The prevalence of depression and anxiety has increased steadily since 2019. Previous research, including a report from HCCI, has identified a concurrent steady increase in the use of antidepressant and anxiolytic medications. Previous studies have found that most people receive prescriptions for psychotropic medications from their primary care providers. This finding describes national prescribing patterns, but few analyses have examined sub-national patterns and whether there is variation at a state level.
This analysis examines antidepressant and anxiolytic medication prescribing across provider types at a national and state level from 2018-2022 among people with Employer Sponsored Insurance (ESI). In our analysis, we group providers into 3 categories. The Primary Care Provider (PCP) category is composed of a variety of specialties, including internal medicine, family medicine, and OBGYN practitioners. A detailed description of our provider categorization is available in the methods note. The second group includes Psychiatrists and Psychiatric Nurse Practitioners (NP). The last group, ‘Other,’ includes other mental health professionals, such as psychologists, addiction specialists, nurses, social workers, counselors, clinics and treatment centers.
Primary care providers prescribe nearly 74% of antidepressants and anxiolytics
Nationally, approximately three quarters of antidepressant and anxiolytic prescription fills are prescribed by a primary care provider. The remaining quarter of fills are prescribed by psychiatrists and psychiatric NPs, and a small fraction (<1%) are prescribed by other mental health professionals.
There is state level variation in prescribing patterns, though PCPs prescribe the majority of fills across all states
At the state level, there is variation in the proportion of antidepressant and anxiolytic fills prescribed by each provider type. The proportion of fills prescribed by a PCP range from 55% in Washington, D.C. to nearly 86% in West Virginia. Likewise, Washington D.C. has the highest proportion of fills prescribed by a psychiatrist or psychiatric NP (44%) while West Virginia has the lowest (14%). The proportion of prescriptions from other mental health providers is highest in Rhode Island (5%) and lowest in Mississippi (0.2%).
Psychiatrists and Psychiatric NPs have prescribed a slightly higher proportion of antidepressants and anxiolytics over time
At a national level, the proportion of antidepressant and anxiolytics prescribed by a psychiatrist or psychiatric NP increased by about 2 percentage points from 2018-2022, while the proportion of these medications prescribed by PCPs has decreased by roughly the same percentage. There was also a slight decrease in the proportion of these medications prescribed by other mental health provider types (0.12 percentage points). States largely followed the same trend, with the exceptions of Illinois, Maine, Michigan, Oklahoma, Pennsylvania, Vermont, Wisconsin, West Virginia and Washington, D.C. Each of these states saw either a slight decrease in prescriptions from psychiatrists and psychiatric NPs or held steady proportions across years.
More research is needed to understand what is driving prescribing trends
Our analysis shows that most antidepressant and anxiolytic prescriptions for people with ESI are prescribed by PCPs, with some variation in prescribing patterns by state. This finding is consistent with previous research that found most psychotropic medications are prescribed by general practitioners.
More research is needed to understand the implications of high levels of PCP prescribing. One study found that patients who are treated by PCPs were less likely to be adherent to antidepressant treatment than patients who are treated by psychiatrists, and that patients treated by multiple providers had lower odds of nonadherence than patients treated by a single provider. Future studies should investigate why patients are receiving antidepressant and anxiolytic prescriptions from PCPs. This phenomenon could be related to mental health provider shortages or could indicate integration of mental health care into primary care, which is an objective of collaborative care models. Additional areas of research should include the role of other mental health providers, including allied health professionals, in prescribing medication, and outcomes associated with these prescribing provider types. Understanding how and why people are prescribed medications to treat mental health conditions is foundational for making informed decisions and effective policy to promote mental health care access.
Methods Note
For this analysis, we used HCCI’s commercial claims dataset for years 2018-2022. We restricted the analysis to include only claims for enrollees in employer sponsored insurance, under the age of 65. We only included pharmacy claims, and counted each distinct claim for a unique patient, service date, and medication as a fill. To categorize mental health provider types, we used the National Plan and Provider Enumeration System (NPPES) taxonomy. We categorized provider types with the grouping of ‘Behavioral Health & Social Service Providers’ or provider types with a specialization with the string ‘Psych’ or the classification of ‘Licensed Psychiatric Technician’ as mental health providers. We further categorized clinical and other mental health professionals into separate categories using the provider classification. Finally, we categorized primary care providers (PCPs) using a crosswalk from a previous primary care analysis that categorizes primary care providers based on provider specialty. We identified antidepressant and anxiolytic fills using NDC codes from the VA RxNORM file.
Acknowledgement: We would like to thank West Health for their support of this project.