Mental health in primary care

Background/introduction

He Ara Oranga (Government Inquiry into Mental Health and Addiction 2018) estimated that around one in five New Zealanders experience mental illness or significant mental distress each year. A recent survey by the Royal New Zealand College of General Practitioners estimated that mental health and addiction makes up around a third of all general practice consultations (RNZCGP 2019).

Primary mental health is provided mainly through general practice and, when required, through referral to community mental health teams or psychological therapy providers. Publicly funded access to psychological therapy is available to selected groups (Māori, Pacific peoples, low income and young people) through primary health organisations (PHOs) (Dowell et al 2009). Access to psychological therapy may as a result be challenging for many because of cost barriers. Treatment options for people with mild or moderate mental health conditions in primary care include lifestyle advice and online self-management, psychological therapy and medication. Concerns have been expressed internationally about increasing rates of psychotropic prescribing, particularly antidepressants (Mars et al 2017) and the use of medication in elderly populations (Westbury et al 2019).

Purpose

The purpose of this Atlas domain is to highlight regional and demographic variation in the use of certain psychotropic medicines, with the goal of prompting debate and raising questions about why differences exist.

An infographic summarising the key findings is shown below and can be downloaded as a PDF (160KB, pdf).

Key findings

In 2018, around 839,936 New Zealanders were dispensed one or more of the psychotropic medicines included in this Atlas domain. Four hundred and twenty-five thousand people received psychotropic medicine regularly throughout the year (that is, were dispensed the medicine in three or four quarters in the year).

Development of this Atlas domain highlighted five key issues:

1. People with a self-reported long-term mental health condition experience greater barriers to accessing primary care than those who did not report a long-term mental health condition.
2. Lower rates of antidepressant dispensing in Māori.
3. Nearly a quarter of older people are regularly dispensed a psychotropic medicine.
4. Over one-tenth (11.3 percent) of older people are regularly dispensed a benzodiazepine or zopiclone.
5. Likely ‘off-label’ use of some medicines (see explanation below).

Discussion points

1. People with a self-reported long-term mental health condition reported greater barriers to accessing primary care than those who did not report a long-term mental health condition.

Data is sourced from the national primary care patient experience survey and aligns with findings from the New Zealand Health Survey. The reason for people wanting to access primary care is not known, ie, the health need could have been physical or related to mental health.

If the survey respondent was Māori or Pacific, they were more likely again to report access and prescription costs as barriers than those of other ethnic groups.

2. Māori were less likely to regularly receive antidepressants compared with non-Māori

• Māori were less likely to receive a selective serotonin reuptake inhibitor (SSRI) in the year compared with non-Māori (7.8 compared with 10.5 percent).
• Māori were half as likely to regularly receive an SSRI compared with non-Māori (3.2 percent compared with 6 percent).
• Anxiety and depression, including major depression, are reported to be higher in Māori than in non-Māori (Russell 2018; Tapsell et al 2018) but Māori are less likely to have a diagnosis of anxiety or depression (Lee et al 2017). The stocktake undertaken for the mental health inquiry found evidence that in both primary and secondary mental health services, Māori are under-served and experience worse outcomes (Cunningham et al 2018). This suggests the lower use of medication observed here is not compensated for by higher use of non-pharmacological therapies.
• The finding that Māori children aged 0–14 years of age were less likely to regularly receive a stimulant/treatment for attention deficit hyperactivity disorder (ADHD) than European/other children (0.77 percent compared with 0.91 percent) may indicate that inequitable access of Māori to psychotropic medicines is not limited to antidepressants

Does this represent underuse of mental health medication for Māori compared with non-Māori?

How does this relate to the use of psychological therapies?

3. Nearly a quarter of the population aged 75 and over were regularly dispensed a psychotropic medicine in 2018.

Of the medicine classes reported, with the exception of stimulants/treatment for ADHD, rates of regular dispensing were highest in those aged 75 and over: 

• Benzodiazepine or zopiclone: 11.3 percent
• SSRI: 9 percent
• Tricyclic or related antidepressant (TCA): 6 percent
• Antipsychotic excluding low-dose quetiapine: 1.9 percent
• Low-dose quetiapine: 1.4 percent.

Does this reflect appropriate care?

4. Benzodiazepine or zopiclone use in older people

Benzodiazepines and zopiclone were regularly dispensed to 11.3 percent of those aged 75 and over in 2018. Benzodiazepines have hypnotic and anxiolytic properties. They can be used to treat insomnia or acute anxiety. Zopiclone is used to treat insomnia.

The New Zealand Formulary notes the following cautions for benzodiazepine use:

• Benzodiazepines should be used to treat insomnia only when it is severe, disabling or causing the patient extreme distress.
• If possible, avoid sedatives and hypnotics in the elderly due to the increased risk of ataxia, confusion and falls.
• Hypnotics should be limited to a short course of treatment, and repeat prescriptions should not be provided without a clinical review.

Are clinical pathways being used to inform practice?
Are clinical pathways realistic for offering alternatives for care?

5. Off-label use of medicines

‘Off-label’ use of a medicine means that Medsafe has not approved the medicine to be used for this indication. Medsafe advises that patients should be informed and consent to this.

This Atlas domain focuses on mental health management in primary care, however some of the medicines included are known to be used ‘off-label’ to treat other conditions. Specifically, the TCAs amitriptyline and nortriptyline are also used to treat neuralgia and chronic pain. At low doses, quetiapine is used as a sedative and anxiolytic rather than as an antipsychotic agent.

It is not possible to differentiate the reason for prescribing, but this raises questions such as: are patients being informed and consenting to off-label use of medicines?

The experience of patients with a self-reported mental health condition

The indicator below shows the response to the national primary care patient experience survey in 2018. For more survey data, including definitions, please read the methodology (322KB, pdf).

Question: In the last 12 months was there a time when you did not visit a GP or nurse because of cost?

People who self-report a mental health condition are more likely to report not visiting a GP or nurse because of cost in the last 12 months.

• A total of 13,141 people answering this question also reported having a long-term mental health condition.
• Of these, 30 percent responded that yes, cost prevented them from visiting their GP or nurse in the past 12 months. By comparison, 20 percent of people who didn’t report having a long-term condition responded ‘yes’ to this question.
• Nearly half of those aged 15–24 years (48 percent) with a mental health condition reported cost as a barrier, compared with 41 percent of the population aged 15–24 years.
• At all ages, Māori reported more barriers to care while those of European/other ethnicity reported fewer (38 percent Māori compared with 28 percent European/other).
• Prescription cost prevented 16 percent of people with a mental health condition from picking up a prescription compared with 9 percent of those not reporting a condition. Māori and Pacific peoples with a self-reported long-term mental health condition were twice as likely to report prescription cost as a barrier compared with those of other ethnic groups.

For a comparison with the general population or other long-term conditions, please visit the health service access Atlas domain and select the long-term conditions tab.

Medicines for mental health conditions

Definition of regular medicine

The indicators below show people who were dispensed a medicine from a community pharmacy. Both any dispensing and ‘regular’ dispensing in a year are reported. Regular dispensing is defined as people dispensed a medicine or medicine class in three or four quarters in a year. This is a measure of ‘persistence’ and is considered to reflect people who are regularly taking the medicine.

Nearly a quarter of the population aged 75 and over were regularly dispensed a psychotropic medicine in 2018

Table 1 shows the rate per 100 resident population dispensed any psychotropic medicine in 2018.

Table 1: People dispensed any of the psychotropic medicines included in this Atlas domain, by age group, 2018

Dispensing type	Age group (years)
	0–14	15–24	25–44	45–64	65–74	75+	Total
Any dispensing	1.8	11.6	16.8	23.8	28.0	36.5	17.2
Regular dispensing	1.1	4.0	7.2	12.5	15.8	23.2	8.7

SSRIs or other re-uptake inhibitors are the most commonly used anti-anxiety and/or antidepressant medicines

• In 2018, around 400,000 people or 8.3 percent of the New Zealand population were dispensed an SSRI or other reuptake inhibitor. SSRIs are first-line treatment for anxiety and/or depression therapy.
• Five percent of the population regularly received an SSRI or other reuptake inhibitor.
• Rates increased with age, from 0.4 percent of 0–14-year-olds up to 13 percent of those aged 75 and over.
• Rates for women were almost twice as high as for males.
• There were marked ethnic differences. Within the same age band, those of European/other ethnicity received 2–3 times the rate of SSRIs than those of all other ethnic groups.
• The difference by ethnicity was even more marked when regular dispensing was measured. A selection of age groups is shown in Table 2 to demonstrate this.

Table 2: Any and regular dispensing of an SSRI or other reuptake inhibitor, by age and ethnic group, 2018

Ethnic group	Age group (years; rate per 100)
	15–24		45–64		75 and over
	Any dispensing	Regular dispensing	Any dispensing	Regular dispensing	Any dispensing	Regular dispensing
Māori	5.3	1.3	9.1	4.9	7.2	4.7
Pacific peoples	2.1	0.4	3.9	2.0	5.1	3.3
Asian	2.1	0.7	3.0	1.5	5.2	3.2
European/other	10.8	4.1	13.7	8.8	13.7	9.6
Total	7.5	2.6	11.3	7.0	12.7	8.9

A total of 193,000 people were dispensed a TCA in 2018

• This represents 4 percent of New Zealand’s population dispensed a TCA in 2018. TCAs are indicated for panic and other anxiety disorders; amitriptyline and nortriptyline are also used ‘off-label’ to treat neuralgia and chronic pain. Ninety-four percent of people dispensed amitriptyline were dispensed either 10 mg or 25 mg tablets. Seventy percent of people dispensed nortriptyline were dispensed 10 mg tablets.
  • Does low-dose use reflect off-label use?
• TCA dispensing rates increased with age; up to 10 percent of the population aged 75 years and over had at least one dispensing in 2018. Six percent of people 75 and over regularly received a TCA.
• At all ages, dispensing rates were highest in European/other ethnic groups and lowest in those of Asian ethnicity. Rates for women were almost twice as high as for men.

In 2018, 1.9 percent aged 75 and over were regularly dispensed an antipsychotic (excluding low-dose quetiapine)

• This equated to nearly 6,000 people aged 75 and over regularly receiving an antipsychotic. In 2018, 15,800 people aged 75 and over received at least one dispensing during the year.
• Antipsychotic drugs are used to reduce agitation and distress whatever the underlying psychopathology, which may be schizophrenia, mania, delirium or agitated depression. Antipsychotic drugs are sometimes used to alleviate severe anxiety, but this should be a short-term measure.
• Due to the higher risk of adverse effects, the New Zealand Formulary recommends antipsychotics should not be used in elderly patients to treat mild psychotic symptoms.
• Rates between DHBs varied over two-fold in those aged 75 and over.

A total of 1.4 percent of those aged 75 and over regularly received low-dose quetiapine in 2018

• This equated to 4,400 people aged 75 and over regularly receiving low-dose quetiapine.
• At low doses quetiapine acts as a sedative and anxiolytic rather than as an antipsychotic agent. Eighty-three percent of people dispensed quetiapine are given 25 mg tablets (this is low dose). There is evidence that in New Zealand it is increasingly being used ‘off-label’ for its hypno-sedative properties (Huthwaite et al 2018).
• Use varied two-fold between DHBs.
• There is debate as to whether low-dose quetiapine to treat insomnia represents good practice (Brett 2015) and this Atlas domain encourages prescribers to review guidance for prescribing in the elderly.
  • Antipsychotic drugs should not be used in elderly patients to treat mild psychotic symptoms.
  • Initial doses of antipsychotic drugs in elderly patients should be reduced (to half the adult dose or less), taking into account factors such as the patient's weight, co-morbidity and concomitant medication.
  • Treatment should be reviewed regularly.

A total of 11.3 percent of those aged 75 and over regularly received a benzodiazepine or zopiclone in 2018

• Across all ages, rates of benzodiazepine or zopiclone dispensing in European/other populations were at least three times higher than those of Māori, Pacific or Asian populations.
• Rates were higher in females than males, at all ages.
• Dispensing rates varied 2.6-fold by DHB, with North Island DHBs tending to have higher rates than South Island DHBs.

For a graphical representation of the risks and benefits of sleeping tablets, visit saferx.

The use of central nervous system (CNS) stimulants or treatment for ADHD varied three-fold by DHB, from 0.5 percent to 1.6 percent of all children aged 0–14 years

• A total of 8,200 children aged 0–14 years were regularly dispensed one of these medicines in 2018.
• For 0–14-year-olds, there were wide differences by ethnicity. The lowest rates were in Asian, Pacific peoples and Māori populations. European/other rates were six times higher than Asian rates and four times higher than Pacific peoples rates.
• Rates were higher in males than females.
• The New Zealand Health Survey reports that the prevalence of attention deficit disorder (ADD) or ADHD is2.2 percent in children aged 2–14 years. The prevalence of ADD/ADHD is also significantly higher in Māori boys than in non-Māori boys.

A note on variation:

• SSRIs: rates of both any and regular use of SSRIs were significantly lower in the four Northern Region DHBs and Hauora Tairāwhiti. Regular use of SSRIs varied between DHBs: in people aged 75 and over there was 1.7-fold variation, while in those aged 25–44 there was 2.8-fold variation.
• TCAs: there was a similar pattern to SSRIs, with significantly lower rates of dispensing in the Northern Region DHBs. Rates within age groups varied around two-fold between DHBs.
• Antipsychotics: the pattern was different, with rates in Auckland and the Central Region DHBs being significantly higher. The regular use of antipsychotics varied two-fold, even in age groups.
• Benzodiazepine/zopiclone. Rates varied 2.6-fold between DHBs, with eight of the nine highest-rating DHBs being in the North Island.
• Stimulant/ADHD treatment: rates in those aged 0–14 years varied nearly three-fold between DHBs. Again, rates were lower in the Northern Region DHBs.

Off-label use of medicines

This Atlas domain reports certain approved medicines where some of the dispensing is likely to reflect ‘off-label’ use.

There are reports that low-dose quetiapine is commonly used off-label as a hypnosedative in New Zealand (Huthwaite et al 2013; Huthwaite et al 2018). At low doses, quetiapine acts as a sedative and anxiolytic rather than as an antipsychotic agent. The data reported in the Atlas domain shows the rate of low-dose quetiapine in those aged 75 and over is twice as high as in other age groups.

Of TCAs, amitriptyline and nortriptyline are the most commonly used, representing around 94 percent of TCAs dispensed to people. Both amitriptyline and nortriptyline are approved in New Zealand to be used for the treatment of depression and unapproved for the treatment of neuropathic pain (in other jurisdictions, such as Australia and the United Kingdom, they are approved for the latter).

Medsafe advises that patients should be informed of and consent to ‘off-label’ use of medicines. The New Zealand Medical Council statement on good prescribing practice advises:

Ensure that the patient (or other lawful authority) is fully informed and consents to the proposed treatment and that he or she receives appropriate information, in a way they can understand, about the options available; including an assessment of the expected risks, adverse effects, benefits and costs of each option.

• Are there local guides or protocols to assist with off-label prescribing, such as that developed by the Royal Australian and New Zealand College of Psychiatrists?
• How do prescribers keep track of approved and unapproved indications? Is this information available at the point of prescribing (Wong et al 2017)?
• What resources are available to inform patients?
• Do GPs need to be given better information about the evidence for off-label use of medicines?

A recent example of the difficulties for prescribers is in the change of funding for pregabalin and gabapentin. From 1 May 2018, pregabalin was added to the Pharmaceutical Schedule as a fully subsidised medicine. It is indicated for epilepsy and neuropathic pain, and unapproved for generalised anxiety disorder. Gabapentin has also had its availability on the schedule increased (removing the special authority) since 1 June 2018. Approved uses are for epilepsy and neuropathic pain. The subsidy changes mean that in 2018, 39,000 more people were dispensed pregabalin or gabapentin than in 2016.

Other findings from the national primary care patient experience survey

Question: does your GP or nurse spend enough time with you?

Twenty-three percent of patients with a self-reported long-term mental health condition did not agree that their GP or nurse always spent enough time with them.

• This compares with 19 percent of those with no long-term mental health condition.
• Thirty-four percent of younger people (aged 15–24) reported that their GP or nurse did not always spend enough time with them, compared with 19 percent of those aged 65 years and over.
• There were limited differences by ethnicity.

Question: have you been involved in decisions about your care and treatment as much as you wanted to be?

Overall, 20 percent of people with a self-reported long-term mental health condition were not as involved in decisions about their care and treatment as they wanted to be.

• This compares with 18 percent of those with no long-term mental health condition.
• While around 3 percent of people were not as involved as they wanted to be, 18 percent of people were only involved as much as they wanted to be to some extent.
• Younger people reported less involvement, with 31 percent of 15–24-year-olds being involved either to some extent or not at all, compared with 15 percent of those aged 75 years and over.

Data sources and limitations

Data for this Atlas domain was drawn from the Pharmaceutical Collection, which contains claim and payment information from community pharmacies for subsidised dispensing. This collection does not allow for analysis of patient conditions or the effectiveness of the dose provided. This means it was not possible to assess the appropriateness or otherwise of prescribing; nor does it indicate if people took the medicine. Unsubsidised dispensing is not included in this analysis.

The methodology is provided here (322KB, pdf).

References

• Brett J. 2015. Concerns about quetiapine. Aust Prescr 38(3): 95–7.
• Cunningham R, Kvalsvig A, Peterson D. 2018. Stocktake Report for the Mental Health and Addiction Inquiry. Wellington: University of Otago.
• Dowell AC, Garrett S, Collings S, et al. 2009. Evaluation of the primary mental health initiatives: summary report 2008. Wellington: University of Otago and Ministry of Health.
• Government Inquiry into Mental Health and Addiction. 2018. He Ara Oranga. Wellington: Government Inquiry into Mental Health and Addiction. URL: www.tetumuwaiora.co.nz/#new-page-2.
• Huthwaite M, Tucker M, McBain L, et al. 2018. Off label or on trend: a review of the use of quetiapine in New Zealand. NZMJ 131(1474): 45–50.
• Huthwaite MA, Andersson V, Stanley J, et al. 2013. Hypnosedative prescribing in outpatient psychiatry. International Clinical Psychopharmacology 28(4):157–63.
• Lee CH, Duck IM, Sibley CG. 2017. Ethnic inequality in diagnosis with depression and anxiety disorders. NZMJ, 130(1454): 10–20.
• Mars B, Heron J, Kessler D. 2017. Influences on antidepressant prescribing trends in the UK: 1995–2011. Social psychiatry and psychiatric epidemiology 52(2): 193–200.
• RNZCGP. 2019. Mental health and addiction consults make up nearly a third of GPs’ work. NZ Doctor. URL: www.nzdoctor.co.nz/article/news/mental-health-and-addiction-consults-make-nearly-third-gps-work.
• Russell L. 2018. Te Oranga Hinengaro: Report on Māori Mental Wellbeing Results from the New Zealand Mental Health Monitor & Health and Lifestyles Survey. Wellington: Health Promotion Agency.
• Tapsell R, Hallett C, Mellsop G. 2018. The Rate of Mental Health Service Use in New Zealand as Analysed by Ethnicity. Australas Psychiatry 26(3): 290–3.
• Westbury J, Gee P, Ling T, et al. 2019. More action needed: Psychotropic prescribing in Australian residential aged care. Australian & New Zealand Journal of Psychiatry 53(2): 136–47.
• Wong J, Motulsky A, Abrahamowicz M, et al. 2017. Off-label indications for antidepressants in primary care: descriptive study of prescriptions from an indication based electronic prescribing system. BMJ 365: j603.

Further information

• EPiC Youth Mental Health and EPiC Annual Prescribing Report: Two data themes that explore the use of medicines used in the treatment of mental health conditions. published by He Ako Hiringa. Data current to last three months. Updated quarterly. Practitioner, practice, and national data: https://epic.akohiringa.co.nz/youth-mental-health, 

  https://epic.akohiringa.co.nz/annual-report