The timely article by Verdoux & Bégaud hopefully begins to redress the imbalance between randomised controlled trials and other ways of evaluating drug treatments. I would like to present further evidence for the ‘gap between guidelines and utilisation... for psychotropic medications’ (Reference Verdoux and BegaudVerdoux & Bégaud, 2004).

Using the Drug Report of the German Public Health Insurance (Schwabe & Pfaffrath, 1996), which is a database of all prescriptions reimbursed by the general health insurance system (which accounts for more than 80% of all prescriptions), and a database from the Institute for Medical Statistics, Frankfurt/Main, which refers to a representative sample of 2806 physicians in private practice who report four times a year all prescriptions during 1 week, we found that only 14% of prescriptions for neuroleptic drugs were for schizophrenic psychoses, 18% for other paranoid psychoses and 5% for affective disorders (Reference Linden and ThielsLinden & Thiels, 2001). Almost half of the neuroleptic prescriptions were written for patients aged 65 years or older. Over the period 1986 to 1995 the prescribing of neuroleptics increased steadily in parallel with a decrease in prescriptions for benzodiazepines.

Also I would like to contradict the assumption that antipsychotics are ‘mainly prescribed by specialists’ (Reference Verdoux and BegaudVerdoux & Bégaud, 2004). Using the pharmaco-epidemiological data described above, we found that only 40% of neuroleptic drugs were prescribed by psychiatrists/neurologists (i.e. by Nervenärzten who trained in both specialties, as most German psychiatrists and neurologists do).

Data from a 6-month prospective drug utilisation observation study on 3858 women and 1594 men prescribed the selective serotonin reuptake inhibitor sertraline shows that it is not only the type of psychotropic drug that determines whether it is ‘commonly prescribed by primary care practitioners’ (Reference Verdoux and BegaudVerdoux & Bégaud, 2004) but also the gender of the patient. A higher percentage of women with depression were treated by general practitioners, compared with men with depression who were more likely to be seen by psychiatrists, although women were more likely to present with recurrent rather than first-episode depression and to have been previously treated for depression.