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11.0 Prescribing Trends in Doing Well Sites
The national Doing Well programme did not aim to impact on prescribing rates per se. These are a product of a number of complex factors. It was recognised that in many cases the target population were not currently receiving treatment and the focus on increasing early detection would result in increased prescribing.
Most local projects did not set out to change GP behaviour in this respect, with the exception of Argyll and Clyde, which sought to introduce a prescribing formulary as part of its overall activities. In addition, the scale of Doing Well projects in some regions, and the relatively small numbers of patients being seen as a proportion of all those seen in primary care with mental health problems, would have made it difficult to detect any significant impact on overall prescribing of antidepressants.
However, several local Doing Well projects were larger in scale ( e.g. Ayrshire and Arran, Grampian and Dumfries and Galloway) and covered the entire Health Board area. In these sites there is scope to examine trends in prescribing and to place these findings in the context of national trends in antidepressants prescribing. In addition trends in Argyll and Clyde are of interest as changing prescribing behaviour was one of its central components.
Several Doing Well projects specifically asked those entering the service about their current use of antidepressants and there was variation in this respect across the Doing Well sites.
Site | Percentage taking or prescribed anti-depressant medication |
Argyll and Clyde | 48% of patients with PHQ>15;
62.8% of patients with PHQ > 20 |
Borders | 41% (includes benzodiazepines) |
Dumfries and Galloway | 37% |
Glasgow | 57% |
Grampian | 38%* and 49%** |
Lanarkshire | 65% |
* Referrals to Grampian PCMHWs
** Referrals to Grampian PCPTTs
Prescribing data was obtained from ISD for all Doing Well sites involved in the national evaluation. Data reflect a period of pre- Doing Well and are presented as quarterly figures from April 2003 to December 2005 1 (latest available at the time of writing). As stated earlier, the Doing Well projects did not all commence at the same time and many activities were staggered in their introduction within Doing Well sites. In general, the Doing Well programme of activities commenced from October 2004 and remains on-going at the time of writing this report.
The following graphs show comparisons of volume of prescribing based on Defined Daily Doses ( DDDs) per 1000 patients for Health Board and all of Scotland data in areas where Doing Well initiatives were Health Board wide (Ayrshire and Arran, Dumfries and Galloway and Grampian). Although Ayrshire and Arran show a reduction in volume in the last quarter (Oct-Dec '05), in general prescribing trends are in line with national activity.
Looking more specifically at LHCC level, the following graphs show comparisons of volume of prescribing based on Defined Daily Doses ( DDDs) per 1000 patients for individual LHCCs involved in Doing Well against non- Doing WellLHCCs within the Health Board and all of Scotland. West Renfrew LHCC can be seen to closely reflect the national average in terms of prescribing and is generally lower than other LHCCs within Argyll and Clyde. Drumchapel has the highest levels of DDDs per 1000 patients, substantially higher than the HB average which is also higher than the Scottish average. However, increases in prescribing are generally reflected in national prescribing trends. The initial intention that Doing Well should not be expected to impact on prescribing levels is generally reflected in these data.
As previously stated, Argyll and Clyde were the only Doing Well site to specifically implement an intervention intended to impact on local prescribing. The aims were to minimise antidepressant use for people with adjustment disorder/mild depression and to optimise use for people with moderate to severe depression. They also aspired to achieve maximal compliance with formulary guidance on the kind of antidepressant used and recommended one of three drugs - Lofepramine, Fluoxetine or Citalopram.
The final set of graphs shows data for individual antidepressant medications prescribed in Argyll and Clyde HB region. The graphs represent the comparison of volumes of prescribing for individual drugs based on DDDs per 1000 patients for West Renfrewshire LHCC against all other non- Doing WellLHCCs within the health board and the all Scotland average. Prescribing of all formulary drugs increased in West Renfrewshire. However, seen within the context of other LHCC areas, the most marked difference is seen in the volume of prescribing of Lofepramine which has increased more than in the other LHCCs within Argyll and Clyde. As for non-formulary drugs: the increase in prescribing of Escitalopram is less than for non- Doing WellLHCCs and for all of Scotland; there has been a large reduction in the prescribing of Paroxetine but this trend has been equally observed in the whole of Scotland; and the reductions in prescribing of Venlafaxine are reflected in similar levels of reduction for the whole of Scotland but are much more marked than reductions seen in the non- Doing WellLHCCs.
Overall, the Gross Ingredient Cost ( GIC) per 1,000 population has reduced in West Renfrewshire LHCC and the level of reduction is greater than the reduction in GIC for all of Scotland and for all non- Doing WellLHCCs in Argyll and Clyde.
The introduction of the formulary within the Doing Well initiative in West Renfrewshire does seem to have impacted on the type of drugs prescribed and resulted in reductions in overall costs associated with antidepressant prescribing.
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