Multi-morbidity and polypharmacy among depressed elderly: implementation of research findings in general and pharmaceutical practice

medication depression

F. Holvast
Prof. dr. P.F.M. Verhaak

Nature of the research:
Qualitative study among GPs, pharmacists, vocational training students family practice

Fields of study:
pharmacology GP medicine

Background / introduction
Depression at older age often coincides with other chronic morbidity.(1)( (2) (3, 4). The most frequently occurring combinations are depression together with hypertension, arthritis, diabetes, COPD/Asthma, stroke, cancer, heart failure or heart disease (4). This results in diagnostic and treatment problems in general and in problems with medication specifically.
Multi-morbidity goes together with poly-pharmacy. Calderon-Larranaga et al. identified seven patterns of poly-pharmacy, among which a depression-anxiety pattern, which is the most occurring pattern among men and women above 65 years. Within this pattern a wide range of drugs can be observed, among which, besides of course different kinds of psychopharmacological drugs, also drugs for peptic ulcer, laxatives, iron preparations, capillary stabilizing agents and cardiac glycosides (5).

The above-mentioned has been translated in to a project ‘multi-morbidity and polypharmacy among older adults with depression in primary care’. We found that depressed patients had a 16% (95% CI 10-24%) higher rate of chronic somatic diseases and had higher odds for multi-morbidity (OR 1.55; 95% CI 1.33-1.81) compared to mentally healthy controls (6). Compared to mentally healthy controls, depressed patients had a 46% (95% CI 39-53%) higher rate of chronically used drugs and had higher odds for polypharmacy (OR 2.89; 95% CI 2.41-3.47).

Further analysis, aimed at specific chronic somatic diseases, learned that the effects were especially outspoken for Diabetes Mellitus and Coronary Heart disease as comorbid chronic diseases (8).

Later analysis (7) learned that practice variation in the above-mentioned aspects was considerable, in which practice region and urbanization explained part of the higher risks of depressed elderly on multimorbidity. Other possible determinants on practice level, like availability of somatic or mental health nurse and N of doctors working in the practice had no significant contribution. Variation in polypharmacy could not be explained on practice level.

Furthermore, analyses has been directed to the impact of multi-morbidity and polypharmacy on patients compliance in starting and continuing medication (9) and on possible alternative way of treating depression among elderly besides medication (10)

These results, reported in scientific papers and several master theses should be translated to professionals in general practice and pharmacy, to implement them in daily practice. What is the opinion of GPs and pharmacists on these results, and how do they think these results should be translated to day-to-day care.
Research question / problem definition
How are findings from the study on multi-morbidity and polypharmacy among depressed elderly received by general practitioners and pharmacists?
To implement results from the study on multi-morbidity and polypharmacy among depressed elderly in daily practice of general practitioners and pharmacists
1) Results will be summarized in a “consumable” format for GPs, Pharmacists, family practice vocational trainees
2) Results will be presented in this format to two mixed (GPs and pharmacists) focus groups (8 participants each) and one focus group with family practice vocational trainees
3) Transcription and analysis of Focus groups discussions
4) Formulation of recommendations to be directed at the national taskforce good medication practice, of ZonMw, the ministry of health, representatives of insurers and pharmacist organizations and the Netherlands Institute of Health Services Research.
1 Caughey GE, Roughead EE, Shakib S, McDermott RA, Vitry AI, Gilbert AL. Comorbidity of chronic disease and potential treatment conflicts in older people dispensed antidepressants. Age Ageing. 2010;39(4):488-94.
2. Iosifescu DV, Nierenberg AA, Alpert JE, Smith M, Bitran S, Dording C, et al. The impact of Medical Comorbidity on acute treatment in major depressive disorder. American Journal of Psychiatry. 2008;160:2122-7.
3. Nuyen J, Volkers AC, Verhaak PF, Schellevis FG, Groenewegen PP, Van den Bos GA. Accuracy of diagnosing depression in primary care: the impact of chronic somatic and psychiatric co-morbidity. Psychol Med. 2005;35(8):1185-95.
4. Sinnige J, Braspenning J, Schellevis F, Stirbu-Wagner I, Westert G, Korevaar J. The prevalence of disease clusters in older adults with multiple chronic diseases--a systematic literature review. PLoS One. 2013;8(11):e79641.
5. Calderon-Larranaga A, Gimeno-Feliu LA, Gonzalez-Rubio F, Poblador-Plou B, Lairla-San Jose M, Abad-Diez JM, et al. Polypharmacy Patterns: Unravelling Systematic Associations between Prescribed Medications. PLoS One. 2013;8(12):e84967.
6 Holvast F, Hattem BA van, Sinnige J, Schellevis F, Taxis K, Burger H, Verhaak, PFM. Late-life depression and the association with multimorbidity and polypharmacy – a cross-sectional study. Accepted by Family Practice
7 Braakman, A. Welke kenmerken van de huisartspraktijk zijn gerelateerd aan het verhoogde risico op multimorbiditeit en polyfarmacie onder depressieve ouderen in de eerste lijn? Scriptie Wetenschappelijke Stage UMCG, Groningen, 2017
8 Leeuw, T. de Polyfarmacie en medicatielast bij depressieve ouderen met chronisch somatische aandoeningen. Scriptie Wetenschappelijke stage UMCG, Groningen, 2018
9 Holvast F.,Wouters H., Hek, K. Schellevis, F.Oude Voshaar, r.;Dijk, L.v. Burger, H.; Verhaak, P. Non-adherence to cardiovascular drugs by older primary care patients with depression – a population-based cohort study. submitted
10 Holvast F, Massoudi B, Oude Voshaar R, Verhaak PFM Non-Pharmacological Treatment for depressed Older Patients in Primary Care: A Systematic Review and Meta-Analysis. PLOS ONE
back to toptop