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Hedna K, Waern M. Use of Psychoactive Medications and Risk of Suicide in Late Life (75+): A Total Population Study. Drugs Real World Outcomes 2023; 10:491-498. [PMID: 37421593 PMCID: PMC10491562 DOI: 10.1007/s40801-023-00380-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND Psychoactive medications play an important role for the mental health and risk of suicidal behaviour in the oldest segment of the population (75+). A better understanding of psychoactive medication use is advocated to prevent suicide in this age group. PURPOSE We investigated the risk of suicide associated with the use of psychoactive medications in the total population aged ≥ 75 years, with and without exposure to antidepressants. METHOD A national population-based register study, including all Swedish residents aged ≥ 75 years between 2006 and 2014 (N = 1,413,806). A nested case-control design was used to investigate psychoactive medications associated with suicide among users and non-users of antidepressants. Risk estimates were calculated in adjusted conditional logistic regression models for the entire cohort and by gender. RESULTS Suicide occurred in 1305 persons (907 men and 398 women). Among them, 555 (42.5%) were on an antidepressant at the time of suicide. Adjusted incidence rate ratio (aIRR) for suicide was increased in those who were on hypnotics in the total cohort (aIRR 2.05, 95% confidence interval 1.74 to 2.41), in both users and non-users of antidepressants and for both genders. Elevated suicide risk was observed in those who concomitantly used anxiolytics with antidepressants (1.51, 1.25 to 1.83). Decreased risk of suicide was observed among those who were on anti-dementia drugs, in the total cohort (0.33, 0.21 to 0.52) and in both users and non-users of antidepressants. Use of antipsychotics and mood stabilisers showed no effect on suicide risk. CONCLUSION Use of hypnotics and concomitant use of anxiolytics with antidepressants was associated with increased risk of late-life suicide. Our findings suggest the need for careful evaluation of the benefit-risk balance of psychoactive medications as well as their availability as a possible suicide means. Future research should consider the indication of use of the psychoactive medications and the severity of psychiatric and medical illnesses of the patients.
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Affiliation(s)
- Khedidja Hedna
- AgeCap Center, Department of Psychiatry and Neurochemistry, Gothenburg University, 41345, Gothenburg, Sweden.
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Statistikkonsulterna Västra AB, Gothenburg, Sweden.
| | - Margda Waern
- AgeCap Center, Department of Psychiatry and Neurochemistry, Gothenburg University, 41345, Gothenburg, Sweden
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Psychosis Clinic, Gothenburg, Sweden
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Hedna K, Jonson M, Sigström R, Åberg M, Wilhelmson K, Waern M. Healthcare visits for mental disorders and use of psychotropic medications before and after self-harm in a cohort aged 75. Aging Ment Health 2023; 27:2052-2060. [PMID: 36803189 DOI: 10.1080/13607863.2023.2179974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 02/05/2023] [Indexed: 02/23/2023]
Abstract
OBJECTIVES Non-fatal self-harm (SH) is a major risk factor for late-life suicide. A better knowledge of the clinical management of older adults who self-harm is needed to establish where improvements could be made for the implementation of effective suicide prevention interventions. We therefore assessed contacts with primary and specialised care for mental disorders and psychotropic drug use during the year before and after a late-life non-fatal SH episode. METHOD Longitudinal population-based study in adults aged ≥75 years with SH episode between 2007 and 2015 retrieved from the regional database VEGA. Healthcare contacts for mental disorders and psychotropic use were assessed during the year before and after the index SH episode. RESULTS There were 659 older adults who self-harmed. During the year before SH, 33.7% had primary care contacts with a mental disorder, 27.8% had such contacts in specialised care. Use of specialised care increased sharply after the SH, reaching a maximum of 68.9%, but this figure dropped to 19.5% by the end of the year. Use of antidepressants increased from 41% before to 60% after the SH episode. Use of hypnotics was extensive before and after SH (60%). Psychotherapy was rare in both primary and specialised care. CONCLUSION The use of specialised care for mental disorders and antidepressant prescribing increased after SH. The drop in long-term healthcare visits should be further explored to align primary and specialised healthcare to the needs of older adults who self-harmed. The psychosocial support of older adults with common mental disorders needs to be strengthened.
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Affiliation(s)
- Khedidja Hedna
- AgeCap Center, Department of Psychiatry and Neurochemistry, Gothenburg University, Gothenburg, Sweden
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Statistikkonsulterna AB, Gothenburg, Sweden
| | - Mattias Jonson
- AgeCap Center, Department of Psychiatry and Neurochemistry, Gothenburg University, Gothenburg, Sweden
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Affective Clinic, Gothenburg, Sweden
| | - Robert Sigström
- AgeCap Center, Department of Psychiatry and Neurochemistry, Gothenburg University, Gothenburg, Sweden
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Cognition and Old Age Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Åberg
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Regionhälsan, Gothenburg, Sweden
| | - Katarina Wilhelmson
- AgeCap Center, Department of Psychiatry and Neurochemistry, Gothenburg University, Gothenburg, Sweden
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Acute Medicine and Geriatrics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Margda Waern
- AgeCap Center, Department of Psychiatry and Neurochemistry, Gothenburg University, Gothenburg, Sweden
- Neuropsychiatric Epidemiology Unit, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Psychosis Clinic, Gothenburg, Sweden
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Hedna K, Montuori C, Forte A, Pompili M, Waern M. Use of antidepressants and risk of repeat self-harm in older adults 75+ with nonfatal self-harm: A 1-year prospective national study. Pharmacoepidemiol Drug Saf 2021; 31:206-213. [PMID: 34687250 DOI: 10.1002/pds.5375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 09/26/2021] [Accepted: 10/15/2021] [Indexed: 11/07/2022]
Abstract
PURPOSE To assess exposure to antidepressants (AD) before and after nonfatal self-harm (SH) in older adults and to examine 1-year rates and risk factors for subsequent SH. METHODS Longitudinal national register-based retrospective cohort study of Swedish residents aged 75+ (N = 2775) with treatment at hospital or specialist outpatient clinic in connection with SH between January 1, 2006, and December 31, 2013. The cohort was followed for 1 year after the index episode. Exposure to AD was assessed at index and at subsequent SH. Cox regression analysis was used to assess factors associated with 1-year repeat SH. RESULTS At the index episode, 51% were prevalent AD users; 23% started AD during the following year. Overall 12% of prevalent AD users, 8% of AD nonusers, and 6% of AD new users repeated SH or died by suicide. About two-thirds of these subsequent behaviors occurred within 3 months after the index episode. Men had increased risk of subsequent SH (Hazard ratio [HR] 1.38, 95% CI: 1.09-1.74); older age (>85 years) was associated with a lower risk (HR 0.72, CI 95% 0.55-0.93). Users of AD did not have an increased risk of repeat SH. CONCLUSIONS Half of older adults who self-harmed were prevalent AD users and a further one fourth started an AD within 1 year after the index SH. Antidepressant use was not associated with increased risk of subsequent SH in this high-risk cohort of older adults.
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Affiliation(s)
- Khedidja Hedna
- Department of Psychiatry and Neurochemistry, AgeCap Center, Gothenburg University, Gothenburg, Sweden.,Statistikkonsulterna AB, Gothenburg, Sweden
| | - Chiara Montuori
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Alberto Forte
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Maurizio Pompili
- Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Margda Waern
- Department of Psychiatry and Neurochemistry, AgeCap Center, Gothenburg University, Gothenburg, Sweden.,Region Västra Götaland, Sahlgrenska University Hospital, Psychosis Clinic, Mölndal, Sweden
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Hempenius M, Luijken K, de Boer A, Klungel O, Groenwold R, Gardarsdottir H. Quality of reporting of drug exposure in pharmacoepidemiological studies. Pharmacoepidemiol Drug Saf 2020; 29:1141-1150. [PMID: 32394589 PMCID: PMC7539966 DOI: 10.1002/pds.5020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 03/26/2020] [Accepted: 04/06/2020] [Indexed: 12/31/2022]
Abstract
Purpose Exposure definitions vary across pharmacoepidemiological studies. Therefore, transparent reporting of exposure definitions is important for interpretation of published study results. We aimed to assess the quality of reporting of exposure to identify where improvement may be needed. Method We systematically reviewed observational pharmacoepidemiological studies that used routinely collected health data, published in 2017 in six pharmacoepidemiological journals. Reporting of exposure was scored using 11 items of the ISPE‐ISPOR guideline on reporting of pharmacoepidemiological studies. Results Of the 91 studies included, all studies reported the type of exposure (100%), while most reported the exposure risk window (85%) and the exposure assessment window (98%). Operationalization of the exposure window was described infrequently: 16% (14/90) of the studies explicitly reported the presence or absence of an induction period if applicable, 11% (5/47), and 35% (17/49) reported how stockpiling and gaps between exposure episodes were handled, respectively, and 35% (17/49) explicitly mentioned the exposure extension. Switching/add‐on was reported in 62% (50/81). How switching between drugs was dealt with and specific drug codes were reported in 52 (57%) and 24 (26%) studies, respectively. Conclusion Publications of pharmacoepidemiological studies frequently reported the type of exposure, the exposure risk window, and the exposure assessment window. However, more details on exposure assessment are needed, especially when it concerns the operationalization of the exposure risk window (eg, the presence or absence of an induction period or exposure extension, handling of stockpiling and gaps, and specific codes), to allow for correct interpretation, reproducibility, and assessment of validity.
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Affiliation(s)
- Mirjam Hempenius
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Kim Luijken
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Olaf Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Rolf Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands.,Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht, the Netherlands.,Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland
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Forsman J, Taipale H, Masterman T, Tiihonen J, Tanskanen A. Adherence to psychotropic medication in completed suicide in Sweden 2006-2013: a forensic-toxicological matched case-control study. Eur J Clin Pharmacol 2019; 75:1421-1430. [PMID: 31218371 DOI: 10.1007/s00228-019-02707-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/04/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate the influence of adherence to psychotropic medications upon the risk of completed suicide by comparing person-level prescriptions and postmortem toxicological findings among complete-suicide cases and non-suicide controls in Sweden 2006-2013. METHODS Using national registries with full coverage on dispensed prescriptions, results of medico-legal autopsies, causes of death, and diagnoses from inpatient care, estimated continuous drug use for 30 commonly prescribed psychotropic medications was compared with forensic-toxicological findings. Subjects who had died by suicide (cases) were matched (1:2) with subjects who had died of other causes (controls) for age, sex, and year of death. Odds ratios were calculated using logistic regression to estimate the risk of completed suicide conferred by partial adherence and non-adherence to pharmacotherapy. Adjustments were made for previous inpatient care and the ratio of initiated and discontinued dispensed prescriptions, a measure of the continued need of treatment preceding death. RESULTS In 5294 suicide cases and 9879 non-suicide controls, after adjusting for the dispensation ratio and other covariates, partial adherence and non-adherence to antipsychotics were associated with 6.7-fold and 12.4-fold risks of completed suicide, respectively, whereas corresponding risk estimates for antidepressant treatment were not statistically significant and corresponding risk increases for incomplete adherence to antidepressant treatment were lower (1.6-fold and 1.5-fold, respectively) and lacked statistical significance. CONCLUSION After adjustment for the need of treatment, biochemically verified incomplete adherence to antipsychotic pharmacotherapy was associated with markedly increased risks of completed suicide.
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Affiliation(s)
- Jonas Forsman
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
- National Board of Forensic Medicine, PO Box 4044, SE-141 04, Huddinge, Sweden.
| | - Heidi Taipale
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Thomas Masterman
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- National Board of Forensic Medicine, PO Box 4044, SE-141 04, Huddinge, Sweden
| | - Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Forensic Psychiatry, Niuvanniemi Hospital, Kuopio, Finland
| | - Antti Tanskanen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Forensic Psychiatry, Niuvanniemi Hospital, Kuopio, Finland
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Hedna K, Andersson Sundell K, Hensing G, Skoog I, Gustavsson S, Waern M. Late-life suicidal behaviours among new users of antidepressants: a prospective population-based study of sociodemographic and gender factors in those aged 75 and above. BMJ Open 2018; 8:e022703. [PMID: 30344173 PMCID: PMC6196854 DOI: 10.1136/bmjopen-2018-022703] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE To investigate sociodemographic and gender factors associated with suicide and suicide attempts among new users of antidepressants aged 75 and above. DESIGN Register-based cohort study. SETTING National population-based cohort of Swedish residents aged ≥75 years. PARTICIPANTS 185 225 patients who initiated antidepressant medication between 1 January 2007 and 31 December 2013 were followed until 31 December 2014. MAIN OUTCOME MEASURES Suicide and suicide attempts. Fine and Gray regression models were used to analyse the sociodemographic factors (age, country of birth, marital status, education level, last occupation, income and social allowance) associated with suicidal behaviours in the entire cohort and by gender. RESULTS During follow-up, 295 suicides and 654 suicide attempts occurred. Adjusted sub-hazard ratios (aSHRs) for suicide were lower among older age groups (aSHR 0.73, 95% CI 0.53 to 0.99 for those 85-89 years; and aSHR 0.53, 95% CI 0.33 to 0.86 for those ≥90 years). A similar pattern was observed for suicide attempts. Suicide attempts were more common among those born in foreign countries (aSHR 1.58, 95% CI 1.16 to 2.15 for those born in another Nordic country; and aSHR 1.43, 95% CI 1.06 to 1.93 for those born in non-Nordic countries). In the gender-stratified analyses, being single or divorced, and born in another Nordic country was associated with a higher risk of suicide among men. Educational and occupational history and being born in a non-Nordic country influenced risk of suicidal behaviours in women. CONCLUSION Suicidal behaviours occurred more commonly among new users who were 'younger' old adults and those with foreign background, suggesting that those groups might require greater support when initiating antidepressant therapy. Our findings suggest the need for gender-specific, multifaceted approaches to the prevention of suicidal behaviours in late life.
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Affiliation(s)
- Khedidja Hedna
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Karolina Andersson Sundell
- Section of Epidemiology and Social Medicine, Department of Public Health and Community Medicine at Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Medical Evidence and Observational Research, AstraZeneca, Mölndal, Sweden
| | - Gunnel Hensing
- Section of Epidemiology and Social Medicine, Department of Public Health and Community Medicine at Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ingmar Skoog
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Sara Gustavsson
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Margda Waern
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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Wiktorsson S, Rydberg Sterner T, Mellqvist Fässberg M, Skoog I, Ingeborg Berg A, Duberstein P, Van Orden K, Waern M. Few Sex Differences in Hospitalized Suicide Attempters Aged 70 and Above. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E141. [PMID: 29337907 PMCID: PMC5800240 DOI: 10.3390/ijerph15010141] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/10/2018] [Accepted: 01/11/2018] [Indexed: 11/21/2022]
Abstract
Relatively little research attention has been paid to sex issues in late life suicidal behaviour. The aim was to compare clinical characteristics of women and men aged 70+ who were hospitalized after a suicide attempt. We hypothesized higher depression and anxiety scores in women, and we expected to find that men would more often attribute the attempt to health problems and compromised autonomy. Participants (56 women and 47 men, mean age 80) were interviewed by a psychologist. In addition to psychiatric and somatic health assessments, participants responded to an open-ended question concerning attributions of the attempt. There were no sex differences in depression and anxiety. Forty-five percent of the men and 14% of the women had a history of substance use disorder (p = 0.02). At least one serious physical disability was noted in 60.7% of the women and 53.2% of the men (p = 0.55). Proportions attributing their attempt to somatic illness did not differ (women, 14.5% vs. men 17.4%, p = 0.79), and similar proportions attributed the attempt to reduced autonomy (women, 21.8% vs. men, 26.1%, p = 0.64). We found strikingly similar figures for depression scores, functional disability and attributions for attempting suicide in older men and women. Larger studies are needed in diverse settings as sex differences might be influenced by cultural context.
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Affiliation(s)
- Stefan Wiktorsson
- Institute of Neuroscience and Physiology, Department of Psychiatry, University of Gothenburg, Blå Stråket 15, SU/Sahlgrenska, 413 45 Gothenburg, Sweden.
| | - Therese Rydberg Sterner
- Institute of Neuroscience and Physiology, Department of Psychiatry, University of Gothenburg, Wallinsgatan 6, SU/Sahlgrenska, 431 41 Mölndal, Sweden.
| | - Madeleine Mellqvist Fässberg
- Institute of Neuroscience and Physiology, Department of Psychiatry, University of Gothenburg, Wallinsgatan 6, SU/Sahlgrenska, 431 41 Mölndal, Sweden.
| | - Ingmar Skoog
- Institute of Neuroscience and Physiology, Department of Psychiatry, University of Gothenburg, Wallinsgatan 6, SU/Sahlgrenska, 431 41 Mölndal, Sweden.
| | - Anne Ingeborg Berg
- Institute of Psychology, University of Gothenburg, Haraldsgatan 1, 413 14 Gothenburg, Sweden.
| | - Paul Duberstein
- University of Rochester Medical Center, 300 Crittenden Blvd, Box Psych, Rochester, NY 14642, USA.
| | - Kimberly Van Orden
- University of Rochester Medical Center, 300 Crittenden Blvd, Box Psych, Rochester, NY 14642, USA.
| | - Margda Waern
- Institute of Neuroscience and Physiology, Department of Psychiatry, University of Gothenburg, Blå Stråket 15, SU/Sahlgrenska, 413 45 Gothenburg, Sweden.
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