared to almost one third in 1972 [3]. The majority of prescription surveys contain only information on the drug, age and sex of the patient. An exception is the Australian survey conducted by the drug industry and an university department, in which physicians recorded their reasons for prescribing drugs for from one week up to a year [7]. In 1974 they found that benzodiazepines were most commonly prescribed for anxiety neurosis, tension headache, transient situational disturbances and, to some extent, other mental disorders; 37% of prescriptions were written for other diseases, such as hypertension, heart disease, migraine, arthritis and duodenal ulcer, as part of the management of associated anxiety. Tricyclic antidepressants were most commonly prescribed for depressive neurosis and phenothiazines for psychosis [7]. In the present survey, insomnia, psychoneurosis and depressio mentis made up two-thirds of the 94 different indications stated for hypnotics, sedatives and minor tranquillisers, and surprisingly also for all psychotropics. If psychoneurosis and insomnia were

253 Table 5. Indications (ICE)) and percentage of prescriptions for hypnotics, sedatives and minor tranqui[[isersgiven to women at the district health centre 1973 (n = number of prescriptions) Indication

per cent (n = 1,415)

per cent women (n = 946)

Insomnia Psychoneurosis Depressio mentis Nervousness Benign essential hypertension Climacteric disorders Psychosomatic disorders Epilepsy Symptomatic heart disease No diagnosis

40.4 20.5 5.2 2.7 2.3 2.0 1.8 1.7 1.5 1.2

Other diagnoses (11-94)

79 21

69 58

100

67

Total

69 71 55 74 82 100 64 54 67 56

Table 6. Indications (ICD) and percentage prescriptions for major tranquillisers given to women at the district health centre 1973 (n = number of prescriptions) Indication

per cent (n = 529)

per cent women (n = 376)

Psychoneurosis Insomnia Depressio mentis Nervousness Ohther symptoms, unspecified Headache, unknown ethiology Benign essential hypertension Gastritis Climacteric disorders Eczema

30.4 22.9 4.7 3.2 3.1 2.5 2.1 2.0 1.5 1.5

Other diagnoses (11-68)

74 26

74 64

100

71

Total

78 76 84 71 59 62 36 50 100 50

Table 7. Indications (ICD) and percentage of prescriptions for antidepressant drugs (tricyclic) given to women at the district health centre 1973 (n = number of prescriptions) Indications

per cent (n = 257)

per cent women (n = 181)

Depressio mentis Psychoneurosis Manic-depressive psychosis

51.8 32.3 5.8

Other diagnoses (4-24)

90 10

70 73

100

70

Total

62 77 100

U. Bergman et al.: Out-Patient Prescription of Psychotropic Drugs

254 Type of doctor

No

Specialized--] general |

1

489

practiti°ner 132

Specialized internist ~ Junior doctors under training

340299

4

463

5

76

6

107

7

233

8

157

Temporary 9-12 junior substitutes Total

12

100

ii

Total

No o f telefone prescriptions in

%

IIIIEIIEII JrlIII[I!II3s M

37

IIIIHIIIIIIIIM III]IIIHII[II124

20

Nlfl/illr/ [Irlrl//I , s N

26

NIIflOJJI[fllIIlt }IIJElllJIIIIII35N

24

r

HII

Illll,llll. ..rlllllll ,,

[]

IllrillllllllNlllllllllll

2201

total

16

Ill/ilIlllllllillllllllllll:,5k a= l Illlll/llll lrllllllll IN II.ll[llIlllllilllrllll[ll[ ,s IN I " IIl,lrlll lllllllll o H

37

~; o f

23 27 18

Fig. 4. Prescription pattern of psychotropic drugs by individual doctors. Hypnotics, sedatives and minor tranquillisers: vertical lines, major tranquillisers (including lithium): white, and antidepressants: horizontal lines. Telephone prescriptions (%) within each group of drugs are denoted in the bars

3

IN

26

I I 210 I ,410 I 610 I 130 I I~

Junior doctors under training. Specialized doctors doctor

80' 60. 40. 20'

insomnia [ ] psychoneurosis [ ]

~

n =92

2

2 20 40 60 80 60 40 20

~

~

n :21

n=148

n =153

0

60 4O 20 20

1~213|41515171819 I10111[ 20. 40 60 80 50 40

doctor

4@ 20-

~ n = 49

11213

6

ll213

617

t

20. 20 40 60. 80. 6O 40 2O

n = 64

n =164

4 20 4O 60 80

n = 112

1011

6O806O40-

n =144

3

7

40 60 80 60

20 20 40 60 811

as f r e q u e n t as indications for m a j o r tranquilliser use in o t h e r parts of the country, this would explain the relatively high use of these drugs in Sweden as c o m p a r e d to o t h e r N o r d i c countries [2]. This is in agreem e n t with an earlier r e c o m m e n d a t i o n in Sweden of m a j o r tranquillisers as the drug of choice in m i n o r psychiatric disturbances [8]. Tricyclic antidepressants were used for fairly nonspecific psychiatric diagnoses, which was also r e p o r t e d in the A u s t r a l i a n survey [7]. In the present

0

n o 18 Fig. 5. Prescription patterns of individual doctors for insomnia (above) and psychoneurosis (below) divided between eleven groups of minor psychotropics: n. 25 1. Barbiturates (phenobarbital etc.) 2. Piperidinedione derivatives (gluthethimide etc.) n =32 3. Propanediol derivatives (meprobamate etc.) 4. Benzodiazepines (diazepam etc.) 5. Alcohols and aldehydes (chloral n 60 hydrate etc.) 5. Antihistamines with sedative effects n =52 (promethazine etc.) 7. Other hypnotics, sedatives and minor tranquillisers (methaqualone, n - 28

a =5s

clomethiazole etc.) 8. Combinations (sedatives/stimulants/ spasmolytics) 9. M a j o r tranquillisers (phenothiazines, butyrophenons) 10. Lithium 11. Antidepressants (amitriptyline etc.) 100% = n

study we c o m p a r e d doses r e c o m m e n d e d for treatm e n t of depression with those actually prescribed. T h e m e a n doses prescribed (amitriptyline 6 2 m g , nortriptyline 47 m g ) c o r r e s p o n d e d to those found in a continuous individual prescription survey in the county of Jfimtland [9], but they w e r e far b e l o w the effective dose (150 mg) suggested for t r e a t m e n t of depressive disorders [10]. T h e low doses used in O r n sk61dsvik were p r o b a b l y due to the fact that antidepressants were prescribed for non-specific indica-

u. Bergman et al.: Out-Patient Prescription of PsychotropicDrugs tions. Possibly the more severely ill psychiatric patients were referred to the hospital. Interestingly, lithium was rarely prescribed, which indicates that this potentially toxic drug was mainly used by specialists. The efficacy of drug treatment is normally determined in controlled clinical trials, in which one drug is compared with another drug or a placebo. In clinical practice, however, multiple drug therapy is common. In the year 1973 about one-fifth (214/1,203) of our patients obtained drugs from more than one of the groups of major psychotropic drugs, 121 at the same consultation (Table 4). In an ongoing prescription study in Prague, Czechoslovakia, several different combinations of psychotropic drugs were found on the same prescription for patients with a psychiatric diagnosis [11]. In Finland at least half of the psychiatric patients obtained more than one psychotropic drug at the same time, a practice of polypharmacy that lacks support from controlled clinical trials [12]. To what extent the prescribed drugs were purchased [13] or taken by the patients [14] or others (cf Fig. 2E) is not known, but they are important questions to follow up together with an evaluation of therapeutic outcome. Although this study only comprised patients who saw doctors at one district health centre, the problems they presented and the drugs prescribed gave useful information to the prescribing doctors, to the local drug committee and to some extent also to the

drug regulatory authorities. For the prescribing doctorit is important to follow why he prescribes various drugs. In this study, prescription of psychotropic drugs does not seem to have been broadened to somatic diseases or social conflict situations to any great extent, as was claimed to be the case in Finland [15] and Australia [7]. However, behind the "depression" or "insomnia", more subtle problems might be hidden, for which other means to solve the underlying cause might be better. Another important finding was that each doctor had prescribed 22-38 different drugs. Moreover, more than thirty different psychotropic drugs had been prescribed for one and the same problem, which makes it difficult for the individual physician to gain experience in the pharmacological profile of various drugs. Furthermore, the lack of accurate methods for estimating the clinical effects contributes to the overflow of indistinguishable drugs on the market [16], and thus also to the large number of different drugs prescribed. Follow-up of one's own prescribing may lead to changes in prescribing behaviour. A general practitioner in Norway, in patients with high consumption

255 Table 8. Average daily dose for the four most commonlyprescribed psychotropic drugs in 1973 at the district health centre. Figures within parenthesis denote total number of prescriptions Average prescribed Daily dose (in adults)°

Average daily dose suggested by manufacturer median range (FASs,1973)

Hypnotics, sedatives and minor tranquillisers Diazepam (216) Nitrazepam (402)

7.6rag 5 mg 2-30 4-15 5.0 mg 5 mg 2.5-10 2.5-10

Major tranquillisers Levomepromazine (200) 13.4 mg 10 mg

5-75

5-20 a

Antidepressants Amitriptyline (160)

62.3 mg 75 mg 20-150 25-100b

a dosage in the treatment of psychoneurosis b maintenancedosage c if variable, the higher dose has been used

of drugs, found that his lack of overview of the patients' total medication contributed to the high use [17]. The doctors at the health care centre have been informed about the results in this study, but we do not know yet to what extent this may have influenced their prescribing behaviour. In agreement with the findings in the county of Jfimtland, Sweden [18], prescription of psychotropic drugs is an important part of the work of a general practitioner. Post-graduate training in psychopharmacology seems to be necessary for this group of doctors. For the local drug committee it is important to know which drugs are being used in an area, and for what reasons, in order to obtain drug lists adjusted to clinical practice. Information from a study like this could lead to stricter recommendations. Since 59 different drugs were used, and only five drugs were responsible for 50% of the prescriptions, a reduction in the number of drugs used in the area would benefit both patients and doctors. In Sweden the drug regulatory agency has continuous access to drug utilization data (sales and prescription figures). However, the figures are difficult to interprete without knowledge of how the drugs are prescribed, i. e. to whom, by whom and why. Even if the data in the present survey were not representative of the country as a whole, they do give some ideas about how psychotropic drugs are prescribed in out-patient care. A future study, starting in the autumn of 1978, and comparing a representative sample of Swedish doctors, who will record the reasons for drug prescribing, might tell which method

256

U. Bergman et al.: Out-Patient Prescription of Psychotropic Drugs

s h o u l d b e u s e d to b e s t satisfy, t h e n e e d s of i n t e r e s t e d parties. Of even greater interest, however, would be a s t u d y of t h e t h e r a p e u t i c effect o f p s y c h o t r o p i c d r u g s r e l a t i v e t o t h e use of n o n - p h a r m a c o l o g i c a l methods of treatment.

7. The Australian general practice morbidity and prescribing survey 1969 to 1974. The Royal Australian College of General Practitioners. Med. J. Austr. Special Suppl. 2, 5-28 (1976) 8. Sedvall, G.: Kliniskt-farmakologiskaaspekter p~ f6rskrivning av sedativa-hypnotika. L/ikartidningen 69, 1373-1377 (1972) 9. Boethius, G., Sj6qvist, F.: Doses and dosage intervals of drugs - clinical practice versus pharmacokinetic principles. Clin. Pharmacol. Ther. 24, 255-263 (1978) 10. Asberg, M.: Treatment of depression with tricyclic drugs pharmacokinetic and pharmacodynamic aspects. Pharmacopsychiatry 9, 18-26 (1976) 11. Vinar, O., Stikfi, L.: Drug combinations prescribed by physicians in Prague 6 for psychiatric diagnoses. Act. Nerv. Super. 14, 85 (1972) 12. Hemminki, E.: Polypharmacy among psychiatric patients. Acta Psychiatr. Scand. 56, 347 (1977) 13. Boethius, G., Westerholm, B.: Purchases of hypnotics, sedatives and minor tranquitlisers among 2566 individuals in the county of J~imtland, Sweden. A 6-year follow-up. Acta Psychiatr. Scand. 56, 147-159 (1977) 14. Bergman, U., Sj6qvist, F., S6derhielm, L.: Use of digoxin in a low density population area in Sweden. Europ. J. clin. Pharmacol. 10, 19-24 (1976) 15. Hemminki, E.: General Practitioners Indications for Psychotropic Drugs. Scand. J. Soc. Med. 2, 79-85 (1974) 16. Nngg~rd, E.: Effektregistrering vid klinisk l~ikemedelspr6vning - behov av f6rbfittrade metoder. I: Klinisk L~ikemedelspr~ivning. 1978: I Socialstyrelsens kommitt6 f6r l~ikemedelsinformation 17. Fugelli, P.: Bruk av legemidier pfi Vaeroy og Rost. OsloBergen-Tromso: Universitetsforlaget 1977 18. Bergstr6m, K., Westerholm, B.: Consumption of sedatives, hypnotics and minor tranquillisers in a Swedish town. Psychiatry. Proceedings of the V. World Congress of Psychiatry, Mexico, D. F., Nov. 25 - Dec. 4, 1971, pp. 94-102. Part I. Amsterdam: Excerpta Medica 1971

W e a r e m o s t g r a t e f u l t o t h e staff at t h e district h e a l t h c e n t r e of Ornsk61dsvik, a n d p a r t i c u l a r l y to U l l a W e s t m a n for h e r k i n d c o o p e r a t i o n . The study was supported by the Arbetsmarknadsstyrelsen (AMS) and from the Karolinska Institutet (funds). S j u k v f i r d e n s o c h socialvglrdens p l a n e r i n g s och r a t i o n a l i s e r i n g s i n s t i t u t (Spri) a n d V f i s t e r n o r r l a n d s L/ins L a n d s t i n g a r e also a c k n o w l e d g e d . Acknowledgement.

Reterences

1. Allgulander, C.: Dependence on Sedative and Hypnotic Drugs. A Comparative Clinical and Social Study. Acta Psychiatr. Scand. Suppl. 270 (1978) 2 a. Grimsson, A., Id~inpfi~in-Heikkil~i,J., Lunde, P. K. M., Olafsson, O., Westerholm, B.: F6rbrukningen av psykofarmak i Finland, Island, Norge och Sverige. Nord. Med. 92, 49-54 (1977) 2b. Gfimsson, A., Idiinp~ifin-Heikkil~i,J., Lunde, P. K. M., Olafsson, O., Westerholm, B,: The utilization of psychotropic drugs in Finland, Iceland, Norway and Sweden. In: Drug Utilization Studies - methods and applications. U. Bergman, A. Grimsson, B. Westerhotm (eds.). Copenhagen: WHO Regional Publications, European Series. In wess (1978). 3. Gunnarsson, C., Maaths, G.: Produktionsredovisningvid Ornsk61dsviks l~ikarstation. Spri rapport 3/74 (Stockholm 1974) 4. Provisofisk diagnoskod f6r 6ppen v~rd. Socialstyrelsens PB 3 (1970) 5. Bergman, U., Gunnarsson, C., Westerholm, B.: F6rskrivning av psykofarmaka vid en flerNkarstation. L~ikartidningen 74, 244-246 (1977) 6. Boethius, G., Westerholm, B.: Psykofarmakaf6rbrukningen i Sverige under 1970-talet. Sven. Farm. Tidskr. 81, 289-295 (1977)

Received: July 31, 1978, accepted in revised form: November 27, 1978 U. Bergman, M. D. Department of Clinical Pharmacology Huddinge University Hospital S-14186 Huddinge/Sweden