BACKGROUND: Since antidepressants are prescribed for multiple indications, the 
use of an antidepressant cannot be equated with a diagnosis of depression.
OBJECTIVE: The objective of this study was to examine the quality of 
antidepressant prescribing in Belgian nursing homes, with a critical evaluation 
of indications and dosages, to see whether depression was appropriately treated 
in terms of drug choice, the indications for which antidepressants were being 
prescribed and whether there was underdosing.
METHODS: This analysis was based on data obtained in the Prescribing in Homes 
for the Elderly in Belgium (PHEBE) study, a cross-sectional, descriptive study 
of a representative, stratified, random sample of 1,730 residents from 76 
Belgian nursing homes. The PHEBE study investigated overall drug utilization in 
Belgian nursing homes in 2006. Clinical and medication data for the present 
study were obtained from this study. A 28-item checklist of clinical conditions 
was designed ad hoc for the PHEBE study and sent to the residents' general 
practitioners (GPs) to collect clinical information. We copied the residents' 
medication charts, classified the drugs using the Anatomical Therapeutic 
Chemical (ATC) classification system codes and transferred the drug names and 
dosages into a database. Information on indications was retrospectively obtained 
from the GPs, so that we could link the indication to each medication. Minimum 
effective doses (MEDs) of antidepressants to treat major depression were 
obtained from the literature to assess underdosing.
RESULTS: The overall use of antidepressants in nursing homes was 39.5 % (95 % CI 
37.2, 41.8). The physicians classified 34.2 % (95 % CI 32.0, 36.4) of the 
residents as having depression, and 80.9 % of these patients were treated with 
an antidepressant. Indications among the single antidepressant users (n = 551) 
were depression (66.2 %), insomnia (13.4 %), anxiety (6.2 %) and neuropathic 
pain (1.6 %). In the indication of depression, 74.8 % used a selective serotonin 
reuptake inhibitor (SSRI), predominantly citalopram, sertraline and 
escitalopram. Venlafaxine was used by 10.7 % of the residents. Dosages for these 
antidepressants were equal to or higher than the MED. But when trazodone, 
amitriptyline or mirtazapine were used to treat depression, respectively, 92.3, 
55.5 and 44.5 % of prescribed dosages were below the MED. In the indication of 
insomnia, most of the time, trazodone (90.5 %) or mirtazapine (5.4 %) were used, 
and in lower dosages than those required for depression treatment (<MED). 
Tricyclic antidepressants were predominantly used for the treatment of 
neuropathic pain and were also used at lower dosages. Of all the residents 
receiving a medication for anxiety, only 13.9 % received an antidepressant 
(mostly an SSRI), and the remaining received a benzodiazepine.
CONCLUSIONS: The number one indication for the use of an antidepressant was 
depression. Within this indication, mostly the recommended SSRIs were used, in 
dosages equal to or higher than the MED. Furthermore, we noticed that there was 
substantial use of sedative antidepressants for insomnia and that the physicians 
preferred to prescribe benzodiazepines over the recommended SSRIs to treat 
anxiety chronically.