Commentary: Medical Prescription of Psychiatric Drugs in Primary Care

The high prevalence of psychiatric illnesses in primary care clinics requires taking diagnostic and therapeutic decisions, hastily in many cases. To evaluate and diagnose problems of anxiety and depression in the short space of time available, involves a challenge and a clinical ability linked, without a doubt, to the knowledge and experience of the family doctor. The psychotherapeutic possibilities (even those called short) are not very feasible in the context of Spanish primary care and the systematic referring of all patients with this illness to the public mental health services is clearly non-viable and unnecessary. For all this, the family doctor has to understand and sensitively manage, in accordance with the scientific knowledge and recommendations,¹ the 2 pharmacological groups used in the treatment of depressive and anxiety syndromes: antidepressants in their different forms and benzodiazepines.

The use of benzodiazepines among the Spanish population is very high. The 2003 National Health Survey, carried out by the National Institute of Statistics and the Ministry of Health,² showed that the percentage of people who had taken, in the previous 2 weeks, tranquilizers, relaxants and sleeping pills, that is to say, benzodiazepines, was quite considerable: 12.79% of the population >16 years took them. As the age of the population increases, the use was higher (24.13%; 15.15% males vs 30.2% females) (Table).

In effect, the levels of benzodiazepines taken in the Spanish adult population is worrying. Vedia et al, authors of the article "Study of the Use of Psychiatric Drugs in Primary Care," present similar data on the predominance of the use of psychiatric drugs among women and the high prescription of benzodiazepines over long periods. The long term use of benzodiazepines has important consequences in several cognitive areas: visuospatial ability, speed of processing and verbal learning.³ While the cognitive function improves on withdrawing the use benzodiazepines, this does not reach the previous level and permanent sequelae are maintained.⁴ For this reason, all the prescribing doctors must periodically review the patients who habitually take benzodiazepines in order to evaluate the opportunity and possibility of carrying out a phased withdrawal, as well as the viable options.

The increase in the use of selective serotonin reuptake inhibitors (SSRI) has been general and corresponds with a higher diagnosis of depressive syndromes and generalised anxiety, as well as a better tolerance by the patients. For years, the recommendations for the early detection and a pharmacological approach, with appropriate doses and the correct duration, of depressive symptoms have been endorsed by international recommendations. The American Academy of Family Physicians,⁵ in a recent document based on the US Preventive Service Task Force,⁶ recommended the carrying out of 2 sifting questions which could help to approach a diagnosis of depression: in the last 2 weeks have you felt depressed or without hope? and in the last 2 weeks have you had little interest or no motivation to carry out your activities? Later, the diagnosis should be confirmed using the standardised instruments. To carry out this approach is feasible and necessary for the family medical practice.

A standard for improving the quality of prescribing can clearly be established, which may lead to the decreased use of the benzodiazepines and a higher use of antidepressants. To inform the doctors that the correct pharmacological approach to the depressive and anxiety syndromes should be a task undertaken to improve the quality of the use of psychiatric drugs