The relationship between socio-economic status and antidepressant prescription: a longitudinal survey and register study of young adults

The epidemiology of major depression among adults in Norway: an observational study on the concurrence between population surveys and registry data - a NCDNOR project

BACKGROUND

Mental health problems, and major depression in particular, are important public health issues. Following trends in the prevalence of major depression is difficult because of the costs and complications of diagnostic interviews and general population self-report health surveys. Scandinavian countries, however, have several central, population-based health registries. We aimed to investigate how well these registries capture the epidemiology of major depression in the population.

METHODS

In two Norwegian regional surveys of general population health, each repeated after 10 years, responders were asked to report depressive symptoms using the Hopkins Symptom Checklist (HSCL) or the Hospital Anxiety and Depression Scale (HADS). Data were linked to three central health registries capturing contact with primary care, specialist care and prescriptions for antidepressants, to investigate how well these registries reflected self-reported depressive symptoms.

RESULTS

Most responders scored low on Hopkins Symptom Checklist (HSCL) and the Hospital Anxiety and Depression Scale (HADS), but 10% and 13%, respectively, scored above cut-off, with only minor changes between the two survey times. Females scored higher than males. Older people scored lower than younger, and a social gradient was visible. Around 12% of those who scored above the cut-off on either scale were recorded in the central health registries during the following year. This correlation was highest in primary care data, followed by prescription data and lowest in specialist care. Females were more often recorded in registries (p < 0.001), as were younger people (p < 0.001).

CONCLUSIONS

There was a strong association between scores on screening for major depression in the general population surveys and being recorded in central health registries. There was a low sensitivity of these registries. and there was some variation in how sensitive the central health registries were in picking up depression, especially for males and older people. However, the stability of the measures over time suggests we may get an impression of the prevalence of major depression in the general population by using data from the central health registries. A combination of primary care data, prescription data and specialist care data have a higher sensitivity.

Loneliness in adolescence and prescription of psychotropic drugs in adulthood: 23-year longitudinal population-based and registry study

BACKGROUND

The role of adolescent loneliness in adult mental health and prescriptions of psychotropic drugs remains underexplored.

AIMS

We aim to determine whether (a) experiencing loneliness in adolescence and (b) changes in loneliness from adolescence to adulthood are prospectively associated with prescriptions for a variety of psychotropic drugs in adulthood.

METHOD

We used data from a Norwegian population-based sample with 2602 participants, collected across four waves between 1992 and 2006. Loneliness was assessed at each wave, with survey data linked to medicinal drug prescription records from the Norwegian Prescription Database. We identified prescription histories of antipsychotics, mood stabilisers, antidepressants and benzodiazepines from 2007 to 2015, for each participant. We use latent growth curve analyses to model the relationship of adolescent loneliness and loneliness change from adolescence to adulthood, with subsequent psychotropic drugs prescription.

RESULTS

Adolescents with heightened loneliness, and adolescents whose loneliness increased into young adulthood, had a greater likelihood of being prescribed antipsychotics, mood stabilisers and antidepressants in adulthood. These associations remained significant after adjustment for confounders such as sociodemographic characteristics, conduct problems, substance use and mental health problems.

CONCLUSIONS

Loneliness in adolescence and its adverse development over a span of 15 years was linked to higher risk of receiving prescriptions for antipsychotics, mood stabilisers and antidepressants later in life. The findings may indicate that loneliness increases the risk for developing psychotic disorders, bipolar disorders and major depression.

Smoking in early adulthood is prospectively associated with prescriptions of antipsychotics, mood stabilizers, antidepressants and anxiolytics

BACKGROUND

Whether smoking should be regarded as a risk factor for mental disorders remains unresolved. Prescribed psychotropic drugs can be used as indications for mental disorders. We investigated how smoking was prospectively related to prescription of antipsychotics, mood stabilizers, antidepressants, and anxiolytics.

METHODS

Information about smoking, including the Fagerström Test for Nicotine Dependence, and relevant confounders, were obtained from the population-based Young in Norway Study (N = 2602), with four data collection waves between 1992 and 2006. These survey data were linked with information on prescriptions for psychotropic drugs from the comprehensive, nationwide Norwegian Prescription Database from 2007 to 2015.

RESULTS

Daily smoking with high dependence in 2006 at age 28.5 (s.d. = 2.0) was associated with filling prescriptions of antipsychotics (OR, 6.57, 95% CI 2.19-19.70, p = 0.001), mood stabilizers (OR, 7.11, 95% CI 2.51-20.15, p < 0.001) and antidepressants (OR, 1.91, 95% CI 1.13-3.23, p = 0.016) 1-9 years later. Associations remained significant after adjustment for a variety of potential confounders measured before the assessment of smoking, including sociodemographic background, conduct problems, cannabis use, mental distress, and previous prescriptions for psychotropic medications. The association between smoking and prescription of anxiolytics was weaker and more unstable.

CONCLUSIONS

In this study of young adults, daily smoking with high dependence was associated with later prescriptions of antipsychotics, mood stabilizers and antidepressants, indicating smoking as a risk factor for mental disorders treated with these drugs.

An analysis of antidepressant prescribing trends in England 2015-2019

Background Growing concerns about the impact of coronavirus disease 2019 (COVID-19) will likely lead to increased mental health diagnoses and treatment. To provide a pre-COVID-19 baseline, we have examined antidepressant prescribing trends for 5 years preceding COVID-19. Methods A retrospective analysis of anonymised data on medicines prescribed by GPs in England from the Open-Prescribing Database (January 2015 to December 2019) identified the 10 most prescribed antidepressant and, for comparison, cardiovascular medicines. Results Prescription items for the 10 most prescribed antidepressants rose 25% from 58 million (2015) to 72 million (2019). Citalopram was the most prescribed antidepressant; prescriptions for sertraline rose fastest at 2 million items year on year. Over the same period, costs for antidepressant prescribing fell 27.8%. Across all Clinical Commissioning Groups (CCGs) in England, antidepressant prescribing levels, adjusted for population were positively correlated with the index of multiple deprivation (IMD) score. In comparison, prescribing for the top 10 most prescribed cardiovascular medicines increased by 2.75% from 207 million (2015) to 213 million (2019) items. Limitations Anonymised data in the Open-Prescribing Database means no patient diagnoses or treatment plans are linked to this data. Conclusion Antidepressant prescribing, particularly sertraline, is increasing. Prescribing is higher in more deprived regions, but costs are falling to < 2% of all items prescribed. Absolute numbers of prescriptions for cardiovascular medicines are higher, likely reflecting the greater prevalence of cardiovascular disease, and are rising more slowly. This study will enable future work to look at the impact of COVID-19 on prescribing for mental health.

Gender Differences in the Prevalence of Mental Health, Psychological Distress and Psychotropic Medication Consumption in Spain: A Nationwide Population-Based Study

BACKGROUND

To assess gender differences in the prevalence of self-reported mental disorders, psychological distress and psychotropic drug consumption, and to identify sociodemographic and health-related variables associated with these conditions in the male and female population (aged ≥ 18 years).

METHODS

A cross-sectional study was carried on 22,141 subjects aged 18 and over, using data from the Spanish National Health Interview Survey 2017.

RESULTS

We found an overall prevalence of mental disorders, psychological distress and psychotropic drug consumption of 13.8%, 18.3% and 13.9%, respectively. After multivariable adjustment, women showed significantly increased probabilities of 1.74-fold for mental disorders, 1.26-fold for psychological distress and 1.26-fold for psychotropic drug consumption compared to men. Variables such as gender, age, nationality, marital status, educational level, self-rated health, the presence of different chronic disorders, alcohol consumption and smoking habit were independently associated with mental disorders, psychological distress and psychotropic drug consumption. Several variables showed a differential effect on mental health status and psychotropic drug consumption according to gender.

CONCLUSIONS

Women suffer from mental disorders, experience psychological distress and consume psychotropic drugs significantly more than men in Spain. Possible explanations for these results may be related to differences in emotional processing, willingness to report diseases and even intrinsic biological traits. Screening for mental health status and psychotropic drug consumption should be considered, particularly in Spanish women, younger adults and individuals who are not married, are obese, have poor self-rated health, suffer from chronic diseases or have a smoking habit.

Associations of antidepressant use with alcohol use and problem drinking: Ontario population data from 1999 to 2017

OBJECTIVE

This study investigated the rates of and change in past-year antidepressant use from 1999 to 2017 among a representative sample of Ontario adults and past-year alcohol users and problem drinkers. It examined whether alcohol use and problem drinking are associated with antidepressant use over time, whether gender moderated the effect of problem drinking on antidepressant use, and the potential correlates of past-year antidepressant use.

METHOD

This study utilized data from the Centre for Addiction and Mental Health Monitor study, a repeat cross-sectional telephone survey of the Ontario general adult population. Data are from 15 annual cycles of the survey 1999-2017 (where relevant variables were included), resulting in a sample size of N = 35,210. Variables of interest included demographic variables, past-year antidepressant use, past-year alcohol use, and past-year problem drinking (e.g., 8+ on the Alcohol Use Disorders Identification Test).

RESULTS

Past-year antidepressant use increased from 1999 to 2017 similarly among the full sample, past-year alcohol users, and past-year problem drinkers. Approximately 9% of Ontarians reported past-year antidepressant use in 2017. Overall, past-year problem drinkers were 1.5 times more likely to use antidepressants than non-problem drinkers. Past-year alcohol use was not associated with antidepressant use. Gender moderated the association between past-year problem drinking and antidepressant use.

CONCLUSION

This study determined that past-year antidepressant use increased from 1999 to 2017, that past-year problem drinkers are more likely to use antidepressants than non-problem drinkers, and that past-year problem drinking is associated with past-year antidepressant use among women but not among men.

Antidepressant use in Sweden: an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA)

INTRODUCTION

Antidepressants are among the most commonly prescribed drugs in Sweden. However, we lack detailed knowledge on the socioeconomic and demographic distribution of antidepressant use in the population. To fill this gap, we performed an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy.

METHODS

Analysing all Swedish residents older than 10 years (n=8,190,990), we measured the absolute risk of antidepressant use across 144 intersectional strata defined by combinations of age, gender, income, country of birth and psychiatric diagnosis. We calculated the strata-specific absolute risk of antidepressant use in a series of multilevel logistic regression models. By means of the variance partitioning coefficient and the area under the receiver operating characteristic curve, we quantified the discriminatory accuracy of the intersectional contexts (i.e. strata) for discerning those who use antidepressants from those who do not.

RESULTS

The absolute risk of antidepressant use ranged between 0.93% and 24.78% among those without a psychiatric diagnosis, and between 21.41% and 77.56% among those with a psychiatric diagnosis. Both the variance partitioning coefficient of 41.88% and the area under the receiver operating characteristic curve of 0.81 were considerable.

CONCLUSIONS

Besides overt psychiatric diagnoses, our study shows that antidepressant use is mainly conditioned by age, which might express the embodiment of socioeconomic conditions across the individual life course. Our analysis provides a detailed and highly discriminatory mapping of the heterogeneous distribution of antidepressant use in the Swedish population, which may be useful in public health management.

[Patterns of antidepressant dispensing among children and adolescents between 2015 and 2017 in the French region of Midi-Pyrenees]

BACKGROUND

In France, consumption of antidepressant drugs by children and teenagers has been on the rise, even though recommendations for use are limited due to their association with serious adverse reactions. The objective of this study was to describe the patterns of antidepressant drug dispensing among children and adolescents in the French region of Midi-Pyrenees.

METHOD

The data regarding the Midi-Pyrenees region were extracted from the French Health Insurance Database (SNDS) using their ATC codes. The reimbursements for antidepressants, benzodiazepines and neuroleptics dispensed to patients from 6 to 17 years old between January 2015 and June 2017 were analyzed, after which data on the antidepressants themselves were selected. The population was divided into sub-groups according to age (children : 6 to 11 years old, teenagers: 12 to 17 years old).

RESULTS

During the 30 months analyzed, 12,783 antidepressants were dispensed to 3506 patients. The antidepressants were primarily issued (90%) to teenagers. In terms of prevalence, 24.7% of the teenagers had amitriptyline delivered at least once, while 31.2% of them received sertraline at least once. Regarding total amount of antidepressant issuances, sertraline was first in both the child (26.9%) and the teenage (40.7%) populations. Benzodiazepine with an antidepressant was issued to 35.1% of the children and teenagers.

CONCLUSIONS

Amitriptyline was the most widely dispensed antidepressant among children, and sertraline among teenagers. However, fluoxetine is recommended as the first-line treatment for depression affecting this population. A psychotropic drug prescription assistance website such as psychotropes.fr addressed to general practitioners might improve the implementation of recommendations and guidelines.

Association between over-indebtedness and antidepressant use: A cross-sectional analysis

Background

Burden of disease caused by depression and its association with socioeconomic status is well documented. However, research on over-indebtedness is scarce although millions of European citizens in all socioeconomic positions are over-indebted. Prior studies suggested that over-indebtedness is associated with poor physical and mental health.

Aims

Investigate the association between over-indebtedness and antidepressant use in Germany.

Method

A cross-sectional survey among debt advice agencies’ clients was conducted in North Rhine-Westphalia, Germany, in 2017 (OID). Data were merged with the first wave of the German Health Interview and Examination Survey for Adults (DEGS1). Descriptive statistics and logistic regression analysis were used to examine antidepressant use in the previous 7 days (OID: n = 699; DEGS1: n = 7115).

Results

Prevalence of antidepressant use was higher in the over-indebted (12.3%) than the general population (5.0%). The over-indebted were significantly more likely to use antidepressants than the general population even after controlling for other socioeconomic, demographic and health factors (adjusted odds ratio 1.83; 95% confidence interval 1.35–2.48).

Conclusions

Stakeholders in health care, debt counselling, research and social policy should consider the link between over-indebtedness and mental illness to advance the understanding of health inequalities and to help those who have mental health and debt problems.

Voting patterns, revoking article 50 and antidepressant trends in England following the Brexit referendum

Unexpected social or economic events have been shown to negatively impact mental health and wellbeing. The result of the 2016 Brexit referendum in the UK has been associated with an increase in uncertainty and consequent anxiety. This study analyses antidepressant prescription trends in the 533 constituencies of England in the year before and three years following the referendum. We examine associations between prescription trends and constituency-level voting patterns in the referendum and later support for the March 2019 "Revoke Article 50", signed by more than 6 million UK citizens. A mixed model analysis revealed the rate of increase in antidepressant prescription trends to be steeper in Leave constituencies and in areas that did not support the petition, after controlling for constituency education, socioeconomic status, median age, total population, and seasonal effects. Proposed interpretations are provided, along with recommendations for future research. Implications for this study include redoubling mental health care service in areas that show significantly higher mental distress following a major political event.

Do people living in disadvantaged circumstances receive different mental health treatments than those from less disadvantaged backgrounds?

BACKGROUND

Socio-economic status (SES) has been linked to treatment outcomes for mental health problems, whilst little to no literature has explored the effects of SES on access to both medication and psychological therapy. The aim of this study was to explore whether access to mental health treatments differed by SES.

METHODS

The North West Coast Household Health Survey (HHS) collected data from residents aged 18+ from across 20 disadvantaged and 8 less disadvantaged neighbourhoods in 2015, and from 20 disadvantaged neighbourhoods in 2018. Logistic regression was used to explore the effects of SES on access to treatment (medication, psychological therapy) for people who had experienced mental health problems in the past 12 months.

RESULTS

Of 6860 participants, 2932 reported experiencing mental health problems in the past 12 months. People from more disadvantaged backgrounds experienced greater rates of anxiety and depression. Anti-depressant and anti-psychotic medication treatment was significantly more common in residents with lower SES, as well as counselling. Regression analysis showed that residents from more disadvantaged neighbourhoods who reported mental distress were more likely to receive medication.

CONCLUSIONS

This appears to be the first study showing higher levels of treatment with medication and psychological therapy in people from disadvantaged backgrounds. Future research needs to address the underlying factors associated with increased mental health treatment uptake in people from lower socio-economic backgrounds.

Do people living in disadvantaged circumstances receive different mental health treatments than those from less disadvantaged backgrounds?

BACKGROUND

Socio-economic status (SES) has been linked to treatment outcomes for mental health problems, whilst little to no literature has explored the effects of SES on access to both medication and psychological therapy. The aim of this study was to explore whether access to mental health treatments differed by SES.

METHODS

The North West Coast Household Health Survey (HHS) collected data from residents aged 18+ from across 20 disadvantaged and 8 less disadvantaged neighbourhoods in 2015, and from 20 disadvantaged neighbourhoods in 2018. Logistic regression was used to explore the effects of SES on access to treatment (medication, psychological therapy) for people who had experienced mental health problems in the past 12 months.

RESULTS

Of 6860 participants, 2932 reported experiencing mental health problems in the past 12 months. People from more disadvantaged backgrounds experienced greater rates of anxiety and depression. Anti-depressant and anti-psychotic medication treatment was significantly more common in residents with lower SES, as well as counselling. Regression analysis showed that residents from more disadvantaged neighbourhoods who reported mental distress were more likely to receive medication.

CONCLUSIONS

This appears to be the first study showing higher levels of treatment with medication and psychological therapy in people from disadvantaged backgrounds. Future research needs to address the underlying factors associated with increased mental health treatment uptake in people from lower socio-economic backgrounds.

Dose-effect of maternal serotonin reuptake inhibitor use during pregnancy on birth outcomes: A prospective cohort study

BACKGROUND

While antidepressant use during pregnancy is increasingly common, there is concern about the possible effects of in-utero antidepressant exposure on the child. Our objective was to examine whether there is a dose-effect of maternal serotonin reuptake inhibitors (SRI) during pregnancy on birth outcomes.

METHODS

Women between 12 and 16 weeks of gestation, who were using an SRI, were eligible for participation in this nation-wide prospective observational cohort study. Recruitment took place between April 2015 and February 2018 (n = 145). SRI exposure and psychopathology symptoms were assessed throughout pregnancy. Exposure was defined as SRI standardized dose at 36 weeks of gestation and mean SRI standardized dose over total pregnancy. Multivariable linear and logistic regression were used to examine the associations with birth weight, gestational age at birth, and being small for gestational age.

RESULTS

Maternal SRI dose at 36 weeks of gestation was significantly associated with birth weight (adjusted ß = -180.7, 95%CI -301.1;-60.2, p-value < 0.01) as was mean SRI standardized dose during total pregnancy (adjusted ß = -187.3, 95%CI -322.0;-52.6, p-value < 0.01). No significant associations between maternal SRI dose and gestational age or being small for gestational age were observed.

LIMITATIONS

Although prospective, we cannot make full causal inferences given that we did not randomize women to different dosages.

CONCLUSION

These findings suggest that careful dosing of SRI use during pregnancy may prevent a negative impact on birth weight and indicate the need for further investigation of causality.

Using a Social Worker Transition Coach to Improve Hospital-to-Home Transitions for High-Risk Nonelderly Patients

High-risk hospitalized younger adults (age ≤60) have 30-day readmission rates comparable to Medicare fee-for-service patients. This younger cohort has a high incidence of comorbid mental health and substance use disorders, which increases the complexity of their postdischarge care. Although few care transition studies have enrolled younger adult patients, findings from our previous work suggest that these patients have postdischarge needs requiring different approaches than those serving elderly patients. Our current pilot study, situated in a safety-net system, targets this younger population, employing a social worker as the Transition Coach (TC). Social workers are explicitly trained to address psychosocial complexities, and we evaluated whether our TC intervention could improve hospital-to-home transitions by assisting patients with medication management, attending follow-up appointments, and addressing medical, psychiatric, and psychosocial needs. Primary outcomes were Patient Activation Measure scores on admission and 30-days postdischarge; outpatient follow-up at 7 and 30 days; and all-cause, in-network 30-, 60-, and 90-day readmissions. At 30 and 60 days, no differences were observed in the primary outcomes; at 90 days, intervention patients demonstrated a trend toward readmission reduction. A social worker-led transitional care program shows promise in reducing readmissions over 90 days among high-risk, lower socioeconomic, nonelderly adult patients.

A longitudinal study of cannabis use increasing the use of asthma medication in young Norwegian adults

Background

A small number of studies have shown that the use of cannabis increases the risk of bronchial asthma. There is, however, a paucity of longitudinal studies which are able to control for known risk factors of bronchial asthma.

Methods

Survey data from a population-based longitudinal study encompassing 2602 young adults followed for 13 years were coupled with individual prescription data on asthma medication (β₂-adrenergic receptor agonists and glucocorticoids for inhalation) from the Norwegian national prescription database, which covers the entire Norwegian population. Current cannabis use, gender, age, years of education, body mass index (BMI; kg/m²) and current smoking were measured.

Results

Prescription of asthma medication was associated with female gender, self-reported earlier asthma and allergies, daily tobacco smoking and current cannabis use. In a model adjusting for gender, age, years of education, BMI, earlier self-reported asthma and allergies and current tobacco smoking the odds ratio for a current cannabis user to fill prescriptions for asthma medication was 1.71 (95% CI: 1.06–2.77; p = 0.028).

Conclusions

This suggests that cannabis is a risk factor for bronchial asthma or use of asthma medication even when known risk factors are taken into consideration. Intake of cannabis through smoking should be avoided in persons at risk.

The Impact of Unemployment on Antidepressant Purchasing: Adjusting for Unobserved Time-constant Confounding in the g-Formula

Supplemental Digital Content is available in the text.

Background:

The estimated effect of unemployment on depression may be biased by time-varying, intermediate, and time-constant confounding. One of the few methods that can account for these sources of bias is the parametric g-formula, but until now this method has required that all relevant confounders be measured.

Methods:

We combine the g-formula with methods to adjust for unmeasured time-constant confounding. We use this method to estimate how antidepressant purchasing is affected by a hypothetical intervention that provides employment to the unemployed. The analyses are based on an 11% random sample of the Finnish population who were 30–35 years of age in 1995 (n = 49,753) and followed until 2012. We compare estimates that adjust for measured baseline confounders and time-varying socioeconomic covariates (confounders and mediators) with estimates that also include individual-level fixed-effect intercepts.

Results:

In the empirical data, around 10% of person-years are unemployed. Setting these person-years to employed, the g-formula without individual intercepts found a 5% (95% confidence interval [CI] = 2.5%, 7.4%) reduction in antidepressant purchasing at the population level. However, when also adjusting for individual intercepts, we find no association (−0.1%; 95% CI = −1.8%, 1.5%).

Conclusions:

The results indicate that the relationship between unemployment and antidepressants is confounded by residual time-constant confounding (selection). However, restrictions on the effective sample when using individual intercepts can compromise the validity of the results. Overall our approach highlights the potential importance of adjusting for unobserved time-constant confounding in epidemiologic studies and demonstrates one way that this can be done.

Associations between TV viewing, sitting time, physical activity and insomnia among 100,839 Brazilian adolescents

Our aim was to examine the relationship between insomnia and levels of physical activity (PA) and time spent sitting and TV viewing among Brazilian adolescents. Data from the Brazilian Scholar Health Survey, a nationally representative survey of 9th grade adolescents [mean: 14.28 years (range: 11-18 years)] conducted in 2015 (n = 100,839) were used. Self-reported insomnia, TV viewing, sitting time and total PA (adapted International PA Questionnaire) were collected. Chronological age, race, type of city (capital or interior) country region, goodies ingestion and ultra-processed foods ingestion were covariates. Logistic regression analyses were conducted to assess the associations. A higher sitting time and TV viewing (≥8 h/day) was associated with a higher risk of insomnia among boys [sitting time: OR = 2.39 (95%CI = 1.88-3.04); TV:OR = 2.49(95%CI = 1.92-3.22) and girls [sitting time: OR = 2.17(95%CI = 1.84-2.57; TV:OR = 1.72(95%CI = 1.44-2.04)]. More than 4 h of sitting time per day was associated with higher risk of insomnia in adolescents who comply [boys: OR = 1.43(95%CI = 1.19-1.73); girls: OR = 1.66(95%CI = 1.41-1.94)] and who do not comply with the 300 min/week of physical activity recommendation [boys = OR = 1.35(95%CI = 1.13-1.60); girls: OR = 1.38(95%CI = 1.20-1.57)]. Our data suggest that higher levels of TV viewing or sitting are associated with sleep difficulties in this large cohort of adolescents, irrespective of their physical activity behavior.

Neighbourhood Material and Social Deprivation and Exposure to Antidepressant Drug Treatment: A Cohort Study Using Administrative Data

OBJECTIVE

To assess whether neighbourhood deprivation is associated with exposure to an antidepressant drug treatment (ADT) and its quality among individuals diagnosed with unipolar depression and insured by the Quebec public drug plan.

METHOD

We conducted an administrative database cohort study of adults covered by the Quebec public drug plan who were diagnosed with a new episode of unipolar depression. We assessed material and social deprivation using an area-based index. We considered exposure to an ADT as having ≥1 claim for an ADT within the 365 days following depression diagnosis. Among those exposed to ADT, ADT quality was assessed with 3 indicators: first-line recommended ADT, persistence with the ADT, and compliance with the ADT. Generalized linear models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (95% CI).

RESULTS

Of 100,432 individuals with unipolar depression, 65,436 (65%) were exposed to an ADT in the year following the diagnosis. Individuals living in the most materially deprived areas were slightly more likely to be exposed to an ADT than those living in the least deprived areas (aPR, 1.04; 95% CI, 1.03 to 1.06). The likelihoods of being exposed to a first-line ADT, persisting for the minimum recommended duration and complying with the ADT were independent of the deprivation levels.

CONCLUSIONS

Neighbourhood deprivation was not associated with ADT quality among individuals insured by the Quebec public drug plan. It might be partly attributable to the public drug plan whose goal is to provide equitable access to prescription drugs regardless of income.

Sedentary behavior and depressive symptoms among 67,077 adolescents aged 12-15 years from 30 low- and middle-income countries

BACKGROUND

Depression is common and burdensome in adolescents. Understanding modifiable environmental risk factors is essential. There is evidence that physical activity is protective of depression. However, the impact of sedentary behavior (SB) on depression is relatively under-researched especially in low- and middle-income countries (LMICs). In this cross-sectional study, we explored the association between SB and depressive symptoms in adolescents from 30 LMICs, controlling for confounders including physical activity.

METHOD

Data from the Global school-based Student Health Survey were analyzed in 67,077 adolescents [mean (SD) age 13.8 (0.9) years; 50.6% girls). Self-report measures assessed depressive symptoms during the past 12 months, and SB, which was a composite variable assessing time spent sitting and watching television, playing computer games, talking with friends during a typical day excluding the hours spent sitting at school and doing homework. Multivariable logistic regression analysis was conducted and a countrywide meta-analysis undertaken.

RESULTS

The prevalence of depressive symptoms and ≥ 3 h/day of SB were 28.7 and 30.6%, respectively. There was a linear increase in the prevalence of depressive symptoms with increasing sedentary time beyond ≥3 h/day (vs. < 1 h/day). Among boys, 1-2 h/day of SB was associated with lower odds for depression (vs. < 1 h/day). Countrywide meta-analysis demonstrated that spending ≥3 h/day versus < 3 h/day was associated with a 20% increased odds for depressive symptoms (OR = 1.20; 95% CI = 1.16-1.24) with low between-country heterogeneity (I2 = 27.6%).

CONCLUSION

Our data indicate that being sedentary for ≥3 h/day is associated with increased odds for depressive symptoms in adolescence. Future longitudinal data are required to confirm/refute the findings to inform public interventions which aim to limit the time spent being sedentary in adolescents.

Trends and Patterns of Antidepressant Use in French Children and Adolescents From 2009 to 2016: A Population-Based Study in the French Health Insurance Database

PURPOSE/BACKGROUND

Over the last decade, the use of antidepressants (ATDs) in children and adolescents has markedly increased in several occidental countries, but recent data in French children are missing. This study aimed to assess trends of ATD use in French children (6-11 years) and adolescents (12-17 years) and to characterize changes in ATD prescribing patterns from 2009 to 2016.

METHODS

Using data from the French Health Insurance Database, annual prevalence and incidence of ATD use and changes in ATD prescribing patterns were analyzed.

RESULTS

Overall ATD prevalence of use rose slightly from 0.51% in 2009 to 0.53% in 2016 (+3.9%), with a decrease in children (0.18%-0.11%; -38.9%) and an increase in adolescents (0.86%-0.98%; +14.0%) and an overall female preponderance (56.7% in 2009; 58.7% in 2016). Serotonin reuptake inhibitor prevalence of use increased from 0.24% to 0.34%, whereas tricyclic ATD use decreased (from 0.20% to 0.16%). Similar trends were obtained with overall incidence of use, from 0.39% in 2009 to 0.36% in 2016 (-7.7%). Sertraline was the most frequently prescribed in adolescents (2009: 22.2% of all ATD prescriptions; 2016: 32.9%), whereas amitriptyline was the most prescribed in children (2009: 42.7% and 2016: 41.2%). Off-label use decreased in adolescents (from 48.4% to 34.8%) but increased in children (from 10.0% to 26.5%).

IMPLICATIONS/CONCLUSIONS

Antidepressant level of use in French children and adolescents was stable in recent years and lower than that observed in other European countries and the United States.

12-month prevalence and concomitants of DSM-IV depression and anxiety disorders in two violence-prone cities in Brazil

BACKGROUND

Estimating 12-month prevalence of depression, anxiety, and comorbid anxiety/depression in noninstitutionalized adults (age 15-75) in two violence-prone cities.

METHODS

The Composite International Diagnostic Interview v2.1 (Portuguese), administered in population-representative surveys (age 15-75) in São Paulo (N = 2536) and Rio de Janeiro (N = 1208), yielded 12-month prevalence of violent events experienced, and DSM-IV diagnoses of depression and anxiety, which were classified into mutually exclusive groups: 1) no anxiety/depression; 2) anxiety only; 3) depression only; 4) comorbid anxiety/depression. Weighted analyses estimated 12-month prevalence, multinomial logistic regression compared the demographic characteristics of the diagnosis groups, and association with experienced violence.

RESULTS

Twelve-month prevalence of anxiety alone, depression alone, and comorbid anxiety/depression was 12.7% (of whom 24.9% were also depressed), 4.9% (of whom 46.2% had anxiety), and 4.2% respectively for São Paulo; and 12.1% (18.2% of whom were depressed), 4.6% (37.0% with anxiety), and 2.7% respectively for Rio de Janeiro. All conditions were approximately twice as prevalent in women than in men in both cities. In São Paulo, comorbidity was associated with age under 60, depression alone was more prevalent among 30-59 year olds, but in 23-29 year-olds in Rio de Janeiro. Exposure to violence increased the odds of anxiety, depression, and their comorbidity. With rare exception, marital status, education, and race/ethnicity were not associated with anxiety, depression, or their comorbidity.

LIMITATIONS

Cross-sectional design.

CONCLUSIONS

Prevalence rates for all conditions were high, and particularly associated with exposure to violence. Means to ameliorate violence, and its mental health effects, particularly for women, are needed.

Fluoxetine and congenital malformations: a systematic review and meta-analysis of cohort studies

AIMS

To investigate the safety of fluoxetine use during pregnancy, and to better understand the relationship between maternal fluoxetine use during the first trimester and congenital malformations in infants.

METHODS

PubMed and Web of Science databases were systematically searched from inception to 21 March 2016. Additional studies were identified in a manual search of the reference lists. Two reviewers independently extracted data. A third reviewer checked the data. Estimates were pooled using a random-effects model to calculate the summarized relative ratios (RR) and 95% confidence intervals (CI).

RESULTS

Among 1918 initially identified articles, 16 cohort studies were included. The offspring of pregnant women exposed to fluoxetine during the first trimester had a statistically increased risk of major malformations (RR = 1.18, 95% CI = 1.08-1.29), cardiovascular malformations (RR = 1.36, 95% CI = 1.17-1.59), septal defects (RR = 1.38, 95% CI = 1.19-1.61), and non-septal defects (RR = 1.39, 95% CI = 1.12-1.73) with low heterogeneity in infants. There were no significant observations of other system-specific malformations in the nervous system, eye, urogenital system, digestive system, respiratory system, or musculoskeletal system, respectively. There was no indication of publication bias.

CONCLUSIONS

The results of this meta-analysis indicate maternal fluoxetine use is associated with a slightly increased risk of cardiovascular malformations in infants. Health care providers and pregnant women must weigh the risk-benefit potential of these drugs when making decisions about whether to treat with fluoxetine during pregnancy.

Time Trend in Psychotropic Medication Use in Spain: A Nationwide Population-Based Study

Background: We performed an epidemiologic study to analyze nationwide time trends in adult psychotropic drug use over a period from 2006 to 2012, and to identify those factors associated with the likelihood of consumption of these drugs during the study period; Methods: Cross-sectional study on psychotropic medication in the Spanish adult population. We used secondary individualized data drawn from the 2006 and 2012 Spanish National Health Surveys (SNHS). The dependent variable was the use of psychotropic drugs in the previous two weeks. Independent variables included socio-demographic characteristics, comorbidity, lifestyles and healthcare resource utilization. Using logistic multivariate regression models, we analyzed the temporal evolution of psychotropic medication consumption between 2006 and 2012 in both sexes; Results: The prevalence of psychotropic drug use was significantly greater in women (18.14% vs. 8.08% in 2012 (p < 0.05). In Spanish women, the variables associated with a greater probability of psychotropic use were, age, unemployment (adjusted odds ratio (AOR), 1.60; 95% CI, 1.24–2.07), negative perception of health or taking non-psychotropic drugs. Among men, psychotropic use is associated with presence of chronic disease, negative perception of health (AOR, 3.27; 95% CI, 2.62–4.07 in 2012) or inactive status; Conclusions: Between 2006 and 2012, the probability of having taken psychotropic drugs increased by 16% among women. Unemployed women aged ≥45 years with a negative perception of their health constitute a clear risk profile in terms of psychotropic drug use. Inactive men who have a negative perception of their health are the group most likely to consume psychotropic drugs.

The relationship between self-reported mental health and redeemed prescriptions of antidepressants: a register-based cohort study

BACKGROUND

Poor mental health is a major problem in most western societies, especially predominant among young adults. However, associations of self-reported poor mental health with subsequent psychiatric or medical treatment are unknown. We examined the relation between self-reported mental health and redeeming prescriptions of antidepressants among three age groups.

METHODS

We analyzed data from 16,233 individuals aged 16 years and over randomly selected to participate in the 2010 North Denmark Region Health Survey completed in February 2010. Mental health was defined according to the Short-Form 12 instrument (SF-12) and dichotomized into poor and good. Outcome data were retrieved from administrative information on redeemed prescriptions of antidepressants between February 2010 and December 2012. Crude cumulative incidence curves were produced to illustrate the probability of redeeming new prescriptions of antidepressants over time. Cox regression analysis was used to estimate risk of redeeming prescriptions of antidepressants when having poor mental health, adjusted for preselected explanatory covariates.

RESULTS

Among the young (16-29 years-old), 620 (23 %) participants suffered from poor mental health. Among the adults (30-59 years-old) and elderly (60 years-old or over), 1592 (18 %) participants and 723 (15 %) reported poor mental health, respectively. Overall, women were more likely than men to rate their mental health as poor. For all age groups, there was an increased probability for redeeming prescriptions of antidepressants when having poor mental health. The hazard ratio [HR] for redeeming prescriptions of antidepressants for those reporting poor versus good mental health, adjusted for sex, ethnicity, marital status, education level, occupational status, smoking and physical activity was 3.1 (95 % confidence interval [CI] 2.20-4.29) for young participants. For adults, the HR was 2.3 (95 % CI 1.86-2.78) and for elderly, it was 3.5 (95 % CI 2.66-4.57).

CONCLUSION

Self-reported poor mental health was more frequent among younger than older participants. Overall, antidepressants were the most often used treatment. An increased probability of redeeming antidepressant prescriptions when having self-reported poor mental health was observed in all age groups. These findings suggest that frequent reporting of poor mental health is a common issue for all age groups that needs more attention.

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.

Mental health among currently enrolled medical students in Germany

OBJECTIVES

The study identifies the prevalence of common mental disorders according to the patient health questionnaire (PHQ) and the use of psychotropic substances in a sample of currently enrolled medical students.

STUDY DESIGN

A cross-sectional survey with a self-administrated questionnaire.

METHODS

All newly enrolled medical students at the University of Dusseldorf, with study beginning either in 2012 or 2013, respectively, were invited to participate. The evaluation was based on 590 completed questionnaires. Mental health outcomes were measured by the PHQ, including major depression, other depressive symptoms (subthreshold depression), anxiety, panic disorders and psychosomatic complaints. Moreover, information about psychotropic substances use (including medication) was obtained. Multiple logistic regression analysis was used to estimate associations between sociodemographic and socio-economic factors and mental health outcomes.

RESULTS

The prevalence rates, measured by the PHQ, were 4.7% for major depression, 5.8% for other depressive symptoms, 4.4% for anxiety, 1.9% for panic disorders, and 15.7% for psychosomatic complaints. These prevalence rates were higher than those reported in the general population, but lower than in medical students in the course of medical training. In all, 10.7% of the students reported regular psychotropic substance use: 5.1% of students used medication 'to calm down,' 4.6% 'to improve their sleep,' 4.4% 'to elevate mood,' and 3.1% 'to improve cognitive performance.' In the fully adjusted model, expected financial difficulties were significantly associated with poor mental health (odds ratio [OR]: 2.14; 95% confidence interval [CI]: 1.31-3.48), psychosomatic symptoms (OR:1.85; 95% CI: 1.11-3.09) and psychotropic substances use (OR: 2.68; 95% CI: 1.51-4.75).

CONCLUSION

The high rates of mental disorders among currently enrolled medical students call for the promotion of mental health, with a special emphasis on vulnerable groups.

The association between alcohol use and depressive symptoms across socioeconomic status among 40- and 45-year-old Norwegian adults

BACKGROUND

Little population-based data among middle-aged adults exists examining the relationships between depressive symptoms, alcohol use, and socio-economic status (SES). This study aimed to describe the relationships between depressive symptoms and alcohol use at different levels of SES and to determine differences across SES levels among a population-based sample of 40 and 45 year old adults in Norway.

METHODS

This analysis was based on data from two Norwegian health studies conducted in 2000 and 2001, and included community-dwelling Norwegian men and women aged 40 and 45 years. Self-reported frequency and quantity of alcoholic drinks was used to calculate past-year typical quantity of drinks consumed and frequency of 5+ drinks per occasion, or heavy episodic drinking (HED). Depressive symptoms were assessed with the 10-item Hopkins Symptom Checklist, and SES was measured as education level and employment status. To observe the association between depressive symptoms and alcohol use at each level of SES we fitted multinomial logistic regression models using each alcohol outcome as a dependent variable stratified by level of education and employment. To observe differences across levels of SES, we examined the interaction between depressive symptoms and SES level in multinomial logistic regression models for each alcohol measures.

RESULTS

Having depressive symptoms was significantly associated with an increased risk of 5+ typical drinks among people in the lowest (RRR = 1.60, p ≤ 0.05) education level, and not among people in the highest. Conversely, significant associations were observed among all levels of employment. For frequency of HED, depressive symptoms was not significantly associated with frequency of HED at any education level. Depressive symptoms was associated with 13+ past year HED episodes among people with no employment (RRR = 1.97, p ≤ 0.05), and part-time employment (RRR = 2.33, p ≤ 0.01), and no association was observed among people with full-time employment. A significant interaction was observed for depressive symptoms and employment for risk of 13+ past-year HED episodes.

CONCLUSIONS

The results show a variety of associations between depressive symptoms and alcohol use among people with lower SES, and suggest type of alcohol use and SES measure may influence the observation of an association between depressive symptoms and alcohol use at different SES levels.

Municipal-level differences in depressive symptoms among adolescents in Norway: Results from the cross-national Ungdata study

AIM

This study aimed to investigate municipal-level variations and individual- and municipal-level predictors of high levels of depressive symptoms among Norwegian adolescents.

METHODS

We used data from the Norwegian cross-national Ungdata study. We included 77,424 adolescents from 171 municipalities attending junior high school (Grades 8-10; age 13-16 years) from 2011 to 2013. Multilevel (two-level) logistic regression models were applied for the data analyses.

RESULTS

The study revealed that 11% of adolescents reported high levels of depressive symptoms. The median odds ratio without adjusting for any individual- or municipal-level predictors was 1.24, indicating a small between-municipalities variability for high levels of depressive symptoms. All individual-level factors, such as gender, school grade, family income, substance use behaviours, bullying and dissatisfaction with different aspects of life, were significantly associated with high levels of depressive symptoms (p < 0.05). As to municipal-level factors, a low annual budgets for municipal health services was the sole significant predictor of high levels of depressive symptoms between municipalities. Municipal-level factors and variables related to survey characteristics explained a moderate proportion of the variation in high levels of depressive symptoms between municipalities.

CONCLUSIONS

The cluster heterogeneity in high levels of depressive symptoms was small between municipalities in Norway. Further research should examine the geographic clustering of mental health problems at the school and neighbourhood level.

Increased risk of severe congenital heart defects in offspring exposed to selective serotonin-reuptake inhibitors in early pregnancy--an epidemiological study using validated EUROCAT data

BACKGROUND

Previous studies suggest a possible association between maternal use of selective serotonin-reuptake inhibitors (SSRIs) during early pregnancy and congenital heart defects (CHD). The purpose of this study was to verify this association by using validated data from the Danish EUROCAT Register, and secondary, to investigate whether the risk differs between various socioeconomic groups.

METHODS

We conducted a cohort study based on Danish administrative register data linked with the Danish EUROCAT Register, which includes all CHD diagnosed in live births, fetal deaths and in pregnancies terminated due to congenital anomalies. The study population consisted of all registered pregnancies (n = 72,280) in Funen, Denmark in the period 1995-2008. SSRI-use was assessed using The Danish National Prescription Registry, information on marital status, maternal educational level, income, and country of origin from Statistics Denmark was used as indicators of socioeconomic situation, and the CHD were studied in subgroups defined by EUROCAT. Logistic Regression was used to investigate the association between redeemed prescriptions for SSRIs and CHD.

RESULTS

The risk of severe CHD in the offspring of the 845 pregnant women who used SSRIs during first trimester increased four times (AOR 4.03 (95% CI 1.75-9.26)). We found no increased risk of septal defects. Socioeconomic position did not modify the association between maternal SSRI-use during pregnancy and severe CHD.

CONCLUSION

This study, which is based on data with high case ascertainment, suggests that maternal use of SSRIs during first trimester increases the risk of severe CHD, but does not support findings from previous studies, based on administrative register data, regarding an increased risk of septal defects. The study was unable to document an interaction between socioeconomic status and maternal SSRI-use on the risk of severe CHD.

Socio-economic differences in use of prescribed and over-the-counter medicine for pain and psychological problems among Danish adolescents--a longitudinal study

The objective for this study was to investigate socio-economic status (SES) differentials in the use of over-the-counter and prescribed medicine for pain and psychological problems among adolescents. Data consisted of questionnaire data on medicine use and health status, collected from 17- to 18-year-old adolescents (n = 2,400) during second round of the West Jutland cohort study 2007, and register data on prescribed medicine use, parental educational level and household income. We used multiple logistic regression analysis to calculate odd ratios for self-reported and register-based use of medicine for pain and psychological problems according to parental educational level and household income. Young girls used twice as much medicine for pain and psychological problems compared to young boys. SES differences based on parental educational level were directly associated with the use of prescribed medicine for psychological problems, and SES differences based on household income were directly associated with overall medicine use and use of over-the-counter medicine. Some of the SES differentials disappeared or decreased after adjusting for health status. There were no SES differentials in the use of prescribed medicine for pain.

CONCLUSION

The risk of use of prescribed medicine for psychological problems increased in adolescents with decreasing parental education, while the risk of overall medicine use and use of over-the-counter medicine was increased in adolescents from low household income. Furthermore, the results indicate that some of the SES differentials in medicine use could be explained by a difference in health status across SES.

Patterns of psychotropic medication prescriptions by psychiatrists for private clinic outpatients in kerman province, iran

OBJECTIVES

The aim of this study was to assess the pattern and utilisation of psychotropic drug prescriptions by psychiatrists in Kerman Province, Iran.

METHODS

The prescriptions of 27 psychiatrists were randomly selected from two Iranian public insurance organisations and were analysed for the mean number of drugs/prescriptions, drug category and the most frequently prescribed drug in each category as well as overall.

RESULTS

A total of 6,414 prescriptions were analysed. The mean number of drugs per prescription was 2.9. Antidepressants (61.0%) were the most frequently prescribed category of psychotropic medications, followed by antipsychotics (29.5%), sedative/hypnotics or anti-anxiety drugs (27.5%) and mood stabilisers (18.5%). The combination of antidepressants with antipsychotics was the most commonly prescribed combination (18.8%). Fluoxetine (16.5%) and trifluoperazine (13.5%) were among the most frequently prescribed antidepressants and antipsychotics, respectively. Clonazepam (10.5%) was the most commonly prescribed benzodiazepine agent, followed by alprazolam (8.5%). In terms of total drug utilisation, sertraline (12.4%) was the most commonly used psychotropic medication followed by fluoxetine (9.7%), trifluoperazine (6.6%), propranolol (4.5%) and clonazepam (3.7%).

CONCLUSION

A high proportion of psychotropic prescriptions in Kerman Province were for antidepressants, followed by antipsychotics and the benzodiazepines. Further research is needed to determine the underlying correlation between prescription practice and the diagnosis and patient characteristics, as well as to investigate the use of different psychotropic medications.

Patterns of benzodiazepine and antidepressant use among middle-aged adults. the Brazilian longitudinal study of adult health (ELSA-Brasil)

BACKGROUND

Antidepressant and benzodiazepine medicines are widely prescribed in high-income countries. Our aim was to investigate and describe clinical and demographic characteristics of their use in a large cohort from a middle-income country.

METHODS

Participants (n=15,105) from the Brazilian Health Longitudinal Study (ELSA-Brasil), a civil servant cohort from six different sites in Brazil were asked about antidepressant and benzodiazepine use. The Clinical Interview Schedule-Revised was used for psychiatric assessment. Sociodemographic and clinical data were also collected.

RESULTS

Current use of antidepressant and benzodiazepine medicines was respectively reported by 6.87% and 3.88% of participants. These numbers were higher in major depression-MDD (16.5% and 13.9%), generalized anxiety disorder-GAD (14% and 9.5%) and any mental disorder (11.7% and 7.8%). The use of antidepressant and benzodiazepine was directly associated with clinical comorbidities and psychiatry diagnosis. In addition, older age was associated with benzodiazepine use and more years of schooling, with antidepressant use. Finally, the use of these medicines was strongly associated (odds ratio=8.48, p<0.001).

LIMITATIONS

Our cohort does not include younger adults (18-34 years), although it includes older (65-75 years) participants.

DISCUSSION

Antidepressant and benzodiazepine use in Brazil is lower than in high-income countries. We found that factors such as age and education level were associated with the use of these medicines, whereas MDD and GAD were poor predictors of psychopharmacotherapy use, suggesting misuse/overuse of psychopharmacotherapy among individuals without psychiatric illness and underuse among those with psychiatric conditions in Brazil.