Antidepressant prevalence for youths: a multi-national comparison

Selective serotonin reuptake inhibitors and suicidality in children and young adults: analyses of pharmacovigilance databases

BACKGROUND

Since the warnings by the United States (US) and European regulatory authorities in 2004 and 2005 it had been discussed whether there is some link between selective serotonin reuptake inhibitors (SSRIs) and suicidality in the pediatric population. The aim of our study was to describe trends and patterns in spontaneous reporting data referring to suicidality in children, adolescents and young adults treated with SSRI after the warnings.

METHODS

Descriptive analyses of reports for 0-24 year olds referring to suicide/suicidal ideations, self-harms and overdoses with SSRIs reported as suspected submitted to the US (FAERS) and the European (EudraVigilance) adverse drug reaction databases until 2019 were performed. The causal relationship was assessed in accordance with the WHO criteria for the European reports. For Germany, prescription data for SSRIs were provided and reporting rates (number of reports/number of prescriptions) were calculated for the reports with possible causal relationship (so called "confirmed reports").

RESULTS

Since 2004, the number of reports referring to suicide/suicidal ideations, self-harm and overdoses increased steadily in the US and EU. However, only a slight increase was seen for the confirmed EU reports. After 2008, the proportion of reports informing about suicidal ideations increased, while the proportion of fatal suicide attempts decreased. Reporting rates were higher for females and adolescents (12-18 years).

CONCLUSIONS

Our results demonstrate the importance of further monitoring suicidality in 0-24 year olds treated with SSRI in order to recognize suicidality early avoiding fatal suicide attempts. The higher reporting rates for females and adolescents should be further investigated.

Antidepressant use and off-label prescribing in primary care in Spain (2013-2018)

INTRODUCTION

Recent studies show an increase in the use of antidepressants in minors (younger than 18 years), although few antidepressants are indicated for this age group. The aim of our study was to calculate the annual prevalence of antidepressant use in children and adolescents and to review the adherence of prescription to current indications.

METHODS

Study of the prevalence of antidepressant use in minors based on the records of the Electronic Database for Pharmacoepidemiologic Studies in Primary Care (BIFAP) of Spain for the 2013-2018 period, considering at least one prescription per year for each patient.

RESULTS

The prevalence of antidepressant prescription in patients from the BIFAP cohort increased between 2013 (7.97 prescriptions per 1000 patients) and 2018 (8.87 prescriptions per 1000 patients), in most groups and in both sexes. In this period, female patients received the most prescriptions, surpassing prescriptions in male patients by up to 2.5 points in the overall rates. In patients younger than 13 years, this trend was inverted and antidepressant use was higher in male patients. The prevalence of prescription rose with increasing patient age, as did the proportion of off-label prescriptions. The use of off-label medication decreased over time.

CONCLUSIONS

There was a gradual increase in the prevalence of antidepressant prescription in minors younger than 18 years, with a predominance of the female sex. The high proportion of unapproved medication use in this age group calls for more thorough investigation of the risk-benefit balance of these treatments and of safer treatment alternatives.

The Impact of Inpatient Multimodal Treatment or Family-Based Treatment on Six-Month Weight Outcomes in Youth with Anorexia Nervosa: A Naturalistic, Cross-Continental Comparison

In the USA, family-based treatment (FBT) with inpatient medical stabilization as needed is the leading evidence-based treatment for youth with anorexia nervosa (AN). In continental Europe, typically inpatient multimodal treatment targeting weight recovery followed by outpatient care (IMT) is standard care, if prior outpatient treatment was not sufficient. Our aim was to compare weekly weight gain and hospital days over six months for adolescents receiving FBT (USA) versus IMT (Germany) using naturalistic treatment data. To yield similar subgroups of youth aged 12−18 years, inclusion criteria were a percent median BMI (%mBMI) between 70−85 and the restrictive AN subtype. Weight gain and hospital days were compared, adjusted further in a multiple linear regression analysis (MLRA) for baseline group differences. Samples differed on baseline %mBMI (FBT [n = 71], 90.5 ± 12.8; IMT [n = 29], 78.3 ± 9.1, p < 0.05). In subgroups with comparable baseline %mBMI, the weekly weight gain over 6 months was similar (FBT [n = 21]: 0.35 ± 0.18 kg/week; IMT [n = 20]: 0.30 ± 0.18, p = 0.390, p = 0.166 after MLRA), but achieved fewer hospital days in FBT (FBT [n = 7]: 4 ± 6 days, IMT [n = 20]: 121 ± 42 days, p < 0.0001 before and after MLRA). FBT may be effective for a subgroup of adolescents with AN currently receiving IMT, but head-to-head studies in the same healthcare system are needed.

The Use of Antidepressants, Antipsychotics, and Stimulants in Youth Residential Care

Objectives: To assess the use of three commonly prescribed psychotropic medications in youth placed in residential care (RC). Methods: Participants were youth aged 0-20 years placed in RC institutions at least once during 2016. Data on filled prescriptions were taken from the Norwegian Prescription Database to compare the use of antidepressants, antipsychotics, and stimulants in RC with the age- and gender-adjusted general child population (GenPop) and how this co-varied with reasons for RC placement, age, and gender. Results: One thousand eight hundred fifty-six children and adolescents were identified in RC, with mean age 14 (range 0-20 years), 46% girls, 81% ≥ 13 years. Among those, 423 or 23% used any of the 3 psychotropics, which was significantly more than the 3.7% in GenPop. The prevalence ratios RC/GenPop were 6.6 for antidepressants, 17.9 for antipsychotics, and 4.4 for stimulants. The median number of days per year for the dispensed defined daily doses varied from 8.3 to 244.0 for the different antipsychotics, indicating short time use for most of the people. Polypharmacy was not frequent in RC, as only 26% used ≥2 classes of medication, but still significantly more frequent than the 10% in GenPop. Youth placed in RC for serious behavior problems had significantly higher use of stimulants than those with other placement reasons. Psychotropics were not used below age 6 years, and although the use of antidepressants and antipsychotics overall increased with age, stimulants were mostly used by 6-16-year olds. The girl/boy ratio for any psychotropic medication use in RC was 1.4 (95% confidence interval [95% CI]: 1.1-1.6), significantly higher than the corresponding ratio in GenPop: 1.0 (95% CI: 0.9-1.0). Conclusion: The present findings do not necessarily suggest an overtreatment with medication in RC. However, the frequent short-term use of antipsychotics, presumably for non-psychotic symptoms, is a concern, as it may reflect that the youth are not provided with the recommended first-line psychological treatments.

Educational and health outcomes of children and adolescents receiving antidepressant medication: Scotland-wide retrospective record linkage cohort study of 766 237 schoolchildren

Background

Childhood depression is relatively common, under-researched and can impact social and cognitive function and self-esteem.

Methods

Record linkage of routinely collected Scotland-wide administrative databases covering prescriptions [prescribing information system (PIS)], hospitalizations (Scottish Morbidity Records 01 and 04), maternity records (Scottish Morbidity Records 02), deaths (National Records of Scotland), annual pupil census, school absences/exclusions, special educational needs (Scottish Exchange of Educational Data; ScotXed), examinations (Scottish Qualifications Authority) and (un)employment (ScotXed) provided data on 766 237 children attending Scottish schools between 2009 and 2013 inclusively. We compared educational and health outcomes of children receiving antidepressant medication with their peers, adjusting for confounders (socio-demographic, maternity and comorbidity) and explored effect modifiers and mediators.

Results

Compared with peers, children receiving antidepressants were more likely to be absent [adjusted incidence rate ratio (IRR) 1.90, 95% confidence interval (CI) 1.85–1.95] or excluded (adjusted IRR 1.48, 95% CI 1.29–1.69) from school, have special educational needs [adjusted odds ratio (OR) 1.77, 95% CI 1.65–1.90], have the lowest level of academic attainment (adjusted OR 3.00, 95% CI 2.51–3.58) and be unemployed after leaving school (adjusted OR 1.88, 95% CI 1.71–2.08). They had increased hospitalization [adjusted hazard ratio (HR) 2.07, 95% CI 1.98–2.18] and mortality (adjusted HR 2.73, 95% CI 1.73–4.29) over 5 years’ follow-up. Higher absenteeism partially explained poorer attainment and unemployment. Treatment with antidepressants was less common among boys than girls (0.5% vs 1.0%) but the associations with special educational need and unemployment were stronger in boys.

Conclusions

Children receiving antidepressants fare worse than their peers across a wide range of education and health outcomes. Interventions to reduce absenteeism or mitigate its effects should be investigated.

Increased Odds of Ventricular Arrhythmias Associated with Selective Serotonin Reuptake Inhibitor Use among the Pediatric and Young Adult Population: A Case-Control Study

OBJECTIVE

To measure the association between selective serotonin reuptake inhibitor (SSRI) use and out-of-hospital ventricular arrhythmia among the pediatric and young adult population.

STUDY DESIGN

Case-control study using US claims data from 2007 to 2018. Cases were subjects with at least 1 event between ages 2 and 24 years. Controls (matched 10:1 on index date, age, sex, and continuous enrollment) had no events during study period. Independent association between current SSRI use (prescription fill with continuous exposure ending on, or after, the index date) and incident out-of-hospital ventricular arrhythmia (hospitalization or emergency room encounter with primary diagnostic code for ventricular arrhythmia) was estimated using multivariable conditional logistic regression. Separate analyses were performed for pediatric (2-17 years of age) vs young adult (18-24 years of age) subjects and between citalopram/escitalopram vs other SSRIs.

RESULTS

During the study period, 237 eligible cases were identified with 2370 matched controls. Cases were more likely to have government insurance and have a mental health, cardiac, or other complex chronic condition. Thirteen cases (5%) and 15 controls (<1%) had current SSRI exposure. After adjustment for mental health and chronic conditions, there was an increased odds of current SSRI use among cases compared with controls (OR 5.11, 95% CI 1.22-21.37). No difference was observed between pediatric and young adult ages, nor between citalopram/escitalopram and other SSRIs.

CONCLUSIONS

These findings demonstrate increased odds of out-of-hospital ventricular arrhythmia associated with SSRI use in the pediatric and young adult population, suggesting a need for heightened awareness and ongoing monitoring of this potential adverse effect.

Prevalence of benzodiazepines and benzodiazepine-related drugs exposure before, during and after pregnancy: A systematic review and meta-analysis

BACKGROUND

Maternal use of benzodiazepines during pregnancy is common and has increased over the last decades. In this systematic review and meta-analysis, we studied the literature to estimate the worldwide use of benzodiazepines before, during and after pregnancy, which could help to estimate benzodiazepine exposure and to prioritize and guide future investigations.

METHODS

We systematically searched Embase, Medline Ovid, Web of Science and Cochrane Central up until July 2019 for studies reporting on benzodiazepine use before (12 months), during and after pregnancy (12 months). Random effects meta-analysis was conducted to calculate pooled prevalence estimates, as well as stratified according to substantive variables.

RESULTS

We identified 32 studies reporting on 28 countries, together reporting on 7,343,571 pregnancies. The worldwide prevalence of benzodiazepine use/prescriptions during pregnancy was 1.9% (95%CI 1.6%-2.2%; I² 97.48%). Highest prevalence was found in the third trimester (3.1%; 95%CI 1.8%-4.5%; I² 99.83%). Lorazepam was the most frequently used/prescribed benzodiazepine (1.5%; 95%CI 0.5%-2.5%; I² 99.87%). Highest prevalence was found in Eastern Europe (14.0%; 95%CI 12.1%-15.9%; I² 0.00%).

LIMITATIONS

All analyses revealed considerable heterogeneity.

CONCLUSIONS

Our meta-analysis confirmed that benzodiazepine use before, during and after pregnancy is prevalent. The relatively common use of benzodiazepines with possible risks for both mother and (unborn) child is worrying and calls for prescription guidelines for women, starting in the preconception period. Given the substantial proportion of children exposed to benzodiazepines in utero, future research should continue to study the short- and long-term safety of maternal benzodiazepine use during pregnancy and to explore non-pharmacological alternative treatments.

A multi-national comparison of antipsychotic drug use in children and adolescents, 2005-2012

Over the last decades, an increase in antipsychotic (AP) prescribing and a shift from first-generation antipsychotics (FGA) to second-generation antipsychotics (SGA) among youth have been reported. However, most AP prescriptions for youth are off-label, and there are worrying long-term safety data in youth. The objective of this study was to assess multinational trends in AP use among children and adolescents. A repeated cross-sectional design was applied to cohorts from varied sources from Denmark, Germany, the Netherlands, the United Kingdom (UK) and the United States (US) for calendar years 2005/2006-2012. The annual prevalence of AP use was assessed, stratified by age group, sex and subclass (FGA/SGA). The prevalence of AP use increased from 0.78 to 1.03% in the Netherlands' data, from 0.26 to 0.48% in the Danish cohort, from 0.23 to 0.32% in the German cohort, and from 0.1 to 0.14% in the UK cohort. In the US cohort, AP use decreased from 0.94 to 0.79%. In the US cohort, nearly all ATP dispensings were for SGA, while among the European cohorts the proportion of SGA dispensings grew to nearly 75% of all AP dispensings. With the exception of the Netherlands, AP use prevalence was highest in 15-19 year-olds. So, from 2005/6 to 2012, AP use prevalence increased in all youth cohorts from European countries and decreased in the US cohort. SGA were favoured in all countries' cohorts.

Trends in ADHD medication use in children and adolescents in five western countries, 2005-2012

Over the last two decades, the use of ADHD medication in US youth has markedly increased. However, less is known about ADHD medication use among European children and adolescents. A repeated cross-sectional design was applied to national or regional data extracts from Denmark, Germany, the Netherlands, the United Kingdom (UK) and the United States (US) for calendar years 2005/2006-2012. The prevalence of ADHD medication use was assessed, stratified by age and sex. Furthermore, the most commonly prescribed ADHD medications were assessed. ADHD medication use prevalence increased from 1.8% to 3.9% in the Netherlands cohort (relative increase: +111.9%), from 3.3% to 3.7% in the US cohort (+10.7%), from 1.3% to 2.2% in the German cohort (+62.4%), from 0.4% to 1.5% in the Danish cohort (+302.7%), and from 0.3% to 0.5% in the UK cohort (+56.6%). ADHD medication use was highest in 10-14-year olds, peaking in the Netherlands (7.1%) and the US (8.8%). Methylphenidate use predominated in Europe, whereas in the US amphetamines were nearly as common as methylphenidate. Although there was a substantially greater use of ADHD medications in the US cohort, there was a relatively greater increase in ADHD medication use in youth in the four European countries. ADHD medication use patterns in the US differed markedly from those in western European countries.

The Prevalence of Stimulant and Antidepressant Use by Australian Children and Adolescents with Attention-Deficit/Hyperactivity Disorder and Major Depressive Disorder: A National Survey

OBJECTIVES

To identify the prevalence of stimulant and antidepressant medication use by children and adolescents with symptoms meeting the criteria for attention-deficit/hyperactivity disorder (ADHD) and major depressive disorder (MDD) in Australia. To identify factors associated with stimulant and antidepressant use by children and adolescents in Australia.

METHODS

Data are from a nationally representative sample of 4- to 17-year-olds (n = 6310). Parents completed the Diagnostic Interview Schedule for Children-Version IV (DISC-IV) and the Strengths and Difficulties Questionnaire. Eleven- to 17-year-olds completed a self-report version of the DISC-IV MDD module. Interviewers recorded prescribed medications used by participants in the previous 2 weeks.

RESULTS

During a 2-week period, 1.3% of all 4- to 17-year-olds and 13.7% of those with symptoms meeting the criteria for ADHD had used stimulant medication, while 0.9% of all 4- to 17-year-olds and 13.4% with MDD had used antidepressants. In total, 22.6% of those using stimulant medications and 57.7% using antidepressant medications did not have symptoms meeting criteria for ADHD or MDD, respectively. Among 11- to 17-year-olds, 5.6% of those with adolescent-only-reported MDD, 10.9% of those with parent/carer-only-reported MDD, and 25.7% of those with MDD reported by both parents/carers and adolescents were using antidepressant medications.

CONCLUSIONS

Only a minority of 4- to 17-year-olds with ADHD and MDD were being treated with stimulant or antidepressant medication. The percentage of adolescents with MDD using antidepressant medications varied depending on whether adolescents, parents/carers, or both identified the presence of MDD. This highlights the importance of using information from both these informants when assessing and treating adolescent depressive disorder.

Trends and patterns of antidepressant use in children and adolescents from five western countries, 2005-2012

Following the FDA black box warning in 2004, substantial reductions in antidepressant (ATD) use were observed within 2 years in children and adolescents in several countries. However, whether these reductions were sustained is not known. The objective of this study was to assess more recent trends in ATD use in youth (0-19 years) for the calendar years 2005/6-2012 using data extracted from regional or national databases of Denmark, Germany, the Netherlands, the United Kingdom (UK), and the United States (US). In a repeated cross-sectional design, the annual prevalence of ATD use was calculated and stratified by age, sex, and according to subclass and specific drug. Across the years, the prevalence of ATD use increased from 1.3% to 1.6% in the US data (+26.1%); 0.7% to 1.1% in the UK data (+54.4%); 0.6% to 1.0% in Denmark data (+60.5%); 0.5% to 0.6% in the Netherlands data (+17.6%); and 0.3% to 0.5% in Germany data (+49.2%). The relative growth was greatest for 15-19 year olds in Denmark, Germany and UK cohorts, and for 10-14 year olds in Netherlands and US cohorts. While SSRIs were the most commonly used ATDs, particularly in Denmark (81.8% of all ATDs), Germany and the UK still displayed notable proportions of tricyclic antidepressant use (23.0% and 19.5%, respectively). Despite the sudden decline in ATD use in the wake of government warnings, this trend did not persist, and by contrast, in recent years, ATD use in children and adolescents has increased substantially in youth cohorts from five Western countries.

Psychotropic drug use among 0-17 year olds during 2004-2014: a nationwide prescription database study

BACKGROUND

Time-trend studies on psychotropic drugs among children and adolescents are scarce, and most of them are outdated. The purpose of this study was to study prevalences of psychotropic drug use during 2004-2014 among Norwegians aged <18 years, overall and in psychotropic sub-groups.

METHODS

Data were obtained from the Norwegian Prescription Database, which covers all dispensed prescription drugs in Norway from 2004 and onwards. Psychotropic drugs included: antipsychotics (ATC-group N05A), anxiolytics (N05B), hypnotic/sedatives (N05C), antidepressants (N06A), stimulants (N06BA), and alimemazine (R06AD01). Period (1-year) prevalence of use, overall and in subgroups of psychotropic drugs, was estimated by identifying individuals <18 years who had at least one psychotropic drug dispensed during each year.

RESULTS

Psychotropic drug use increased in 0-17 year olds over an 11-year period, in which the main contributing drugs were stimulants (boys overall; 15.0 to 20.8/1000, girls overall; 3.8 to 8.5/1000), hypnotic/sedative drugs in adolescents (boys overall; 4.2 to 10.8/1000, girls overall; 2.6 to 8.8/1000) and to some extent antidepressants among adolescent girls (girls overall from 3.1 to 4.0/1000). Psychotropic drug use was, however, reduced by half in the youngest children, attributed to reduction of alimemazine only (1-year olds: boys; from 36.6 to 10.2/1000, girls; 26.9 to 7.2/1000). A higher level of psychotropic drug use was observed among younger boys, but there is a shift towards girls using more psychotropic drugs than boys during adolescence for all psychotropic drugs except for stimulants.

CONCLUSION

Different trends in psychotropic drug use exist in age and gender subgroups. Psychotropic drug use has decreased among the youngest children, attributed to alimemazine, and increased in older children and adolescents, attributed mainly to stimulants and hypnotics/sedatives.

[Structural quality in inpatient and daycare child and adolescent psychiatry- indicators for planning future staff ratios for the era following the Psychiatry Personnel Act]

The German Psychiatry Personnel Act, which went into effect in 1990, has led to a decrease in the number of child and adolescent psychiatry inpatient beds, to a decrease in the length of stay, and to an increase in inpatient psychotherapy. Today, this act is outdated~ for a number of reasons, such as changes in the morbidity of the population, the rising number of emergencies, and new professional standards such as documentation. In addition, new legal provisions and conventions (like the UN Convention on the Rights of the Child) necessitate a complete reevaluation. Child and adolescent psychiatry needs a normative act to enable the necessary implementation. Many different rationales are available to support the debate.

Antidepressant prescribing in Irish children: secular trends and international comparison in the context of a safety warning

BACKGROUND

In 2003, the Irish Medicines Board (IMB) warned against the treatment of childhood depression with selective serotonin reuptake inhibitors (SSRIs) due to increased risk of suicide. This study examined the effect of this warning on the prevalence of anti-depressants in Irish children and compared age and gender trends and international comparisons of prescription rates.

METHODS

A retrospective cohort study of the Irish Health Service Executive (HSE) pharmacy claims database for the General Medical Services (GMS) scheme for dispensed medication. Data were obtained for 2002-2011 for those aged ≤ 15 years. Prevalence of anti-depressants per 1000 eligible population, along with 95% confidence intervals, were calculated. A negative binomial regression analysis was used to investigate trends and compare rates across years, sex and age groups (0-4, 5-11, 12-15 years). International prescribing data were retrieved from the literature.

RESULTS

The prevalence of anti-depressants decreased from 4.74/1000 population (95% CI: 4.47-5.01) in 2002 to 2.61/1000 population (95% CI: 2.43-2.80) in 2008. SSRI rates decreased from 2002 to 2008. Prescription rates for contra-indicated SSRIs paroxetine, sertraline and citralopram decreased significantly from 2002 to 2005, and, apart from paroxetine, only small fluctuations were seen from 2005 onwards. Fluoxetine was the most frequently prescribed anti-depressant and rates increased between 2002 and 2011. Anti-depressant rates were higher for younger boys and older girls. The Irish prevalence was lower than the US, similar to the U.K. and higher than Germany and Denmark.

CONCLUSIONS

The direction and timing of these trends suggest that medical practitioners followed the IMB advice.

Recent international trends in psychotropic medication prescriptions for children and adolescents

Prescriptions of psychotropic medications have become an important intervention for many children and adolescents with mental disorders, and the rise of these prescriptions is debated intensively both among experts and the public. This review reports some recent international findings on point prevalence rates, cross-country comparisons, and time trends in psychotropic medication prescriptions for children and adolescents. Besides the total prescription rates, figures for antidepressants, antipsychotics, stimulants, and anxiolytics prescriptions are provided. The overall prescription rates of psychotropics in general and the major medication subgroups prescribed to children and adolescents vary substantially between countries with the US consumption being markedly higher than the use in European countries. However, even among the latter there are marked variations in findings. Studies reporting on time trends clearly indicate that there was a marked increase in the use of psychotropics for children and adolescents in the recent past. However, only a single study adjusted prevalence rates for the increasing number of children and adolescents assessed and treated in institutions providing mental health care. Considering the increasing numbers of children and adolescents seen in psychiatric services, the increase of psychotropic medications is less strong though still pronounced enough to stimulate further reflections on the use of these interventions.

Psychotropic medication use in French children and adolescents

OBJECTIVE

The purpose of this study was to describe the patterns of psychotropic drug use in a large representative population of children and adolescents drawn from the French National Health Insurance databank.

METHODS

Data were drawn from a sample of 1% of the beneficiaries of the French national health insurance, selecting those 0-17 years old in 2010 (n=128,298). In addition to age and gender, data included the identification number of each drug allowing a European Pharmaceutical Marketing Research Association (EphMRA) classification, as well as the type of the prescriber.

RESULTS

Overall, 2.5% of children and adolescents had been prescribed psychotropic medication. A majority were prescribed anxiolytics (1.9%), followed by antidepressants (0.3%), antipsychotics (0.3%), and stimulants (0.2%). Between the ages of 15 and 17, 6.1% of girls were prescribed anxiolytics and 1.1% were prescribed antidepressants. For boys, the anxiolytics remained the most prescribed psychotropic medication; however, between the ages of 11 and 14, and between the ages of 15 and 17 they received more antipsychotics (0.7% and 0.8%) and between the ages of 6 and 10, and between the ages of 11 and 14 (0.7% and 0.6%), they were prescribed more stimulants than were girls. Among those who received a prescription, a majority of youth (84.6%) received only one class of drugs, and general practitioners were found to be prescribing most of these prescriptions (81.7%).

CONCLUSIONS

The prevalence of psychotropic drug use in France is similar to that of the Netherlands and much lower than what is observed in the United States. Stimulants are less frequently prescribed in France than in other European countries, but anxiolytics are prescribed considerably more in France than in any other country.

Use of SSRIs among Danish children: a nationwide study

Our objective was to describe the use of selective serotonin reuptake inhibitors (SSRIs) in the entire Danish population of children and adolescents from 1995 to 2011. Data on filled SSRIs were obtained for all children in Denmark aged 5-17 during 1995-2011. The amount and type of SSRIs filled were calculated as well as incidence rates and prevalence proportions. Furthermore, we looked at concurrent use of other psychotropic drug treatment duration. A total of 23,547 children aged 5-17 used SSRIs during the study period, most commonly sertraline followed by citalopram. Overall, the incidence rate increased from 0.57 per 1,000 person years in 1997 to 3.30 in 2010 and fell to 2.55 in 2011, while the prevalence proportion rose from 0.1 per 1,000 children at the end of 1995 to 3.3 at the end of 2011. However, these findings were driven entirely by an increase among adolescents (12-17 years), where the prevalence proportion rose from 0.11 and 0.36 to 4.64 and 8.52 per 1,000 boys and girls, respectively. A significant proportion of SSRI users used other psychotropic drugs concurrently, most notably antipsychotics (12-28 %) and psychostimulants (10-33 %). About 50 % of adolescents and 40 % of children discontinued treatment within 12 months of initiation. We found a marked increase in the use of SSRI drugs among adolescents in Denmark between 1995 and 2011. Whether this increase reflects a true increase in disorder occurrence, an increase in diagnostic intensity or more aggressive treatment remains uncertain.

Polypharmacy with antidepressants in children and adolescents

The aim of this study was to review current epidemiological data on the use of antidepressants in co-prescription with other psychotropic drugs in children and adolescents, as well as available efficacy and safety information. A Medline search from inception until February 2012 was performed to identify epidemiological and clinical studies, reviews and reports containing potentially relevant information on polypharmacy with antidepressants in young people. There has been an increase in polypharmacy in children and adolescents involving antidepressants in recent years. Antidepressants have become one of the drug classes most frequently prescribed in combination and are commonly co-prescribed with stimulants and antipsychotics. Most information regarding efficacy and safety of polypharmacy patterns was provided by case series and open-label studies. Efficacy studies gave some support for the use of a combination of antidepressants and antipsychotics in the management of refractory obsessive-compulsive disorder and some residual symptoms in major depressive disorder. Even less empirical support was found for a combination of stimulants and antidepressants in co-morbid attention deficit hyperactivity disorder and mood or anxiety disorders. Adverse events were similar to those found with individual medication groups, with severe adverse events mostly reported by individual case reports. The use of polypharmacy with antidepressants has become a regular practice in clinical settings. Although there is still little efficacy and safety information, preliminary evidence points to the potential clinical usefulness of some polypharmacy patterns. Further research on patients with co-morbidities or more severe conditions is needed, in order to improve knowledge of this issue.

Antidepressant prescribing in five European countries: application of common definitions to assess the prevalence, clinical observations, and methodological implications

PURPOSE

Drug utilization studies have applied different methods to various data types to describe medication use, which hampers comparisons across populations. The aim of this study was to describe the time trends in antidepressant prescribing in the last decade and the variation in the prevalence, calculated in a uniform manner, in seven European electronic healthcare databases.

METHODS

Annual prevalence per 10,000 person-years (PYs) was calculated for 2001-2009 in databases from Spain, Germany, Denmark, the United Kingdom (UK), and the Netherlands. Prevalence data were stratified according to age, sex, antidepressant type (selective serotonin re-uptake inhibitors [SSRIs] or tricyclic antidepressants [TCAs]) and major indications.

RESULTS

The age- and sex-standardized prevalence was lowest in the two Dutch (391 and 429 users per 10,000 PYs) and highest in the two UK (913 and 936 users per 10,000 PYs) populations in 2008. The prevalence in the Danish, German, and Spanish populations was 637, 618, and 644 users per 10,000 PY respectively. Antidepressants were prescribed most often in 20- to 60-year-olds in the two UK populations compared with the others. SSRIs were prescribed more often than TCAs in all except the German population. In the majority of countries we observed an increasing trend of antidepressant prescribing over time. Two different methods identifying recorded indications yielded different ranges of proportions of patients recorded with the specific indication (15-57% and 39-69% for depression respectively).

CONCLUSION

Despite applying uniform methods, variations in the prevalence of antidepressant prescribing were obvious in the different populations. Database characteristics and clinical factors may both explain these variations.

Social defeat stress induces a depression-like phenotype in adolescent male c57BL/6 mice

Abstract Exposure to stress is highly correlated with the emergence of mood-related illnesses. Because major depressive disorder often emerges in adolescence, we assessed the effects of social defeat stress on responses to depressive-like behaviors in juvenile mice. To do this, postnatal day (PD) 35 male c57BL/6 mice were exposed to 10 days of social defeat stress (PD35-44), while control mice were handled daily. Twenty-four hours after the last episode of defeat (PD45), separate groups of mice were tested in the social interaction, forced swimming, sucrose preference, and elevated plus-maze behavioral assays (n = 7-12 per group). Also, we examined body weight gain across days of social defeat and levels of blood serum corticosterone 40 min after the last episode of defeat stress. Our data indicates that defeated mice exhibited a depressive-like phenotype as inferred from increased social avoidance, increased immobility in the forced swim test, and reduced sucrose preference (a measure of anhedonia), when compared to non-defeated controls. Defeated mice also displayed an anxiogenic-like phenotype when tested on the elevated plus-maze. Lastly, stressed mice displayed lower body weight gain, along with increased blood serum corticosterone levels, when compared to non-stressed controls. Overall, we show that in adolescent male c57BL/6 mice, social defeat stress induces a depression- and anxiety-like phenotype 24 h after the last episode of stress. These data suggest that the social defeat paradigm may be used to examine the etiology of stress-induced mood-related disorders during adolescence.

Are antidepressants effective in quality of life improvement among children and adolescents? A systematic review

There is some evidence indicating that psychotropic medications might lead to health-related quality of life (QOL) improvements among children and adolescents with psychiatric disorders. The aim of this systematic review is to assess evidence regarding whether antidepressant treatment improves QOL among children and adolescents with depressive or anxiety disorders. A comprehensive search resulted in 5 clinical trials to be included in this review: 4 trials with major depressive disorder (MDD) and 1 trial with social anxiety disorder (SAD). In one MDD trial, fluoxetine combined with cognitive behavior therapy (CBT) significantly improved QOL compared to fluoxetine or CBT alone (effect sizes were 0.53 and 0.69, respectively). In 2 combined trials, sertraline alone significantly improved QOL among adolescents with MDD (effect size was 0.29), but not among children with MDD. Essentially, it was observed that antidepressants in these trials had minor positive effects on QOL improvement, which were lower than their potential to improve depressive symptoms. Although fluoxetine with CBT or sertraline monotherapy were shown to have some potential to improve QOL, this systematic review found inconclusive evidence that antidepressant treatments improve QOL among children and adolescents with depressive or anxiety disorders. More research is required, considering that QOL is currently under-evaluated in clinical trials with antidepressants among children and adolescents and available trials have limited methodological quality when reporting QOL data.

Nationwide time trends in dispensed prescriptions of psychotropic medication for children and adolescents in Denmark

OBJECTIVE

The analysis of time trends in dispensed prescriptions of psychotropic medications for children and adolescents in Denmark.

METHOD

The entire data set of the Danish prescription register covering stimulants, antidepressants, antipsychotics, and anxiolytics used in children and adolescents over a 15-year time span from 1996 to 2010 was analyzed. Both non-adjusted age-standardized prevalence rates and adjusted age-standardized prevalence rates considering the increase in patient numbers over time were calculated, and time trends were assessed based on 105908 patient-years.

RESULTS

For stimulants, antidepressants, and antipsychotics, the non-adjusted prevalence rates increased significantly. These trends were strongest for the stimulants. However, all adjusted prevalence rates were much lower with the anxiolytics even declining significantly. The prevalence rates of stimulants and antipsychotics were significantly higher among males than females, whereas females received significantly more antidepressants. The increase in prescription rates for both antidepressants and antipsychotics was mainly due to increased use among the 14- to 17-year-olds. Stratification by diagnoses revealed significantly increasing prevalence rates of dispensed antidepressants and antipsychotics in six major diagnostic indications.

CONCLUSION

Although increasing, the unadjusted Danish prevalence rates of dispensed prescriptions of psychotropics for children and adolescents are still lower than in many other Western countries.

Long-term trend in pediatric antidepressant use, 1983-2007: a population-based study

OBJECTIVE

Research is needed to clarify and improve our understanding of appropriateness and safety issues concerning antidepressant (AD) treatment. We explored the long-term trend in the dispensing of pediatric ADs using provincial, population-based data from Canada.

METHODS

Data covering 22 ADs were drawn from the Saskatchewan Ministry of Health administrative data files in outpatient settings. The data were for 9 triennial years from 1983 to 2007, a 24-year period, for those aged 0 to 19 in the general population. Descriptive analyses were used.

RESULTS

In 1983, 5.9 per 1000 population aged 0 to 19 were dispensed at least 1 AD; this decreased to 5.1 per 1000 population in 1989, and then increased to 15.4 per 1000 population in 2007, with a slower increase after 2004. Both sexes were dispensed more ADs from 1989 onwards, with females being the heavier users. The rate of AD use increased significantly with age, and this trend became more pronounced after 1998. Family physicians were the major prescribers and their prescriptions significantly increased from 1989 to 2004 and decreased in 2007. The use of selective serotonin reuptake inhibitors (SSRIs) was the major reason for the increase. The number of AD scripts per patient also increased.

CONCLUSIONS

The growth in the prevalence of AD use among children and youth was largely caused by the use of SSRIs. The possibility of safety issues induced by AD use among children and adolescents, and different patterns of medication practice, suggest continuing education is warranted.

Non-medical use of prescription opioids and prescription opioid-related harms: why so markedly higher in North America compared to the rest of the world?

AIMS

This paper aims to identify possible system-level factors contributing to the marked differences in the levels of non-medical prescription opioid use (NMPOU) and prescription opioid (PO)-related harms in North America (i.e. the United States and Canada) compared to other global regions.

METHODS

Scientific literature and information related to relevant areas of health systems, policy and practice were reviewed and integrated.

RESULTS

We identified several but different factors contributing to the observed differences. First, North American health-care systems consume substantially more Pos-even when compared to other high-income countries-than any other global region, with dispensing levels associated strongly with levels of NMPOU and PO-related harms. Secondly, North American health-care systems, compared to other systems, appear to have lesser regulatory access restrictions for, and rely more upon, community-based dispensing mechanisms of POs, facilitating higher dissemination level and availability (e.g. through diversion) of POs implicated in NMPOU and harms. Thirdly, we note that the generally high levels of psychotrophic drug use, dynamics of medical-professional culture (including patient expectations for 'effective treatment'), as well as the more pronounced 'for-profit' orientation of key elements of health care (including pharmaceutical advertising), may have boosted the PO-related problems observed in North America.

CONCLUSIONS

Differences in the organization of health systems, prescription practices, dispensing and medical cultures and patient expectations appear to contribute to the observed inter-regional differences in non-medical prescription opioid use and prescription opioid-related harms, although consistent evidence and causal analyses are limited. Further comparative examination of these and other potential drivers is needed, and also for evidence-based intervention and policy development.

Fluoxetine exposure during adolescence alters responses to aversive stimuli in adulthood

The mechanisms underlying the enduring neurobiological consequences of antidepressant exposure during adolescence are poorly understood. Here, we assessed the long-term effects of exposure to fluoxetine (FLX), a selective serotonin reuptake inhibitor, during adolescence on behavioral reactivity to emotion-eliciting stimuli. We administered FLX (10 mg/kg, bi-daily, for 15 d) to male adolescent [postnatal day 35 (P35) to P49] C57BL/6 mice. Three weeks after treatment (P70), reactivity to aversive stimuli (i.e., social defeat stress, forced swimming, and elevated plus maze) was assessed. We also examined the effects of FLX on the expression of extracellular signal-regulated kinase (ERK) 1/2-related signaling within the ventral tegmental area (VTA) of adolescent mice and Sprague Dawley rats. Adolescent FLX exposure suppressed depression-like behavior, as measured by the social interaction and forced swim tests, while enhancing anxiety-like responses in the elevated plus maze in adulthood. This complex behavioral profile was accompanied by decreases in ERK2 mRNA and protein phosphorylation within the VTA, while stress alone resulted in opposite neurobiological effects. Pharmacological (U0126) inhibition, as well as virus-mediated downregulation of ERK within the VTA mimicked the antidepressant-like profile observed after juvenile FLX treatment. Conversely, overexpression of ERK2 induced a depressive-like response, regardless of FLX pre-exposure. These findings demonstrate that exposure to FLX during adolescence modulates responsiveness to emotion-eliciting stimuli in adulthood, at least partially, via long-lasting adaptations in ERK-related signaling within the VTA. Our results further delineate the role ERK plays in regulating mood-related behaviors across the lifespan.

Polypharmacy reduction in youth in a residential treatment center leads to positive treatment outcomes and significant cost savings

OBJECTIVE

The purpose of this study was to assess whether polypharmacy regimens can be safely and effectively reduced for youth placed in a residential treatment center, and to assess the cost savings achieved from medication reductions.

METHODS

Data were collected for 131 youth ages 11-18, who were admitted to and discharged from a residential treatment center between 2007 and 2011. Six month postdischarge data were available for 51 youth. Data include demographics, admission and discharge medications, place of discharge, and postdischarge stability level.

RESULTS

Upon admission, 30 youth were not on medication, at discharge 48 were not; a 60% increase. Mean number of admission medications was 2.16 (SD=0.97) versus 1.55 (SD=0.70) upon discharge. Upon admission, one youth was on five and nine were on four medications. At end-point, only one youth was on four medications. The number of youth needing two or more medications declined by 55%, and the number of those needing three or more declined by 69%. The largest reduction was seen in the number of antipsychotics and antidepressants. Mood stabilizer and antipsychotic combinations declined by 65%. Youth with medication reduction were more likely to be discharged to a less restrictive setting than were youth without medication reduction (72.6% vs. 53.8%), p=0.03. At 6 months postdischarge, of the 51 out of 131 youth with available follow-up data, 71% were doing well. Cost analysis based on discontinued medication by class showed monthly savings of $21,365, or $256,368 yearly. The largest contributor was the reduction in the use of antipsychotics, accounting for $205,332 of the total savings.

CONCLUSIONS

Our study indicates that comprehensive treatment can lead to significant reductions in polypharmacy, and positive short- and longer-term treatment outcomes. Judicial prescribing also resulted in significant cost reduction in an already costly healthcare system.

Antidepressant drug use and off-label prescribing in children and adolescents in Germany: results from a large population-based cohort study

The off-label use of drugs in children and adolescents is widespread. In Germany, the use of selective serotonin reuptake inhibitors (SSRIs) and other antidepressants (OADs) is not licensed for the treatment of depressive disorders in children and adolescents except for fluoxetine, which was approved in 2006. Against this background, antidepressant drug (ATD) use with a particular focus on off-label prescribing was characterised in a retrospective cohort study including cross-sectional analyses based on claims data of 2,599,685 patients up to 17 years of age. Prevalence of ATD use was 1.84 (95% CI 1.78-1.90) per 1,000 children in 2004, 1.57 (95% CI 1.52-1.62) in 2005 and 1.66 (95% CI 1.61-1.72) in 2006. More than half of all children treated with ATDs (51.29%) received only one single prescription of an ATD during the study period. Of all prescribed ATDs, 11,172 (42.09%) were tricyclic antidepressants 9,179 (34.58%) were SSRIs, 4,371 (16.47%) were St John's wort preparations and 1,821 (6.86%) were OADs. Around half of all children and adolescents who were treated with ATDs were diagnosed with depressive disorders (56.30%). Overall, 13,035 (49.11%) of all ATDs were prescribed off-label. Off-label use by age (40.18%) was found to be more common than off-label use by indication (16.63%) with 7.70% of off-label use occurring in both categories. Specialist treatment by hospital-based physicians increased the risk (odds ratio: 2.26, 95% CI 2.05-2.48) of receiving an off-label prescription compared to treatment by general practitioners. In summary, off-label use of ATDs in children and adolescents was substantial in Germany.

Trends, correlates, and disease patterns of antidepressant use among children and adolescents in Taiwan

The authors used a population-based database to investigate antidepressant use among children and adolescents in Taiwan. The National Health Research Institutes provided a database of 1 000 000 random subjects for study. The authors adopted this sample of subjects who were younger than 18 years during 1997 to 2005. Subjects with at least 1 antidepressant prescription were identified. Trends, prevalence, associated factors, and disease patterns of antidepressant use were detected. The 1-year prevalence of pediatric antidepressant use increased from 0.27% in 1997 to 0.47% in 2005. The 1-year prevalence of tricyclic antidepressant, selective serotonin reuptake inhibitor, and other antidepressant use among pediatric population was 0.23%, 0.20%, and 0.08%, respectively, in 2005. The prevalence of pediatric antidepressant use increased from 1997 to 2005. Among pediatric subjects with antidepressant use, selective serotonin reuptake inhibitors, and other antidepressants were used the most for psychiatric disorders, whereas tricyclic antidepressant was used the most for nonpsychiatric disorders.

Increase in psychotropic drug use between 2006 and 2010 among adolescents in Norway: a nationwide prescription database study

Background

The purposes of this study were to investigate the prevalence of psychotropic (hypnotic, antidepressant, and anxiolytic) drug use among adolescents aged 15–16 years during the period 2006–2010 according to gender and subcategories of psychotropics, and to study psychotropic drug use over the period 2007–2010 among incident users in 2007.

Methods

This was a one-year prevalence and follow-up study based on information retrieved from the nationwide Norwegian prescription database for the period 2006–2010. The study population consisted of adolescents aged 15–16 years who had filled at least one prescription for a psychotropic drug in the study period. The main outcome measures were filling of hypnotic, antidepressant, and/or anxiolytic drug prescriptions.

Results

Overall use of psychotropic drugs increased from 13.9 to 21.5 per 1000 among boys and from 19.7 to 24.7 per 1000 among girls during the 2006– 2010 period. Hypnotic drugs, and melatonin in particular, accounted for most of the increase. For melatonin, the annual median amount dispensed was 180 defined daily doses through the period until 2010, at which time it decreased to 90 defined daily doses. In total, 16.4% of all incident psychotropic drug users in 2007 were still having prescriptions dispensed in 2010.

Conclusion

This study shows an increase in hypnotic drugs dispensed for adolescents in Norway, mainly attributable to the increasing use of melatonin. The amount of melatonin dispensed indicates more than sporadic use over longer periods, despite melatonin only being licensed in Norway for use in insomnia for individuals aged 55 years or older.

Mental distress and subsequent use of psychotropic drugs among adolescents-a prospective register linkage study

PURPOSE

To investigate the association between mental distress, other factors, and subsequent use of psychotropic drugs in adolescents aged 15-16 years.

METHODS

This study is based on information retrieved from the Norwegian Youth Health Surveys (2000-2003) and linked to prescription data from the Norwegian Prescription Database (2004-2009). The study population included 11,620 adolescents aged 15-16 (87% response rate) years. Self-reported mental distress (Hopkins Symptom Checklist-10 score 1.85) was recorded along with health and lifestyle habits, education plans, and family economics. Incident psychotropic drug use (outcome measure) was defined ≥1 prescriptions of one of the following psychotropic drugs: anxiolytics, hypnotics, antidepressants, or phenothiazines registered in the Norwegian Prescription Database.

RESULTS

Overall, 15.5% of the adolescents reported mental distress, 75% of them were girls. For both genders, incident psychotropic use was significantly higher among those reporting mental distresses at baseline, compared with the rest of the participants. The highest psychotropic drug use was observed among mentally distressed girls (27.7%). Mental distress was significantly associated with incident use of psychotropic drugs (odds ratio: 2.25, 95% confidence interval: 1.97-2.55). After adjustment for confounding factors and inclusion of potential mediating factors, the odds ratio attenuated to 1.59 (95% confidence interval: 1.35-1.86).

CONCLUSIONS

The prevalence of mental distress among adolescents may have consequences for health promotion. Public health nurses in Norway, working in health centers and schools, have a responsibility to promote health and prevent health problems. They have the opportunity and a responsibility to identify vulnerable young people.

Outpatient treatment in German adolescents with depression: an analysis of nationwide health insurance data

PURPOSE

Data on medical treatment of adolescents with depression are scarce. This study aimed to examine outpatient health services utilisation of depressive disorders in adolescents.

METHODS

Data of a statutory health insurance company were analysed and outpatients from 12 to 18 years old with diagnosed depression during a 1-year period (2009) were identified. For this cohort, the prescription of antidepressants and psychotherapy was evaluated with respect to age and sex.

RESULTS

A total of 4295 patients (41.2% males; mean age, 15.5 years) matched the inclusion criteria. Of the patients, 29.7% consulted a child and adolescent psychiatrist. A total of 59.6% were treated with psychotherapy only, 9.6% were treated with a combination of psychotherapy and antidepressants, and 1.9% received only antidepressants. For 28.8% of patients, no specific depression-related treatment was prescribed. A total of 1357 packages of antidepressants were analysed, of which fluoxetine (24.4% of prescriptions), citalopram (14.0%), and mirtazapine (9.7%) were the most frequently prescribed substances. Regarding substance classes, selective serotonin reuptake inhibitors (SSRIs; 55.6%), tricyclic antidepressants (TCAs; 17.9%), and hypericum (St. John's wort; 8.5%) were most common.

CONCLUSIONS

Although the underlying data were coded for insurance purposes, which might result in some data impreciseness, this naturalistic study furnishes evidence that outpatient treatment of adolescents with depressive disorders in Germany only partly complies with guideline recommendations for first-line treatment: Although the prescriptions of SSRI for adolescent depression have risen over recent years, still, a quarter of antidepressant prescriptions for adolescents with depression were TCA or hypericum. Therefore, dissemination of knowledge on state-of-the-art treatment for adolescent depression remains a major educational goal.

Age-dependent effects of chronic fluoxetine treatment on the serotonergic system one week following treatment

RATIONALE

Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine are increasingly used for the treatment of depression in children. Limited data are, however, available on their effects on brain development and their efficacy remains debated. Moreover, previous experimental studies are seriously hampered in their clinical relevance.

OBJECTIVES

The aim of the present study was to investigate putative age-related effects of a chronic treatment with fluoxetine (5 mg/kg, either orally or i.p. for 3 weeks, 1 week washout) using conventional methods (behavioral testing and binding assay using [(123)I]β-CIT) and a novel magnetic resonance imaging (MRI) approach.

METHODS

Behavior was assessed, as well as serotonin transporter (SERT) availability and function through ex vivo binding assays and in vivo pharmacological MRI (phMRI) with an acute fluoxetine challenge (10 mg/kg oral or 5 mg/kg i.v.) in adolescent and adult rats.

RESULTS

Fluoxetine caused an increase in anxiety-like behavior in treated adult, but not adolescent, rats. On the binding assays, we observed increased SERT densities in most cortical brain regions and hypothalamus in adolescent, but not adult, treated rats. Finally, reductions in brain activation were observed with phMRI following treatment, in both adult and adolescent treated animals.

CONCLUSION

Collectively, our data indicate that the short-term effects of fluoxetine on the 5-HT system may be age-dependent. These findings could reflect structural and functional rearrangements in the developing brain that do not occur in the matured rat brain. phMRI possibly will be well suited to study this important issue in the pediatric population.

Pediatric oncologists' practices of prescribing selective serotonin reuptake inhibitors (SSRIs) for children and adolescents with cancer: a multi-site study

OBJECTIVE

To survey pediatric oncologists regarding prescription of selective serotonin reuptake inhibitors (SSRIs) and related medications for the treatment of depression and anxiety disorders in children with cancer. Specifically, we sought to determine (a) how frequently pediatric oncologists prescribed SSRIs and what were the most commonly prescribed agents; (b) how decisions were made to prescribe, particularly whether mental health professionals were consulted; (c) how patients were monitored while on the agents; and (d) how the FDA black box warning has affected prescribing practices.

METHOD

Oncologists from nine children's cancer centers (N = 151) from across the U.S. were surveyed, responding to either on-line or paper versions of a questionnaire developed for this study.

RESULTS

A majority of oncologists (71%) reported prescribing SSRIs for their patients. Oncologists reported difficulties differentiating symptoms of depression from aspects of cancer treatment. Mental health practitioners are consulted occasionally but not routinely, and oncologists reported a need for increased mental health resources. Approximately half of oncologists (51%) reported that the FDA black box warning had not affected their practice. In addition, only 28% reported monitoring patients on SSRIs at FDA recommended intervals, and only 9% indicated assessing for suicidality.

CONCLUSIONS

Prescription of SSRIs is a common practice of pediatric oncologists, often without consultation with mental health professionals. Post-prescription monitoring appears to be suboptimal, and does not follow FDA guidelines.

Childhood predictors of use and costs of antidepressant medication by age 24 years: findings from the Finnish Nationwide 1981 Birth Cohort Study

OBJECTIVE

Prior studies on antidepressant use in late adolescence and young adulthood have been cross-sectional, and prospective associations with childhood psychiatric problems have not been examined. The objective was to study the association between childhood problems and lifetime prevalence and costs of antidepressant medication by age 24 years.

METHOD

A total of 5,547 subjects from a nation-wide birth cohort were linked to the National Prescription Register. Information about parent- and teacher-reported conduct, hyperkinetic and emotional symptoms, and self-reported depressive symptoms was gathered at age 8 years. The main outcome measure was national register-based lifetime information about purchases of antidepressants between ages 8 and 24 years. In addition, antidepressant costs were analyzed using a Heckman maximum likelihood model.

RESULTS

In all, 8.8% of males and 13.8% of females had used antidepressants between age 13 and 24 years. Among males, conduct problems independently predicted later antidepressant use. In both genders, self-reported depressive symptoms and living in other than a family with two biological parent at age 8 years independently predicted later antidepressant use. Significant gender interactions were found for conduct and hyperkinetic problems, indicating that more males who had these problems at age 8 have used antidepressants compared with females with the same problems.

CONCLUSIONS

Childhood psychopathology predicts use of antidepressants, but the type of childhood psychopathology predicting antidepressant use is different among males and females.

Antidepressant utilization patterns and mortality in Swedish men and women aged 20-34 years

PURPOSE

To compare antidepressant utilization patterns and mortality in relation to antidepressant use in men and women aged 20-34 years.

METHODS

We used data from the Swedish Prescribed Drug Register to identify adults aged 20-34 years who purchased at least one antidepressant in 2006. Information on death and migration was obtained from the Total Population Register by record linkage. One-year prevalence and proportion of new users, amount of purchased antidepressants, concurrent use of other antidepressants, mood stabilizers and antipsychotics and mortality were assessed.

RESULTS

The one-year prevalence of antidepressant use was 5.6% among all Swedes aged 20-34 years (n = 94,239) and was higher among women than men (7.2 vs. 4.0%, p < 0.001). Selective serotonin reuptake inhibitors were the most dominant class of antidepressants at baseline and were more common among women than men (78.7 vs. 71.7%, p < 0.001). Of the new users, 22.3% filled only one prescription during the study period, men more often than women (24.1 vs. 21.4%, p < 0.001). The mortality rate was higher in men than in women (24 vs. 14 per 10,000, p = 0.009). Concurrent use of mood stabilizers (48 vs. 16 per 10,000, p < 0.001) and antipsychotics (50 vs. 14 per 10,000, p < 0.001) was associated with increased mortality in men and women.

CONCLUSIONS

Almost twice as many Swedish women than men aged 20-34 years purchased antidepressants in 2006. Differences in utilization patterns between sexes were rather small. Discontinuation rates were high, indicating that health care providers need to acquire an increased awareness on attitudes to treatment. In both sexes, mortality rates were elevated among those concurrently using mood stabilizers and antipsychotics, which needs further investigation.

Patterns of antidepressant use in Quebec children and adolescents: trends and predictors

Antidepressants are highly prescribed in youth although most products have not been approved for use in this population. Furthermore, regulatory warnings have led to changes in antidepressant use that might have differed across various countries. Our study aimed at determining factors associated with antidepressant prescribing practices and at assessing trends in use from 1997 to 2005 in Quebec youth.A retrospective cohort study was conducted through claims databases of the Quebec public health care program (RAMQ). The study included 5094 children (age 2-14) and 11,121 adolescents (age 15-19) who were incident users of antidepressant between 1997 and 2005. The characteristics of users and prescribers were the main independent variables.Tricyclics were the most frequently dispensed products among children (50.9%) and selective serotonin reuptake inhibitors among adolescents (58.8%). Selection of an antidepressant class was associated with patient characteristics and with prescriber specialty. The number of antidepressant users increased from 1997 until 2001 then decreased thereafter.The selection of an antidepressant class was associated with clinical and non-clinical characteristics. Although antidepressant use decreased after regulatory warnings, there appears to be a care gap between the evidence generated by efficacy studies and the products prescribed in a real-life setting.

Short- and long-term functional consequences of fluoxetine exposure during adolescence in male rats

BACKGROUND

Fluoxetine (FLX), a selective serotonin reuptake inhibitor, is prescribed for the treatment of major depressive disorder in young populations. Here, we explore the short- and long-term consequences of adolescent exposure to FLX on behavioral reactivity to emotion-eliciting stimuli.

METHODS

Adolescent male rats received FLX (10 mg/kg) twice daily for 15 consecutive days (postnatal days 35-49). The influence of FLX on behavioral reactivity to rewarding and aversive stimuli was assessed 24 hours (short-term) or 3 weeks after FLX treatment (long-term). A separate group of adult rats was also treated with FLX (postnatal days 65-79) and responsiveness to forced swimming was assessed at identical time intervals as with the adolescents.

RESULTS

Fluoxetine exposure during adolescence resulted in long-lasting decreases in behavioral reactivity to forced swimming stress and enhanced sensitivity to sucrose and to anxiety-eliciting situations in adulthood. The FLX-induced anxiety-like behavior was alleviated by re-exposure to FLX in adulthood. Fluoxetine treatment during adolescence also impaired sexual copulatory behaviors in adulthood. Fluoxetine-treated adult rats did not show changes in behavioral reactivity to forced swim stress as observed in those treated during adolescence and tested in adulthood.

CONCLUSIONS

Treating adolescent rats with FLX results in long-lived complex outputs regulated by the emotional valence of the stimulus, the environment in which it is experienced, and the brain circuitry likely being engaged by it. Our findings highlight the need for further research to improve our understanding of the alterations that psychotropic exposure may induce on the developing nervous system and the potential enduring effects resulting from such treatments.

Impact of regulatory safety warnings on the use of antidepressants among children and adolescents in Finland

OBJECTIVE

The aim of this study was to analyze changes in the prevalence and incidence of antidepressant use among children and adolescents in Finland post October, 2003.

METHOD

The sample comprised all children and adolescents in Finland aged < or =19.0 years (n = 27,676) who collected one or more reimbursed prescriptions for an antidepressant in noninstitutional and nonhospital settings between January, 1998, and December, 2005. Time-series models were used to compare antidepressant use 60 months before and 24 months after the health advisory issued by the Food and Drug Administration (FDA) in October, 2003.

RESULTS

The annual prevalence (users/1,000 youths) of antidepressant use increased from 5.24 in 2002 to 5.93 in 2005. There was an increase in the monthly incidence (users = 1,000 youths) of selective serotonin reuptake inhibitors (SSRIs) use (+0.02498), fluoxetine use (+0.00691), and sertraline use (+0.00727) post October, 2003. When considering preadvisory trends in antidepressant use, only fluoxetine use was higher than the predicted post October 2003, use (<0.001). The use of all other SSRIs was significantly lower than predicted.

CONCLUSIONS

In contrast to many other countries, the use of antidepressants continued to increase among children and adolescents in Finland post October, 2003. While the rate of fluoxetine use increased, there was a decline in the rate at which all other SSRIs were used.

Bipolar disorder in children and adolescents in Germany: national trends in the rates of inpatients, 2000-2007

OBJECTIVES

Increasing admission and prevalence rates of bipolar disorder (BD) are a matter of controversy in international child and adolescent psychiatry. We seek to contribute to this discussion by presenting data obtained in a population of German children and adolescents.

METHODS

Nationwide, whole population changes in inpatient admissions of BD and other psychiatric disorders between 2000 and 2007 were analyzed in individuals aged up to 19 years using registry data from the German Federal Health Monitoring System.

RESULTS

Inpatient admissions for BD in individuals aged up to 19 years increased from 1.13 to 1.91 per 100,000 or 68.5% between 2000 and 2007 (odds ratio: 1.69; 95% confidence interval: 1.41-2.02), with a nonsignificant decline in children less than 15 years and the largest relative increase in adolescents aged 15-19 years. Inpatient rates for depressive disorders increased by 219.6% and for hyperkinetic disorder by 111.3%. Conduct disorders increased by 18.1%, considerably less than the 38.1% general rise for all mental disorders in children and adolescents. The only significant decline in a diagnostic category occurred for psychotic disorders (-11.8%). BD inpatient admission represented only 0.22% of all mental disorder admissions in 2000 and 0.27% in 2007.

CONCLUSIONS

An elevation of inpatient admissions of BD in Germany in adolescents was detected, exceeding the general trend for increased mental disorder admissions. The results may indicate a higher clinical awareness and appreciation of mood symptoms at earlier ages and, in part, a reconceptualization of previously diagnosed psychotic disorders in youth. However, a diagnosis of BD in youngsters is still extremely rare in Germany. Diagnoses were based on the judgment of the treating physician. A correction for multiple admissions in the data set is not possible.