Cohort of one million patients initiating antidepressant treatment in France: 12-month follow-up

The Danish Ibbis Trials for Sickness Absentees with Common Mental Disorders: A Phase 4 Prospective Study Comparing Randomized Trial and Real-World Data

Introduction

In two randomized controlled trials (RCT) we tested the efficacy of a novel integrated vocational rehabilitation and mental healthcare intervention, coined INT, for sickness absentees with common mental disorders. The aim was to improve vocational outcomes compared to Service As Usual (SAU). Contrary to expectations, the delivered intervention caused worse outcomes within some diagnostic groups and some benefits in others. In this phase 4 study, we examined the effectiveness of the intervention in real-world practice.

Method

In this prospective intervention study, we allocated adult sickness absentees with either depression, anxiety, or adjustment disorder to receive INT in a real-world setting in a Danish Municipality. We compared the vocational outcomes of this group to a matched group who received INT as a part of the RCTs, after randomization to the intervention group herein. Primary outcome was return to work at any point within 12 months.

Results

In the real-world group, 151 participants received INT during 2019. From the randomized trials, 302 matched participants who received INT between 2016-2018 were included. On the primary outcome - return to work within 12 months - the real-word group fared worse (48.3 vs 64.6 %, OR 0.54 [95%CI: 0.37-0.79], p = 0.001). Across most other vocational outcomes, a similar pattern of statistically significant poorer outcomes in the real-world group was observed: Lower number of weeks in work and lower proportion in work at 12 months (42.3% vs. 58.3% (p = 0.002)).

Discussion

The real-word group showed significantly worse vocational outcomes. Like in many other studies of complex interventions, implementation was difficult in the original randomized trials and perhaps even more difficult in the less structured real-world setting. Since the intervention was less effective for some groups compared to SAU in the original trial, this negative effect may be even more pronounced in a real-world setting.

VE-MMODE - A randomized controlled trial of Venlafaxine versus Escitalopram for treatment of mild to moderate depression in persons with epilepsy

OBJECTIVES

Depression in persons with epilepsy (PWE) goes undiagnosed and untreated. Despite being common, there are no direct efficacy comparisons of available antidepressants in PWE. Our aim was to compare the effectiveness of Venlafaxine (VEN) and Escitalopram (ESCIT) in comorbid depression in PWE.

METHODS

In a single-center, prospective, double-blinded randomized controlled trial (RCT) 90 PWE (age ≥18 years) with mild to moderate depression, were randomized in a 1:1 ratio to receive ESCIT (5-20 mg/day) or VEN (37.5-150 mg/day) for 8 weeks. The primary outcome was to study differences in the efficacy, based on the change in scores of the Hamilton depression rating scale (HAM-D) at 8 weeks. Seizure frequency, QOLIE-31, adverse event profile, and medication adherence were secondary outcome measures.

RESULTS

Using the NDDI-E scale, we screened 350 PWE, 90 were enrolled. ITT analysis included all participants and the PP analysis included 40 participants to VEN group and 42 to ESCIT group. Baseline mean (±SD) HAM-D scores for both groups were similar (13.53 ± 3.27; 13.02 ± 3.57). The mean difference (95%CI) on HAM-D scores at 8 weeks was found to be significant within both groups (ITT/PP- VEN: 7.75(6.75, 8.79)/7.92 (7.06, 8.78); p < 0.001, ESCIT: 8.21 (7.39, 9.03)/8.23(7.43, 9.04); p < 0.001). However, there was no significant difference in the efficacy of VEN versus ESCIT at 8 weeks. A significant improvement in QOLIE-31 index and seizure frequency was observed from baseline in both the groups. 90% of those on VEN and 92.9% of those using ESCITadhered to the treatment at week 8. Adverse events were more in VEN group than the ESCIT group.

CONCLUSIONS

This study found that HAMD scores improved significantly in the ESCIT and VEN groups, despite the fact that there was no clinically meaningful difference observed between the two groups. Trials with a larger sample size and longer duration are required to establish whether ESCIT or VEN is superior.

Did the pattern of use of zolpidem change since the enforcement of a new prescription rule? A latent class analysis using the French health insurance database

BACKGROUND

In recent years, zolpidem has been the subject of numerous reports of misuse, abuse and dependence. In view of these risks, the French drug agency decreed the implementation of secure prescription pads in April, 2017. The objective of this study was to characterize the impact of this regulatory change on the patterns of zolpidem use.

RESEARCH DESIGN AND METHODS

We included patients with at least one reimbursement for zolpidem before and/or after the regulatory change using a sample of the French health insurance database. For each period, we identified profiles of users using a latent class analysis (LCA).

RESULTS

In total, 15,550 zolpidem users were identified before the measure and 8,301 after the measure. We identified the same three profiles of zolpidem users before and after the measure: non-problematic users (the most prevalent), users whose drug prescriptions suggest psychiatric disorder and potential problematic users. The profile of potential problematic users was similar after the regulatory change but represented a lower absolute number of patients.

CONCLUSION

In conclusion, the regulatory change had a positive impact on the patterns of zolpidem use, but the impact should be reevaluated, because withdrawal can take a long time, especially in long-term users.

TRIAL REGISTRATION

The study was registered at www.clinicaltrials.gov under the reference number NCT03584542.

Outcomes associated with antidepressant treatment according to the number of prescriptions and treatment changes: 5-year follow-up of a nation-wide cohort study

BACKGROUND

Naturalistic studies regarding clinical outcomes associated with antidepressant treatment duration have yielded conflicting results, possibly because they did not consider the occurrence of treatment changes. This nation-wide population-based study examined the association between the number of filled prescriptions and treatment changes and long-term psychiatric outcomes after antidepressant treatment initiation.

METHODS

Based on the French national health insurance database, 842,175 adults who initiated an antidepressant treatment in 2011 were included. Cox proportional-hazard multi-adjusted regression models examined the association between the number of filled prescriptions and the occurrence of treatment changes 12 months after initiation and four outcomes during a 5-year follow-up: psychiatric hospitalizations, suicide attempts, sick leaves for a psychiatric diagnosis, new episodes of antidepressant treatment.

RESULTS

During a mean follow-up of 4.5 years, the incidence rates of the four above-mentioned outcomes were 13.49, 2.47, 4.57, and 92.76 per 1,000 person-years, respectively. The number of filled prescriptions was associated with each outcome (adjusted HRs [95% CI] for one additional prescription ranging from 1.01 [1.00-1.02] to 1.10 [1.09-1.11]), as was the occurrence of at least one treatment change vs. none (adjusted HRs [95% CI] ranging from 1.18 [1.16-1.21] to 1.57 [1.79-1.65]). Furthermore, the adjusted HRs [95% CI] of the number of filled prescriptions were greater in patients with (vs. without) a treatment change for psychiatric hospitalizations (1.12 [1.11-1.14] vs. 1.09 [1.08-1.10], p for interaction = 0.002) and suicide attempts (1.12 [1.09-1.15] vs. 1.06 [1.04-1.08], p for interaction = 0.006).

LIMITATIONS

Lack of clinical data about the disorders warranting the prescriptions or their severity.

CONCLUSION

Considering treatment changes is critical when using administrative claims database to examine the long-term psychiatric outcomes of antidepressant treatments in real-life settings.

Predictors of sick leave days in patients affected by major depressive disorder receiving antidepressant treatment in general practice setting in Germany

OBJECTIVE

To identify sick leave days (SLD) predictors after starting antidepressant (AD) treatment in patients affected by major depressive disorder (MDD), managed by general practitioners, with a focus on different AD therapeutic approaches.

METHODS

Retrospective study on German IQVIA^® Disease Analyser database. 19-64 year old MDD patients initiating AD treatment between July-2016 and June-2018 were grouped by therapeutic approach (AD monotherapy versus combination/switch/add-on). Data were analysed descriptively by AD therapeutic approach, while a zero-inflated Poisson (ZIP) multiple regression model was run to evaluate SLD predictors.

RESULTS

8,891 patients met inclusion criteria (monotherapy: 66%; combination/switch/add-on: 34%). All covariates had an influence on SLD after AD treatment initiation. Focussing on variables that physicians may more easily intervene to improve outcomes, it was found that the expected SLD number of combination/switch/add-on patients was 1.6 times that of monotherapy patients, and the expected SLD number of patients diagnosed with MDD before the decision to start AD treatment was 1.2 times that of patients not diagnosed with MDD.

CONCLUSIONS

A patient tailored approach in the selection of AD treatment at the time of MDD diagnosis may improve functional recovery and help to reduce the socio-economic burden of the disease.KEY POINTSFew studies previously investigated the effect of antidepressant treatment approaches on sick leave days in major depressive disorder.To the authors' knowledge, this is the first study evaluating the effect of different antidepressant treatment approaches on sick leave days in major depressive disorder in German patients.Patients receiving antidepressant monotherapy treatment seemed to lose fewer working days than patients receiving antidepressants combination/switch/add-on therapy, both before and after starting treatment, even if differences were more pronounced after treatment has started.The use of antidepressant monotherapy or combination/switch/add-on therapy was the strongest predictor of sick leave days after starting antidepressant treatment: the expected number of sick leave days for the combination/switch/add-on group was 1.6 times that of the monotherapy group.Among factors associated with increased sick leave days, antidepressant therapeutic approach and the promptness of starting the antidepressant treatment when major depressive disorder is diagnosed, are those on which physicians may more easily intervene to improve outcomes.Findings from the present study suggest that a patient tailored approach may improve functional recovery and help reducing the socio-economic burden of the disease.

Drug exposure misclassification in pharmacoepidemiology: Sources and relative impact

BACKGROUND

Drug exposure assessment based on dispensing data can be misclassified when patients do not adhere to their therapy or when information about over-the-counter drugs is not captured in the study database. Previous research has considered hypothetical sensitivity and specificity values, whereas this study aims to assess the impact of literature-based real values of exposure misclassification.

METHODS

A synthetic cohort study was constructed based on the proportion of exposure theoretically captured in a database (range 0.5-1.0) and the level of adherence (0.5-1.0). Three scenarios were explored: nondifferential misclassification, differential misclassification (misclassifications dependent on an unmeasured risk factor doubling the outcome risk), and nondifferential misclassification in a comparative effectiveness study (RR_A and RR_B both 2.0 compared to nonuse, RR_A-B 1.0).

RESULTS

For the scenarios with nondifferential misclassification, 25% nonadherence or 25% uncaptured exposure changed the RR from 2.0 to 1.75, and 1.95, respectively. Applying different proportions of nonadherence or uncaptured use (20% vs. 40%) for subgroups with and without the risk factor, an RR of 0.95 was observed in the absence of a true effect (i.e., true RR = 1). In the comparative effectiveness study, no effect on RR was seen for different proportions of uncaptured exposure; however, different levels of nonadherence for the drugs (20% vs. 40%) led to an underestimation of RR_A-B (0.89).

DISCUSSION

All scenarios led to biased estimates, but the magnitude of the bias differed across scenarios. When testing the robustness of findings of pharmacoepidemiologic studies, we recommend using realistic values of nonadherence and uncaptured exposure based on real-world data.

The role of sickness absence diagnosis for the risk of future inpatient- or specialized outpatient care in a Swedish population-based twin sample

BACKGROUND

Studies of consequences of sickness absence such as health and well-being have been rare whereas risk factors for sickness absence have been studied extensively. This study assumed the consequences of sickness absence would differ by diagnostic group or by patient care type. The aim was to investigate sickness absence due to various diagnosis groups as a predictor for subsequent inpatient- and specialized outpatient care while controlling for familial confounding.

METHODS

We utilized the register data of 69,552 twin individuals between 16 and 80 years of age (48% women). The first incident sickness absence spell, from baseline year 2005, including diagnosis of sickness absence was our primary exposure of interest and we followed them until the first incident inpatient- and specialized outpatient care episode with main diagnosis code or until 31.12.2013.

RESULTS

A total of 7464 incident sickness absence spells took place (11%), 42% had inpatient care and 83% specialized outpatient care (mean follow-up time 3.2 years, SD 3.1 years). All the main sickness absence diagnosis groups were associated with increased risk of future care in comparison to no sickness absence. Controlling for confounders attenuated the associations in magnitude but with retaining direction, and we could not confirm an effect of familial factors.

CONCLUSIONS

Sickness absence predicts both inpatient- and specialized outpatient care and the association is universal across diagnosis groups. The lower survival time and incidence rates of inpatient than specialized outpatient care point towards severity of diseases assumption. This finding was also universal across sickness absence diagnosis groups.

The predictive role of sickness absence spell durations in associations with inpatient- and specialized outpatient care among a population-based Swedish twin sample

BACKGROUND

The associations between a sickness absence spell duration and patient care have been rarely studied. An assumption is that associations would differ by spell duration and by the patient care type, inpatient- or specialized outpatient, due to severity of diseases and/or conditions. We aimed to investigate sickness absence spells in various spell durations as a predictor for subsequent inpatient- and specialized outpatient care separately, and to study if familial confounding plays a role in these associations.

METHODS

We followed a population-based sample of Swedish twins born 1925-90 with national registers from 2001 for first incident sickness absence spell (days to calculate spell duration categorized into ≤30 days, 31-90 days, 91-180 days and ≥ 181 days), or no sickness absence, and for inpatient- and specialized outpatient care until 2013 (n = 24,975). Cox proportional hazards models were applied for hazard ratios (HR) with 95% confidence intervals (CI) while accounting for covariates and familial confounding.

RESULTS

First incident sickness absence spell across all duration categories was associated with an increased risk of inpatient- (age- and sex adjusted HR 1.28 to 6.05) or specialized outpatient care (HR 1.17-2.50), both in comparison to those without any sickness absence or the shortest sickness absence spell category (1-30 days). The associations remained statistically significant while controlling for covariates or familial confounding.

CONCLUSIONS

First incident sickness absence spell increases the risk of inpatient care or specialized outpatient care regardless of the duration of the sickness absence spell. Hence, incident sickness absence spells should be noted and targeted to actions at workplaces as well as in primary and occupational health care.

The Shared Decision-Making Process in the Pharmacological Management of Depression

Shared decision making (SDM) is a model of interaction between doctors and patients in which both actors contribute to the medical decision-making process. There is an international consensus across medicine about the importance of SDM interventions, which have raised great interest in mental healthcare over the last decade. Yet SDM is not widely adopted, particularly in the field of psychiatry. The purpose of the present article is to examine, from a patient and physician perspective, the importance of SDM in the management of healthcare with a focus on mental health; it reviews the enablers and barriers (and how to overcome them) to implementing a SDM process in psychiatric practice. SDM models have been developed recently for involving patients with depression in the decision-making process, which could result in augmenting the proportion of patients who adhere to their antidepressant or other treatments for a duration that complies with the current recommendations. To implement this approach, more physicians need training in the SDM approach and access to appropriate tools that help engage in collaborative deliberation, and practice generally needs to be reorganized around the principles of patient engagement.

Early Detection of Prescription Drug Abuse Using Doctor Shopping Monitoring From Claims Databases: Illustration From the Experience of the French Addictovigilance Network

Opioid analgesics and maintenance treatments, benzodiazepines and z-drugs, and other sedatives and stimulants are increasingly being abused to induce psychoactive effects or alter the effects of other drugs, eventually leading to dependence. Awareness of prescription drug abuse has been increasing in the last two decades, and organizations such as the International Narcotics Control Board has predicted that, worldwide, prescription drug abuse may exceed the use of illicit drugs. Assessment of prescription drug abuse tackles an issue that is hidden by nature, which therefore requires a specific monitoring. The current best practice is to use multiple detection systems to assess prescription drug abuse by various populations in a timely, sensitive, and specific manner. In the early 2000's, we designed a method to detect and quantify doctor shopping for prescription drugs from the French National Health Data System, which is one of the world's largest claims database, and a first-class data source for pharmacoepidemiological studies. Doctor shopping is a well-known behavior that involves overlapping prescriptions from multiple prescribers for the same drug, to obtain higher doses than those prescribed by each prescriber on an individual basis. In addition, doctor shopping may play an important role in supplying the black market. The paper aims to review how doctor shopping monitoring can improve the early detection of prescription drug abuse within a multidimensional monitoring. The paper provides an in-depth overview of two decades of development and validation of the method as a complementary component of the multidimensional monitoring conducted by the French Addictovigilance Network. The process accounted for the relevant determinants of prescription drug abuse, such as pharmacological data (e.g., formulations and doses), chronological and geographical data (e.g., impact of measures and comparison between regions), and epidemiological and outcome data (e.g., profiles of patients and trajectories of care) for several pharmacological classes (e.g., opioids, benzodiazepines, antidepressants, and methylphenidate).

Agomelatine in Standard Medical Practice in Depressed Patients: Results of a 1-Year Multicentre Observational Study In France

Background and Objectives

Non-interventional studies are a valuable source of evidence that is complementary to traditional randomised, blinded and controlled clinical trials, for evaluating antidepressants in a real-world setting. The aim of the present study was to document the use of agomelatine in current medical practice and evaluate its effectiveness and safety in outpatients prescribed agomelatine to treat their current depressive episode.

Methods

This 12-month observational French study included patients initiating agomelatine treatment. The intensity and severity of depression were assessed using the 17-item Hamilton Depression Rating Scale (HAM-D17) total score and the Clinical Global Impression-Severity of Illness (CGI-S) scale. Patients’ quality of life and functioning were measured using the Quality of Life in Depression Scale and the Sheehan Disability Scale, respectively. The safety measures included emergent adverse events and biological samplings, with a focus on liver acceptability.

Results

A total of 1484 patients (70% of women; 49.6 ± 15.4 years of age) were enrolled in the study. Most patients (62.3%) were treated with agomelatine for at least 6 months and 28.8% were treated for at least 1 year. Mean HAM-D17 total score and mean CGI-S scores decreased by 13.6 ± 8.1 and 2.1 ± 1.5 points, respectively, from baseline to last visit on agomelatine. Rates of responders (i.e. with a decrease in HAM-D17 total score by at least 50%) and remitters (HAM-D total score < 7) at the last visit were 90.7% and 56.0%, respectively. The mean HAM-D total score decreased after agomelatine withdrawal (− 4.1 ± 6.7) until the last visit. The quality of life and daily functioning of patients improved, while the numbers of days lost and underproductive days decreased over the follow-up period. Safety findings were in accordance with the known information regarding agomelatine.

Conclusion

In the current medical practice, this study confirms the effectiveness and good tolerability of agomelatine administered for a treatment period in agreement with guideline recommendations.

Trial registration number

ISRCTN53570733 on 27 August 2010.

A Cross-Sectional Study of Treatments for Behavioral Disorders Following Traumatic Brain Injury: Comparison With French Recommendations

OBJECTIVE

To give a cross-sectional overview of ongoing management of behavioral disorders following traumatic brain injury (TBI) in a region of France, to compare this with recent recommendations from the French Society of Physical Medicine and Rehabilitation (SOFMER), and to evaluate associations between treatments and participant characteristics.

SETTING

Outpatients referred to medical or community-based facilities in a region of France.

PARTICIPANTS

One hundred twenty-nine adults with moderate to severe TBI, in the postacute period (over 3 months postinjury).

DESIGN

Cross-sectional cohort study.

MAIN MEASURES

Sociodemographic data, ongoing interventions including psychotherapy and medication, behavioral disorders assessed by the Behavioral Dysexecutive Syndrome Inventory (BDSI).

RESULTS

Thirty-three percent of participants received ongoing psychotherapy and 43% were on medication. The most prescribed medications were antidepressants (21%), neuroleptics (18%), anxiolytics (16%), and mood stabilizers (14%). Eighty-five participants (71%) presented a current Behavioral Dysexecutive Syndrome (BDS) according to the BDSI. These participants more frequently received treatment (P = .004), psychotherapy (P = .048), medications (often 2 or more) (P = .007), and particularly antiepileptic mood stabilizers (P = .037) compared with those without BDS.

CONCLUSION

Although recommended as first-line treatment, few participants with BDS received psychotherapy. Medications were overused, especially neuroleptics in view of their potential adverse effects. In contrast, recommended medications, such as mood stabilizers and β-blockers, did not appear to be highly prescribed whatever the evolution. Compliance with recommendations seemed insufficient.

Prevalence of mental disorders is higher in patients with multiple sclerosis than in the general population or in patients with rheumatoid arthritis in France

Background

Mental disorders (MDs) in multiple sclerosis (MS) patients decreases treatment adherence and quality of life, and increases the risk of disability progression and care consumption.

Objective

This study was to assess the prevalence of MDs in MS patients compared with healthy controls (HC) of the French general population and rheumatoid arthritis (RA) patients.

Methods

The 2015 prevalence of MDs for MS patients, RA patients and general population was estimated using a random population-based data sample from ‘National Inter-Scheme Information System on Health Insurance’ in the 2011–2015 period. Two control groups (1:5 ratio for the HC and 1:1 for the RA group) were matched to the MS group for year of birth, gender, area of residence and health insurance scheme.

Results

A total of 1145 MS patients were identified (sex ratio of 2.5 (F/M); median age 50 years). The prevalence of MDs was higher in the population of patients with MS (37.3%) than in the French general population (13.6%), and to a lesser extent in the RA group (21.1%) leading to the prevalence ratios of 2.8 (95% confidence intervals (CIs) 2.5–3.0) and 1.9 (95% CI 1.7–2.3), respectively.

Conclusions

This study confirmed that MS patients are at a higher risk of MDs than the French general population or RA patients.

Using filled prescription sequences to rank antidepressants according to their acceptability in the general population: The Constances cohort

Ranking antidepressants according to their acceptability (i.e. a combination of both efficacy and tolerability) in the general population may help choosing the best first-line medication. This study aimed to rank antidepressants according to the proportion of filled prescription sequences consistent with a continuation of the first treatment versus those consistent with a change. A first step was validating this measure as a proxy of acceptability by examining the association of these two kinds of sequences with levels of depressive symptoms. Among 64,467 individuals included in the French population-based Constances cohort, reimbursements of antidepressants from January 2009 to December 2015 were extracted from the French national health insurance system claims database. Depressive symptoms were measured at inclusion with the Center for Epidemiologic Studies-Depression scale (CES-D). Between January 2010 and December 2015, 6675 participants newly initiated an antidepressant (34.5% men, mean (SD) age: 48.3 (12.1) years). Among the subsample of participants included during the six-month period following treatment initiation, individuals with continuation sequences had lower levels of depressive symptoms than those with change sequences (mean (SE) CES-D score: 18.9 (0.8) versus 26.5 (2.1), p < 0.001). According to the continuation/change ratio observed over this six-month period in all participants, escitalopram ranked first, followed by sertraline, venlafaxine, citalopram, fluoxetine and paroxetine. In an independent replication sample representative of the French national population, the same six medications ranked first, with escitalopram remaining in first place. The proportion of filled prescription sequences consistent with a continuation versus a change of the first prescribed treatment may provide a widely available measure of antidepressant acceptability in community practice.

Treatment patterns and sequences of pharmacotherapy for patients diagnosed with depression in the United States: 2014 through 2019

BACKGROUND

Understanding how patients are treated in the real-world is vital to identifying potential gaps in care. We describe the current pharmacologic treatment patterns for the treatment of depression.

METHODS

Patients with depression were identified from four large national claims databases during 1/1/2014-1/31/2019. Patients had ≥2 diagnoses for depression or an inpatient hospitalization with a diagnosis of depression. Patients were required to have enrollment in the database ≥1 year prior to and 3 years following their first depression diagnosis. Treatment patterns were captured at the class level and included selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, other antidepressants, anxiolytics, hypnotics/sedatives, and antipsychotics. Treatment patterns were captured during all available follow-up.

RESULTS

We identified 269,668 patients diagnosed with depression. The proportion not receiving any pharmacological treatment during follow-up ranged from 29 to 52%. Of the treated, approximately half received ≥2 different classes of therapy, a quarter received ≥3 classes and more than 10% received 4 or more. SSRIs were the most common first-line treatment; however, many patients received an anxiolytic, hypnotic/sedative, or antipsychotic prior to any antidepressive treatment. Treatment with a combination of classes ranged from approximately 20% of first-line therapies to 40% of fourth-line.

CONCLUSIONS

Many patients diagnosed with depression go untreated and many others receive a non-antidepressant medication class as their first treatment. More than half of patients received more than one type of treatment class during the study follow up, suggesting that the first treatment received may not be optimal for most patients.

Antidepressants during pregnancy: a French drug utilisation study in EFEMERIS cohort

BACKGROUND

Previous studies have suggested that exposure to some antidepressants (AD) during pregnancy could be associated with an increased risk of congenital malformations and neurodevelopment disorders for the child. We conducted a study to describe the use of AD during pregnancy in France.

METHODS

We performed a drug utilisation study in EFEMERIS, a French cohort of pregnant women. At the time of the present study, 89,170 pregnant women, who were pregnant from 2005 to 2014 in Haute-Garonne were included. Prevalence and incidence of AD prescriptions during pregnancy, characteristics of AD users, and trends in AD use over the 10-year period were studied.

RESULTS

During the 10-year study period, 1620 women registered in EFEMERIS (1.8%) received at least one prescription and dispensation for AD during pregnancy: 1363 during the first (1.5%), 591 during the second (0.7%), and 412 during the third (0.5%) trimester. A total of 2874 women (3.2%) got a prescription for an AD during the 3 months before and/or during pregnancy; 2187 of them (76.1%) stopped AD before pregnancy or during the first trimester. Selective serotonin reuptake inhibitors represented the most prescribed class during pregnancy (1.3%). A very slight decrease in the prevalence of AD prescriptions in pregnant women over time (1.7% in 2014 vs 2% in 2005) and some variations within classes were observed.

CONCLUSIONS

Nearly, 2% of women received antidepressant drugs during pregnancy. This assessment encourages following research on these drugs including the potential risk of neurodevelopmental disorders in children after an exposure to antidepressants during pregnancy.

Experimenting locally with a stepped-care approach for the treatment of mild to moderate mental disorders in France: Challenges and opportunities

In France, publicly funded mental care services are mostly hospital-based and focused on treating severe illnesses. Mild to moderate mental disorders are typically managed by general practitioners (GP) who often lack specific training to treat these conditions. Antidepressant prescribing levels for mild to moderate conditions are inadequately high. Public reimbursement for psychotherapies provided by psychologists is generally not available. This paper presents a local experiment with a stepped-care approach for the treatment of mild to moderate mental disorders in four French départements launched in 2018. The experiment includes the introduction of a standardized assessment protocol for GPs, clear referral guidelines, and full reimbursement of visits to psychologists upon GP referral. Seemingly simple, the policy raises several issues related to the regulation, training and reimbursement of psychologists, and illustrates the need for careful preparation and workforce planning to ensure success and stakeholder support. An independent evaluation of the local experiments is planned, which provides the opportunity to fine-tune the policy before any broader rollout. The issues raised in France and the on-going debate is relevant for other countries preparing similar policies for improving mental care.

Detection of Cases of Noncompliance to Drug Treatment in Patient Forum Posts: Topic Model Approach

Background

Medication nonadherence is a major impediment to the management of many health conditions. A better understanding of the factors underlying noncompliance to treatment may help health professionals to address it. Patients use peer-to-peer virtual communities and social media to share their experiences regarding their treatments and diseases. Using topic models makes it possible to model themes present in a collection of posts, thus to identify cases of noncompliance.

Objective

The aim of this study was to detect messages describing patients’ noncompliant behaviors associated with a drug of interest. Thus, the objective was the clustering of posts featuring a homogeneous vocabulary related to nonadherent attitudes.

Methods

We focused on escitalopram and aripiprazole used to treat depression and psychotic conditions, respectively. We implemented a probabilistic topic model to identify the topics that occurred in a corpus of messages mentioning these drugs, posted from 2004 to 2013 on three of the most popular French forums. Data were collected using a Web crawler designed by Kappa Santé as part of the Detec’t project to analyze social media for drug safety. Several topics were related to noncompliance to treatment.

Results

Starting from a corpus of 3650 posts related to an antidepressant drug (escitalopram) and 2164 posts related to an antipsychotic drug (aripiprazole), the use of latent Dirichlet allocation allowed us to model several themes, including interruptions of treatment and changes in dosage.

The topic model approach detected cases of noncompliance behaviors with a recall of 98.5% (272/276) and a precision of 32.6% (272/844).

Conclusions

Topic models enabled us to explore patients’ discussions on community websites and to identify posts related with noncompliant behaviors. After a manual review of the messages in the noncompliance topics, we found that noncompliance to treatment was present in 6.17% (276/4469) of the posts.

Estimating the prevalence of depression associated with healthcare use in France using administrative databases

BACKGROUND

Quantitative indicators are needed in order to define priorities, plan policies and evaluate public health interventions in mental health. The aim of this study was to assess the contribution of a large and exhaustive French national administrative database to study and monitor treated depression by comparing the prevalence and characteristics of the population using significant healthcare resources for depression as identified by different estimation methods and sources and to discuss the advantages and drawbacks of these methods.

METHODS

This study included the French population covered by the main health insurance scheme in 2012 (Régime général, 86% of the insured French population). Data were extracted from the French health insurance claim database (SNIIRAM), which contains information on all reimbursements, including treatments and hospital stays in France. The following distinct sources of the SNIIRAM were used to select persons with depression: diagnoses of long-term or costly conditions, data from national hospital claims and data concerning all national health insurance reimbursements for drugs.

RESULTS

In 2012, we included 58,753,200 individuals covered by the main health insurance scheme; 271,275 individuals had full coverage for depression; 179,470 individuals had been admitted to a psychiatric hospital and 66,595 individuals admitted to a general hospital with a diagnosis of depression during a 2-year timeframe and 144,670 individuals had more than three reimbursements for antidepressants during the study year (with a history of hospitalisation for depression during the past 5 years). Only 16% of individuals were selected by more than one source.

CONCLUSIONS

We propose an algorithm that includes persons recently hospitalised for depression, or with a history of hospitalisation for depression and still taking antidepressants, or with full coverage for depression as a specific long-term or costly condition, yielding a prevalence estimate of 0.93% or 544,105 individuals. Changes in the case selection methodology have major consequences on the frequency count and characteristics of the selected population, and consequently on the conclusions that can be drawn from the data, emphasizing the importance of defining the characteristics of the target population before the study in order to produce relevant results.