Antidepressant use in suicides: a case-control study from the Friuli Venezia Giulia Region, Italy, 2005-2014

Last general practitioner consultation during the final month of life: a national medical record review of suicides in Sweden

OBJECTIVES

Individuals who die by suicide often consult their general practitioners (GPs) in their final weeks of life. The aim of this study was to gain a deeper knowledge of the clinical characteristics and GP assessments and treatments among individuals who consulted their GPs during the month preceding suicide. Further, we compared these features in those with and without contact with psychiatric services (PC and NPC, respectively) during the two years that preceded the suicide.

DESIGN

A nationwide retrospective explorative study investigating medical records.

SETTING

Primary care in Sweden.

PARTICIPANTS

Individuals who died by suicide in Sweden in 2015 with a GP visit within 30 days of death.

RESULTS

The study cohort corresponds to one fifth (n = 238) of all suicides that occurred in Sweden in 2015 (n = 1179), representing all those with available primary care records showing contact with a GP during the final 30 days of life (NPC: n = 125; PC: n = 113). The mean age was 58 years ± 19. Patients in the NPC group were older (NPC: 63 years ± 19 vs. PC: 53 years ± 18, p < 0.0001) and presented psychiatric symptoms less often (NPC: 50% vs. PC: 67%, p < 0.006). Somatic symptoms were as common as psychiatric symptoms for the whole sample, being present in more than half of individuals. Suicide risk was noted in only 6% of all individuals. Referral to psychiatric services occurred in 14%, less commonly for the NPC group (NPC: 6% vs. PC: 22%, p < 0.001). Cardiovascular or respiratory symptoms were noted in 19%, more often in the NPC group (NPC: 30% vs. PC: 6%, p < 0.001), as were diagnoses involving the circulatory system (all 10%, NPC:14% vs. PC: 5%, p < 0.020).

CONCLUSION

A high level of somatic symptoms was observed in primary care patients both with and without psychiatric contact, and this might have influenced GPs' management decisions. Psychiatric symptoms were noted in two thirds of those with psychiatric contact but only half of those without. While GPs noted psychiatric symptoms in over half of all individuals included in the study, they seldom noted suicide risk. These findings highlight the need for increased attention to psychiatric symptoms and suicide risk assessment, particularly among middle-aged and older individuals presenting with somatic symptoms.

STRENGTHS AND LIMITATIONS OF THIS STUDY

The National Cause of Death Register has excellent coverage of suicide deaths and access to medical records was very good. The medical record review provided detailed information regarding primary care utilization before death by suicide. Because of the lack of statistical power, due to the limited number of persons with GP contact during the last month of life, we chose not to correct for multiple comparisons. Our study approach did not capture the reasons behind GPs' documentation of elevated suicide risk. No systematic inter-rater reliability (IRR) testing was made, however, reviewers received training and continuous support from the research group.

Association between previous SARs-CoV-2 infection and new prescription of antidepressant drugs: a case-control study in Friuli Venezia Giulia region, Italy

PURPOSE

A rise in affective and anxiety disorders and in antidepressant (AD) treatment during the COVID-19 pandemic has been extensively described, but few studies were provided at the individual level, further considering COVID-19 severity and vaccination status.

METHODS

Case-control study evaluating the association between the new use of ADs and a previous COVID-19 infection, in Friuli Venezia Giulia Region, Italy, from March 1, 2020, to July 19, 2022. Multiple conditional logistic regressions assess the association between a new AD use and a COVID-19 infection previous to the index date, stratified by gender, age and anti-COVID-19 vaccination status. Odds Ratios (OR) and 95% confidence intervals were reported.

RESULTS

COVID-19 was associated with AD treatment after the infection. The disease severity was positively associated with a growing risk of being dispensed an AD, with the highest risk in unvaccinated subjects previously hospitalised in ICU (OR = 28.77). The risk of using ADs after COVID-19 infection was higher in unvaccinated subjects aged 65 years and older, both females and males. The association between COVID-19 infection and AD dispensation in vaccinated subjects was not significant, with the exception of females aged 65 years and over.

CONCLUSIONS

Anti-COVID-19 vaccination, especially among the elderly, might prevent post-COVID AD treatment. Clinicians should be aware that COVID-19 patients requiring hospitalisation are more likely to experience these symptoms, given their higher risk of being dispensed ADs. Future studies may benefit by analysing the incidence of both mental disorders and psychotropic treatment in post-COVID patients, considering socioeconomic factors and vaccination status.

Increased antidepressant use during the COVID-19 pandemic: Findings from the Friuli Venezia Giulia region, Italy, 2015-2020

BACKGROUND

Few studies investigated the impact of the pandemic on antidepressant (AD) use.

METHODS

The Social and Health Information System of Friuli Venezia Giulia region, Italy, provided data on AD use. Sex, age, AD class and month used the amount of AD prescriptions, measured by defined daily doses (DDD) per 1000 inhabitants per day, to compare AD use in 2020 with the period 2015-2019. A linear trend model predicted AD use for 2020, based on years 2015-2019.

RESULTS

AD use was on average 20% higher in each month of 2020 when compared with the same month for the period 2015-2019, with an increase of more than 30% in the first four and in the last two months of 2020. The observed AD use in 2020 was higher than predicted, particularly in men, and in the 30-59 years age group.

LIMITATIONS

Descriptive study of AD use without analysis of data at the individual level. No information on psychiatric diagnoses of AD users.

CONCLUSION

AD use was higher in the first year of the COVID-19 pandemic. Further research is warranted to understand if this may be related to a rise in mental disorders in the general population during the COVID-19 pandemic.

Association between mirtazapine use and serious self-harm in people with depression: an active comparator cohort study using UK electronic health records

Background

Studies report an increased risk of self-harm or suicide in people prescribed mirtazapine compared with other antidepressants.

Objectives

To compare the risk of serious self-harm in people prescribed mirtazapine versus other antidepressants as second-line treatments.

Design and setting

Cohort study using anonymised English primary care electronic health records, hospital admission data and mortality data with study window 1 January 2005 to 30 November 2018.

Participants

24 516 people diagnosed with depression, aged 18–99 years, initially prescribed a selective serotonin reuptake inhibitor (SSRI) and then prescribed mirtazapine, a different SSRI, amitriptyline or venlafaxine.

Main outcome measures

Hospitalisation or death due to deliberate self-harm. Age–sex standardised rates were calculated and survival analyses were performed using inverse probability of treatment weighting to account for baseline covariates.

Results

Standardised rates of serious self-harm ranged from 3.8/1000 person-years (amitriptyline) to 14.1/1000 person-years (mirtazapine). After weighting, the risk of serious self-harm did not differ significantly between the mirtazapine group and the SSRI or venlafaxine groups (HRs (95% CI) 1.18 (0.84 to 1.65) and 0.85 (0.51 to 1.41) respectively). The risk was significantly higher in the mirtazapine than the amitriptyline group (3.04 (1.36 to 6.79)) but was attenuated after adjusting for dose.

Conclusions

There was no evidence for a difference in risk between mirtazapine and SSRIs or venlafaxine after accounting for baseline characteristics. The higher risk in the mirtazapine versus the amitriptyline group might reflect residual confounding if amitriptyline is avoided in people considered at risk of self-harm.

Clinical implications

Addressing baseline risk factors and careful monitoring might improve outcomes for people at risk of serious self-harm.

Effects of somatic treatments on suicidal ideation and completed suicides

OBJECTIVE

This work was undertaken to define and characterize the role of currently available somatic treatments in psychiatry in either increasing or reducing the risk for suicide.

METHODS

Members of the Suicide Prevention Task Group of the National Network of Depression Centers performed a literature review of somatic treatments known to increase or reduce the risk for suicide. The reviews ventured to include all relevant information about the risk for both suicide ideation and completed suicides.

RESULTS

Lithium and clozapine are the only two somatic treatments that have high-quality data documenting their antisuicide effects in mood disorders and schizophrenia, respectively. Lithium discontinuation is also associated with increased suicide risk. Ketamine and esketamine may have a small, but immediate, antisuicide effect. Despite the recent Food and Drug Administration approval of esketamine use in depressed suicidal patients, the small disproportional overrepresentation of suicide in subjects who had received esketamine versus placebo (3 vs. 0 among > 3500 subjects) requires ongoing evaluation. The purported antisuicide effect of electroconvulsive therapy is based on low-quality data. The effect of antidepressants is not at all clear. There appears to be direct evidence for antidepressants increasing suicidal ideation and the risk for suicide over the short-term in young people, but indirect (low quality) evidence that antidepressants reduce suicide risk over the long term.

CONCLUSIONS

Clinicians have an expanding pharmacopeia to address suicide potential in their patients. Some of the agents with documented antisuicide effects may also increase suicidality under specific circumstances.

The impact of Covid-19 pandemic on community-oriented mental health services: The experience of Friuli Venezia Giulia region, Italy

OBJECTIVES

to assess the changes in prevalence, incidence and hospitalisation rates during the first four months of 2020, compared to the same period of 2019, in Friuli Venezia Giulia Mental Health Departments (MHDs); to analyse the features of MHDs patients tested for Sars-Cov-2, and to monitor whether MHDs applied and adhered to regional recommendations.

METHODS

Observational study using MHDs' administrative data and individual data on suspected and positive cases of Sars-Cov-2. Adherence to recommentations was assessed using 21 indicators. Changes in rates were calculated by Poisson regression analysis, while the Fisher exact test was used for assessing differences between suspected and positive cases.

RESULTS

The decrease in voluntary admission rates on 100,000 inhabitants in hospital services was significantly larger from January to April 2020, compared to the same period of 2019 (P<0.001), while no other data showed a significant decrease. Among the 82 cases tested for Sars-Cov-2, five were positive, and they significantly differ from suspected cases only in that they were at home or in supported housing facilities prior to the test. The MHDs mostly complied with the indicators in the month after the publication of recommendations.

CONCLUSIONS

Outpatient services continued to work normally during the emergency, while hospital services decreased their activities. A low number of positive cases was found among MHDs' users, which might be linked to a rapid reconversion of services, with an extensive use of home visits and telepsychiatry. These preliminary data should be interpreted with caution, due to the small size and the limited period of observation.

Suicidal ideation and behavior in adults with major depressive disorder treated with vortioxetine: post hoc pooled analyses of randomized, placebo-controlled, short-term and open-label, long-term extension trials

OBJECTIVES

This study aimed to evaluate the risk of suicidal ideation and behavior associated with vortioxetine treatment in adults with major depressive disorder (MDD).

METHODS

Suicide-related events were evaluated post hoc using 2 study pools: one short-term pool of 10 randomized, placebo-controlled studies (6-8 weeks) and another long-term pool that included 3 open-label extension studies (52 weeks). Evaluation of suicide-related events was performed using Columbia-Suicide Severity Rating Scale (C-SSRS) scores and treatment-emergent adverse events (TEAEs) data.

RESULTS

At baseline, the percentage of patients reporting any C-SSRS ideation or behavior events in short-term studies was similar between placebo (14.7%), vortioxetine (19.8%, 13.0%, 11.2%, and 13.7% for 5-, 10-, 15-, and 20-mg groups, respectively), and duloxetine active reference (13.2%) and did not change throughout the 6- to 8-week treatment period for placebo (17.0%), vortioxetine (19.3%, 13.5%, 12.6%, and 15% for 5-, 10-, 15-, and 20-mg groups, respectively), or duloxetine (11.3%). The incidence of suicide-related events for TEAEs in the short-term pool was 0.4% for placebo, 0.2% or 1.0% for vortioxetine 5 mg or 10 mg, and 0.7% each for vortioxetine 15 mg and 20 mg, as well as duloxetine. After 52-week treatment with vortioxetine, suicidal ideation based on C-SSRS was 9.8%, C-SSRS suicidal behavior was 0.2%, and the incidence of suicide-related events based on TEAEs was <1%. There were no completed suicides in any study.

CONCLUSIONS

Vortioxetine is not associated with increased risk of suicidal ideation or behavior in MDD patients.

Occupational status and hospitalisation for mental disorders: findings from Friuli Venezia Giulia region, Italy, 2008-2017

Purpose: To investigate to which extent occupational status, and job titles, were associated with types of hospitalisations and psychiatric diagnoses among inpatients of Friuli Venezia Giulia Region, Italy.Methods: Cross-sectional study based on 10 years register data (2008-2017) on 2929 subjects hospitalised in General Hospital Psychiatric Units. Odds ratios (OR) of hospitalisations and psychiatric diagnoses for occupational status and job titles were calculated by logistic regression analysis.Results: Employed were at lower risk of urgent and involuntary hospitalisation. The risk of urgent hospitalisation was higher for affective, organic or other disorders, while all psychiatric diagnoses were at lower risk of involuntary hospitalisation than psychosis. Using white collars as reference category, army showed a higher risk for urgent hospitalisation (OR = 2.3) and affective disorders (OR = 1.9). A higher risk for affective disorders was found in managers (OR = 2.0). Blue collars were at higher risk for alcohol and substance abuse (OR = 1.7).Conclusions: Employment was protective for urgent and involuntary hospitalisations and severe diagnoses. Hospitalisation for affective disorders was more likely in managers, army, and for substances abuse in blue collars. More research is needed to assess the association between specific occupational groups and involuntary hospitalisation.KeypointsEmployment was shown to be a protective factor for both urgent and involuntary hospitalisations and diagnosis of severe mental disorder.Managers, police and military forces were at higher risk of being hospitalised for affective disorders, while blue collars were at higher risk of hospitalisation for alcohol and substances abuse.Future research would benefit from a better analysis on the association between more specific occupational groups and hospitalisation for psychiatric disorders, with a particular focus on involuntary treatment.Further research is needed to compare the risk of hospitalisation for mental disorders in temporary or permanent position, according to recent international changes in labour market and its impact on mental health.

Value of the Rare Disease Registry of the Italian Region Friuli Venezia Giulia

BACKGROUND

The lack of epidemiological and clinical data is a major obstacle in health service planning for rare diseases. Patient registries are examples of real-world data that may fill the information gap.

OBJECTIVE

We describe the Rare Disease Registry of the Friuli Venezia Giulia region of Italy and its potential for research and health planning.

METHODS

The Rare Disease Registry data were linked with information on mortality, hospital discharges, ambulatory care, and drug prescriptions contained in administrative databases. All information is anonymous, and data linkage was based on a stochastic key univocal for each patient. Average annual costs owing to hospitalizations, outpatient care, and medications were estimated.

RESULTS

Implementation of the Registry started in 2010, and 4250 participants were registered up to 2017. A total of 2696 patients were living in the region as of January 1, 2017. The overall raw prevalence of rare diseases was 22 per 10,000 inhabitants, with higher prevalence in the pediatric population. The most common disease groups were congenital malformations, chromosomal and genetic syndromes, and circulatory and nervous diseases. In 2017, 30 patients died, 648 were hospitalized, and 2355 received some type of ambulatory care. The total annual estimated cost was approximately €6.5 million, with great variability in the average patient cost across diseases.

CONCLUSIONS

The possibility of following the detailed real-world care experience of patients with each specific rare disease and assessing the costs related to each step in their care path represents a unique opportunity to identify inefficiencies, optimize care, and reduce waste of resources.