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Dal Pan GJ. The Use of Real-World Data to Assess the Impact of Safety-Related Regulatory Interventions. Clin Pharmacol Ther 2021; 111:98-107. [PMID: 34699061 DOI: 10.1002/cpt.2464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 10/06/2021] [Indexed: 11/05/2022]
Abstract
The regulation of medicines seeks to ensure the efficacy, safety, and quality of prescription and non-prescription medicines. Given that the conditions under which a medicine's benefits outweigh its risks are complex, it is essential that communications about the safe and effective use of medicines be clear and actionable. Assessing the impact of interventions to improve the safe and effective use of medicines is a developing area, and one in which real-world data are playing an increasingly important role. Although real-world data are commonly used to assess the impact of regulatory interventions, there are several areas where their use could be improved. Specific areas for improvement include assessing regulatory interventions across a wider range of medicines, rather than concentrating on a relatively few therapeutic areas; assessing more clinically relevant outcomes rather than relying on measures such as changes in the number of prescriptions, which may not always correlate with the desired impact; assessing the potential unintended or negative consequences of regulatory interventions; applying methods to address potential confounders; assessing long-term, rather than just short-term, impacts of an intervention; increasing the use of comparator groups, when feasible; and evaluating the impact of regulatory interventions from multiple dimensions, rather than from a single dimension. Expanded use of real-world data could inform some of these efforts, although data sources beyond administrative claims data will likely be necessary to achieve all these goals.
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Affiliation(s)
- Gerald J Dal Pan
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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2
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Barthez S, Revet A, Chouchana L, Jonville-Bera AP, Pizzoglio V, Raynaud JP, Chebane L, Lapeyre-Mestre M, Montastruc F. Adverse drug reactions in infants, children and adolescents exposed to antidepressants: a French pharmacovigilance study. Eur J Clin Pharmacol 2020; 76:1591-1599. [DOI: 10.1007/s00228-020-02944-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/19/2020] [Indexed: 12/22/2022]
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Anxiolytic Effect of Alcohol-Water Extracted Suanzaoren-Wuweizi Herb-Pair by Regulating ECS-BDNF-ERK Signaling Pathway Expression in Acute Restraint Stress Male Rats. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2020; 2020:2078932. [PMID: 32655658 PMCID: PMC7317328 DOI: 10.1155/2020/2078932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 02/28/2020] [Accepted: 03/24/2020] [Indexed: 01/04/2023]
Abstract
Herb-pairs are the basic units of composition in Chinese herbal formulae, where the bridge linking Chinese medicine and prescription consists of two Chinese medicine herbs. The Suanzaoren-Wuweizi herb-pair (SWHP) is commonly used as a sedative or tranquilizer. SWHP has been demonstrated to exert an antianxiety effect in animal models of anxiety. However, little information about its mechanism is available and the effects of SWHP have not been investigated. This study examined the effects of SWHP on ameliorating anxiety-like behaviors by regulating endocannabinoids system (ECS)-brain-derived neurotrophic factor (BDNF)-extracellular regulated protein kinases (ERK) signaling pathway expression, induced by restraint stress (RS) procedures. The antianxiety effects of SWHP on RS rats were then examined through the open-field test (OF) and the elevated plus maze test (EPM). The concentration of BNDF, ERK1/2, p-ERK1/2, cAMP-response element binding protein (CREB), and p-CREB expression in the prefrontal cortex and hippocampus of the rats was then measured by western blot. The number of positive cells of CB1 and CB2 in the rats' hippocampus CA1 region was measured by immunohistochemistry. These results gave compelling evidence that SWHP could modify anxiety-like behaviors of RS rats through regulation of the ECS-BDNF-ERK signaling pathway. Our study demonstrated that SWHP improved anxiety-like behaviors in RS rat models by regulating the ECS-BDNF-ERK signaling pathway. The findings indicate that SWHP may have a therapeutic application in the RS model of anxiety disorder, which proposes a potential new direction for research into anxiety disorders regarding mechanisms and the development of novel antianxiety drugs.
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Georgi U, Lämmel J, Datzmann T, Schmitt J, Deckert S. Do drug-related safety warnings have the expected impact on drug therapy? A systematic review. Pharmacoepidemiol Drug Saf 2020; 29:229-251. [PMID: 32045502 DOI: 10.1002/pds.4968] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/22/2019] [Accepted: 01/28/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE The need for drug-related safety warnings is undisputed, and their impact should also be evaluated. This systematic review investigates and assesses the impact of safety warnings on drug therapy. METHODS Studies published in English between January 1998 and December 2018 were searched in EMBASE and MEDLINE, complemented by manual search. Randomised controlled trials, cohort studies with a before/after component, and case-control studies were included, selected to predefined criteria, and assessed for their reporting and methodological quality. RESULTS Out of 7454 references identified, 72 studies were included. A total of 28/72 (39%) studies described the impact of safety warnings on drug therapy as being effective, whereas 12/72 (17%) studies did not. Further, 26/72 (36%) studies described a partial implementation of the warnings (one part of the warning had an impact on drug therapy and another did not). Unintended effects were investigated in 6/72 (8%) studies. While 34 (47%) studies examined safety warnings on psychotropic drugs using an interrupted time series (ITS) design (53%), a before/after (26%), and a time series design (21%), 38 (53%) studied other substances using an ITS design (34%), a before/after (40%), and a time series design (26%). The proportion of an effective impact on drug therapy was lower in the "psychotropic drugs" group (23%) than in the "others" group (53%). CONCLUSION Drug-related safety warnings induce intended and unintended effects. The included studies are of broadly varying methodological quality. To better compare their effectiveness, studies should be conducted using standardised procedures.
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Affiliation(s)
- Ulrike Georgi
- Pharmacy Service of Clinical Center, Chemnitz, Germany.,Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Julia Lämmel
- Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany.,Pharmacy Service, Medical Center of the Carl Gustav Carus Technical University, Dresden, Germany
| | - Thomas Datzmann
- Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany.,National Center for Tumor Diseases, Dresden, Germany
| | - Jochen Schmitt
- Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Stefanie Deckert
- Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany
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Weatherburn CJ, Guthrie B, Dreischulte T, Morales DR. Impact of medicines regulatory risk communications in the UK on prescribing and clinical outcomes: Systematic review, time series analysis and meta-analysis. Br J Clin Pharmacol 2019; 86:698-710. [PMID: 31465123 DOI: 10.1111/bcp.14104] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 08/13/2019] [Accepted: 08/20/2019] [Indexed: 12/18/2022] Open
Abstract
AIMS Regulatory risk communications are important to ensure medication safety, but their impact is poorly understood. The aim was to quantify the impact of UK risk communications on medication use and other outcomes. METHODS We conducted a systematic review of studies reporting prescribing/health outcome data relevant to UK regulatory risk communication. Data were reanalysed using interrupted time series regression 12 months after each regulatory intervention. Mean changes were pooled using random-effects generic inverse variance examining the following subgroups: drug withdrawals; restrictions/changes in indications; be aware messages without specific recommendations for action; communication via direct healthcare practitioner communications; communication via drug bulletins. RESULTS Of 11 466 articles screened, 40 studies examining 25 UK regulatory risk communications were included. Product withdrawals, restriction in indications and be aware communications were associated with relative mean changes of -78% (95% confidence interval [CI] -60 to -96%), -34% (95% confidence interval [CI] -12 to -55%) and -11% (95%CI -8 to -15%) in targeted drug prescribing respectively. Direct healthcare professional communications were associated with relative mean changes of -47% (95%CI -27 to -68%) compared to -13% (95%CI -6 to -20%) for drug bulletins. Of 7 studies examining unique health outcomes related to the safety concern, risk communications were associated with a mean -10% (95%CI -3 to -16%) decrease in intended and a 7% (95%CI 4 to 10%) increase in unintended health outcomes. DISCUSSION UK regulatory risk communications were associated with significant changes in targeted prescribing and potential changes in clinical outcomes. Further research is needed to systematically study the impact of regulatory interventions.
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Affiliation(s)
| | - Bruce Guthrie
- General Practice, Centre for Population Health Sciences, Usher Institute, University of Edinburgh, UK
| | - Tobias Dreischulte
- Clinical Health Services Research, Institute of General Practice and Family Medicine, University Hospital of Ludwig-Maximilians-University Munich, Germany
| | - Daniel R Morales
- Discovery Fellow and General Practitioner, Division of Population Health and Genomics, University of Dundee, UK
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Tiffin PA, Mediavilla JL, Close H, Kasim AS, Welsh P, Paton LW, Mason JM. What were the impacts of the Committee on Safety of Medicines warning and publication of the NICE guidelines on trends in child and adolescent antidepressant prescribing in primary care? A population based study. BMJ Open 2019; 9:e028201. [PMID: 31391190 PMCID: PMC6686994 DOI: 10.1136/bmjopen-2018-028201] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To assess the impact of both the Committee on Safety of Medicines (CSM) warning (December 2003) and the National Institute for Health and Care Excellence (NICE) guidance (September 2005) on antidepressant prescription rates in children and adolescents within the UK primary care service. SETTING Population based study of primary care antidepressant prescribing using the Clinical Practice Research Datalink (CPRD). PARTICIPANTS Under-18s presenting to primary care with a depressive disorder or related diagnostic code recorded in the CPRD. PRIMARY OUTCOME MEASURE Antidepressant prescription rates per month per 100 000 depressed 4-17 year olds. RESULTS Following the CSM warning, the prior trend towards increased prescribing rates for selective serotonin reuptake inhibitors (SSRIs) in children was significantly reversed (β for change in trend -12.34 (95% CI -18.67 to -6.00, p<0.001)). However, after the publication of the NICE guidelines the prior trend towards increased prescribing resumed for those SSRIs mentioned as potential treatments in the guidance (fluoxetine, citalopram and sertraline) (β for change in trend 11.52 (95% CI 5.32 to 17.73, p<0.001)). Prescribing of other SSRIs and tricyclics remained low. CONCLUSIONS Despite a strong emphasis on psychosocial interventions for child and adolescent depression, it may be that the NICE guidelines inadvertently encouraged further antidepressant prescribing, at least for those SSRIs cited. Although the guidelines gave cautions and caveats for the use of antidepressants, practitioners may have interpreted these recommendations as endorsing their use in young people with depression and related conditions. However, more accurate prevalence trend estimates for depression in this age group, and information on the use of psychosocial interventions would be needed to rule out other reasons underlying this increase in prescribing.
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Affiliation(s)
- Paul A Tiffin
- Department of Health Sciences, University of York, York, UK
- Health Professions Education Unit, Hull York Medical School, York, UK
| | - Jose L Mediavilla
- Darlington Community Team for Children and Young People, Tees Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK
| | - Helen Close
- The Research Design Service North East and Cumbria, Institute of Health and Society, University of Newcastle, Newcastle, UK
| | - Adetayo S Kasim
- Wolfson Research Institute for Health and Wellbeing, Durham University, Stockton-on-Tees, UK
| | - Patrick Welsh
- The Research Design Service North East and Cumbria, Institute of Health and Society, University of Newcastle, Newcastle, UK
| | - Lewis W Paton
- Department of Health Sciences, University of York, York, UK
| | - James M Mason
- Warwick Medical School, University of Warwick, Coventry, UK
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Daly C, Griffin E, Ashcroft DM, Webb RT, Perry IJ, Arensman E. Frequently used drug types and alcohol involvement in intentional drug overdoses in Ireland: a national registry study. Eur J Public Health 2019. [PMID: 29538652 DOI: 10.1093/eurpub/cky031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Intentional drug overdose (IDO) is the most common form of hospital-treated self-harm, yet no national study has systematically classified the range of drugs involved using a validated system. We aimed to determine the profile of patients engaging in overdose, to identify drugs frequently used and to quantify the contributions of multiple drug use and alcohol involvement. Methods Between 2012 and 2014, the National Self-Harm Registry, Ireland recorded 18 329 presentations of non-fatal IDO to Irish emergency departments. Information on demographic and overdose characteristics were obtained. Drugs were categorized using the Anatomical Therapeutic Chemical classification system. Results Analgesics (32.4%), antidepressants (21.9%), anxiolytics (21.2%) and hypnotics and sedatives (21.0%) were the most frequently used drugs types involved in overdose. Presentations involving analgesic and antidepressant medication were more common for females whereas males more often took illegal, anxiolytic and hypnotic and sedative drugs. Overdoses with drugs other than those which affect the nervous system were identified, including musculoskeletal drugs, taken in 12.0% of presentations. Paracetamol was the most frequently used drug, particularly among females (32.0%) and persons under 25 years (36.2%). Alcohol was most often present in overdoses involving anxiolytics and illegal drugs. Multiple drug use was a factor in almost half (47.1%) of presentations. Conclusions People who engage in IDO frequently take prescription only or sales restricted drugs, often involving alcohol and/or multiple drug use. These findings highlight the importance of addressing drug and alcohol misuse, potential inappropriate prescribing and the enforcement of legislation restricting specific drug sales.
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Affiliation(s)
- Caroline Daly
- National Suicide Research Foundation, School of Public Health, University College Cork, Cork, Ireland
| | - Eve Griffin
- National Suicide Research Foundation, School of Public Health, University College Cork, Cork, Ireland
| | - Darren M Ashcroft
- Division of Pharmacy & Optometry, Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Roger T Webb
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK.,Division of Psychology & Mental Health, Centre for Mental Health and Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Ivan J Perry
- National Suicide Research Foundation, School of Public Health, University College Cork, Cork, Ireland.,School of Public Health, University College Cork, Cork, Ireland
| | - Ella Arensman
- National Suicide Research Foundation, School of Public Health, University College Cork, Cork, Ireland.,School of Public Health, University College Cork, Cork, Ireland
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Kennedy C, Duggan E, Bennett K, Williams DJ. Rates of reported codeine-related poisonings and codeine prescribing following new national guidance in Ireland. Pharmacoepidemiol Drug Saf 2019; 28:106-111. [DOI: 10.1002/pds.4725] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/15/2018] [Accepted: 12/05/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Cormac Kennedy
- Department of Geriatrics and Stroke Medicine; Royal College of Surgeons in Ireland; Dublin Ireland
| | - Edel Duggan
- National Poisons Information Centre; Beaumont Hospital; Dublin Ireland
| | - Kathleen Bennett
- Division of Population Health Sciences; Royal College of Surgeons in Ireland; Dublin 2 Ireland
| | - David J. Williams
- Department of Geriatrics and Stroke Medicine; Royal College of Surgeons in Ireland; Dublin Ireland
- Department of Geriatrics and Stroke Medicine; Beaumont Hospital; Dublin 9 Ireland
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Daly C, Mörch CM, Kirtley OJ. Preventing Suicide - What Precedes Us Will Propel Us. CRISIS 2018; 39:409-415. [PMID: 30465618 DOI: 10.1027/0227-5910/a000575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Caroline Daly
- 1 National Suicide Research Foundation, Cork, Ireland.,2 School of Public Health, University College Cork, Ireland
| | - Carl-Maria Mörch
- 3 Centre for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices (CRISE), Université du Québec à Montréal, Canada
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Revet A, Montastruc F, Raynaud JP, Baricault B, Montastruc JL, Lapeyre-Mestre M. 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. J Clin Psychopharmacol 2018; 38:327-335. [PMID: 29851707 DOI: 10.1097/jcp.0000000000000891] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Goedecke T, Morales DR, Pacurariu A, Kurz X. Measuring the impact of medicines regulatory interventions - Systematic review and methodological considerations. Br J Clin Pharmacol 2018; 84:419-433. [PMID: 29105853 PMCID: PMC5809349 DOI: 10.1111/bcp.13469] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/24/2017] [Accepted: 10/31/2017] [Indexed: 12/20/2022] Open
Abstract
AIMS Evaluating the public health impact of regulatory interventions is important but there is currently no common methodological approach to guide this evaluation. This systematic review provides a descriptive overview of the analytical methods for impact research. METHODS We searched MEDLINE and EMBASE for articles with an empirical analysis evaluating the impact of European Union or non-European Union regulatory actions to safeguard public health published until March 2017. References from systematic reviews and articles from other known sources were added. Regulatory interventions, data sources, outcomes of interest, methodology and key findings were extracted. RESULTS From 1246 screened articles, 229 were eligible for full-text review and 153 articles in English language were included in the descriptive analysis. Over a third of articles studied analgesics and antidepressants. Interventions most frequently evaluated are regulatory safety communications (28.8%), black box warnings (23.5%) and direct healthcare professional communications (10.5%); 55% of studies measured changes in drug utilization patterns, 27% evaluated health outcomes, and 18% targeted knowledge, behaviour or changes in clinical practice. Unintended consequences like switching therapies or spill-over effects were rarely evaluated. Two-thirds used before-after time series and 15.7% before-after cross-sectional study designs. Various analytical approaches were applied including interrupted time series regression (31.4%), simple descriptive analysis (28.8%) and descriptive analysis with significance tests (23.5%). CONCLUSION Whilst impact evaluation of pharmacovigilance and product-specific regulatory interventions is increasing, the marked heterogeneity in study conduct and reporting highlights the need for scientific guidance to ensure robust methodologies are applied and systematic dissemination of results occurs.
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Affiliation(s)
- Thomas Goedecke
- Pharmacovigilance and Epidemiology Department, Inspections Human Medicines Pharmacovigilance and Committees DivisionEuropean Medicines Agency (EMA)LondonE14 5EUUK
| | - Daniel R. Morales
- Pharmacovigilance and Epidemiology Department, Inspections Human Medicines Pharmacovigilance and Committees DivisionEuropean Medicines Agency (EMA)LondonE14 5EUUK
- Division of Population Health SciencesUniversity of DundeeDundeeDD2 4BFUK
| | - Alexandra Pacurariu
- Pharmacovigilance and Epidemiology Department, Inspections Human Medicines Pharmacovigilance and Committees DivisionEuropean Medicines Agency (EMA)LondonE14 5EUUK
- Dutch Medicines Evaluation Board3531AHUtrechtThe Netherlands
| | - Xavier Kurz
- Pharmacovigilance and Epidemiology Department, Inspections Human Medicines Pharmacovigilance and Committees DivisionEuropean Medicines Agency (EMA)LondonE14 5EUUK
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12
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Pariente A, Mansiaux Y, Jarné A, Salvo F, Pageot C, Bezin J, Smith A, Bégaud B. Impact of pioglitazone regulatory withdrawal on antidiabetic drug use and health in diabetic patients. Eur J Clin Pharmacol 2017; 73:1655-1663. [DOI: 10.1007/s00228-017-2326-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 08/22/2017] [Indexed: 11/25/2022]
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Mars B, Heron J, Kessler D, Davies NM, Martin RM, Thomas KH, Gunnell D. Influences on antidepressant prescribing trends in the UK: 1995-2011. Soc Psychiatry Psychiatr Epidemiol 2017; 52:193-200. [PMID: 27885400 PMCID: PMC5329088 DOI: 10.1007/s00127-016-1306-4] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 10/30/2016] [Indexed: 11/21/2022]
Abstract
PURPOSE The number of antidepressants prescribed in the UK has been increasing over the last 25 years; however, the reasons for this are not clear. This study examined trends in antidepressant prescribing in the UK between 1995 and 2011 according to age, sex, and drug class, and investigated reasons for the increase in prescribing over this period. METHODS This is a retrospective analysis of antidepressant prescribing data from the Clinical Practice Research Datalink: a large, anonymised, primary care database in the UK. The dataset used in this study included 138 practices, at which a total of 1,524,201 eligible patients were registered across the 17-year period. The proportion of patients who received at least one antidepressant prescription and the number of patients who started a course of antidepressants were calculated for each year of the study. We used person years (PY) at risk as the denominator. The duration of treatment for those starting antidepressants was also examined. RESULTS 23% of patients were prescribed an antidepressant on at least one occasion over the 17-year study period. Antidepressant prescriptions rose from 61.9 per 1000 PY in 1995 to 129.9 per 1000 PY in 2011. This was largely driven by an increase in prescribing of selective serotonin reuptake inhibitors and 'other' antidepressants. In contrast, incidence rates of those starting antidepressants remained relatively stable (1995: 21.3 per 1000 PY; 2011: 17.9 per 1000 PY). The duration of treatment increased with later starting years, with an increasing proportion of long-term use, and decrease in short-term use. CONCLUSION The increase in antidepressant prescribing over the study period appears to be driven by an increase in long-term use of these medications.
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Affiliation(s)
- Becky Mars
- Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Oakfield House, Bristol, BS8 2BN, UK.
| | - Jon Heron
- Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Oakfield House, Bristol, BS8 2BN, UK
| | - David Kessler
- Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Oakfield House, Bristol, BS8 2BN, UK
| | - Neil M Davies
- Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Oakfield House, Bristol, BS8 2BN, UK
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - Richard M Martin
- Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Oakfield House, Bristol, BS8 2BN, UK
| | - Kyla H Thomas
- Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Oakfield House, Bristol, BS8 2BN, UK
| | - David Gunnell
- Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Oakfield House, Bristol, BS8 2BN, UK
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14
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Trends and patterns of antidepressant use in children and adolescents from five western countries, 2005-2012. Eur Neuropsychopharmacol 2016; 26:411-9. [PMID: 26970020 DOI: 10.1016/j.euroneuro.2016.02.001] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 01/15/2016] [Accepted: 02/01/2016] [Indexed: 11/22/2022]
Abstract
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.
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Acheampong P, Cooper G, Khazaeli B, Lupton DJ, White S, May MT, Thomas SHL. Effects of MHRA drug safety advice on time trends in prescribing volume and indices of clinical toxicity for quinine. Br J Clin Pharmacol 2014; 76:973-9. [PMID: 23594200 DOI: 10.1111/bcp.12130] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 04/04/2013] [Indexed: 11/28/2022] Open
Abstract
AIMS To ascertain the effects of the Medicines and Healthcare products Regulatory Agency's (MHRA) safety update in June 2010 on the volume of prescribing of quinine and on indices of quinine toxicity. METHODS We analysed quarterly primary care total and quinine prescribing data for England and quinine prescribing volume for individual Primary Care Trusts in the North East of England from 2007/8 to 2011/12 obtained from the ePACT.net database. We also analysed quinine toxicity enquiries to the National Poisons Information Service (NPIS) via Toxbase(®) and by telephone between 2004/5 and 2011/12. Joinpoint regression and Pearson's correlation tests were used to ascertain changes in trends in prescribing and indices of toxicity and associations between prescribing and indices of toxicity, respectively. RESULTS Total prescribing continued to increase, but annual growth in quinine prescribing in England declined from 6.0 to -0.6% following the MHRA update [difference -0.04 (95% confidence interval -0.07 to -0.01) quinine prescriptions per 100 patients per quarter, P = 0.0111]. Much larger reductions were observed in Primary Care Trusts that introduced comprehensive prescribing reviews. The previously increasing trend in Toxbase(®) quinine searches was reversed [difference -19.76 (95% confidence interval -39.28 to -9.20) user sessions per quarter, P = 0.0575]. Telephone enquiries to NPIS for quinine have declined, with stabilization of the proportion of moderate to severe cases of quinine poisoning since the update. CONCLUSIONS The MHRA advice was followed by limited reductions in the growth in quinine prescribing and in indicators of quinine overdose and toxicity. Quinine prescribing, however, remains common, and further efforts are needed to reduce availability and use.
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Affiliation(s)
- Paul Acheampong
- Regional Drug and Therapeutics Centre, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, NE2 4HH, UK
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Hsiao FY, Chou HC, Chen WW. Impact of safety-related regulation on use of parenteral ketorolac in a nationally representative population. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2014. [DOI: 10.1111/jphs.12054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Fei-Yuan Hsiao
- Graduate Institute of Clinical Pharmacy; National Taiwan University; Taipei Taiwan
- School of Pharmacy; College of Medicine; National Taiwan University; Taipei Taiwan
- Department of Pharmacy; National Taiwan University Hospital; Taipei Taiwan
| | - Hsin-Chun Chou
- Graduate Institute of Clinical Pharmacy; National Taiwan University; Taipei Taiwan
| | - Wen-Wen Chen
- Taiwan National Adverse Drug Reaction Reporting Center; Taipei Taiwan
- Drug Safety Division; Taiwan Drug Relief Foundation; Taipei Taiwan
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Isacsson G, Ahlner J. Antidepressants and the risk of suicide in young persons--prescription trends and toxicological analyses. Acta Psychiatr Scand 2014; 129:296-302. [PMID: 23773187 PMCID: PMC4224008 DOI: 10.1111/acps.12160] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess trends in the use of antidepressants among young suicides after the warning that these drugs might increase the risk of suicide. METHOD Individual data of all 845 suicides in the 10- to 19-year age group in Sweden in the time period 1992-2003 (baseline), and in 2004-2010 (after the warning). Outcome data are prescriptions of antidepressants prior to death and detections of antidepressants in post-mortem toxicology. RESULTS After the warning, suicide in this age group increased for five consecutive years (60.5%). The increase occurred among individuals not treated with antidepressants. CONCLUSION This study provides further support for the hypothesis that the warning, contrary to its intention, may have increased young suicides by leaving a number of suicidal young persons without treatment with antidepressants.
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Affiliation(s)
- G Isacsson
- Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Psychiatry Southwest, Karolinska University Hospital-HuddingeStockholm, Sweden
| | - J Ahlner
- Department of Forensic Toxicology and Forensic Genetics, National Board of Forensic MedicineLinköping, Sweden
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Rhodes AE, Bethell J, Carlisle C, Rosychuk RJ, Lu H, Newton A. Time trends in suicide-related behaviours in girls and boys. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2014; 59:152-9. [PMID: 24881164 PMCID: PMC4079127 DOI: 10.1177/070674371405900307] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the incidence and nature of emergency department (ED) presentations for nonfatal suicide-related behaviours (SRBs) over time, in boys and girls living in Ontario. We hypothesize declining rates (fiscal years [FYs] 2002/03 to 2006/07) ceased thereafter owing to renewed regulatory warnings against prescribing antidepressants and the economic recession. METHOD We graphed and tested differences in ED SRB incidence rates for FYs 2002/03 to 2010/11. We estimated rate ratios and 95% confidence intervals using negative binomial regression controlling for changes in the underlying population (age, community size, and neighbourhood income quintile). We examined the nature of the incident (index) presentations over time in terms of the method(s) used and events occurring before and after the index event. RESULTS ED SRB incidence rates decreased by 30% in boys and girls from FYs 2002/03 to 2006/07, but not thereafter. This trend was most evident in girls who self-poisoned and in girls' presentations to hospital with mental illness in the preceding year. Within a year of the index event, the proportion of girls with a repeat ED SRB presentation also declined by about one-third, but beyond FYs 2005/06 to 2009/10. However, the proportion admitted subsequent to the index event increased by about one-third. In boys, their patterns of presentations to hospital with mental illness and SRB repetition over time were similar to girls, but estimated with greater variability. CONCLUSIONS While the decline in ED SRB rates to FY 2006/07 is encouraging, the lack of decline thereafter and an increase in subsequent admissions merits ongoing monitoring and evaluation.
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Affiliation(s)
- Anne E Rhodes
- Research Scientist, Suicide Studies Research Unit and the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario; Associate Professor, Department of Psychiatry, Faculty of Medicine, University of Toronto and the Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto, Ontario; Adjunct Scientist, Institute for Clinical Evaluative Sciences, Toronto, Ontario
| | - Jennifer Bethell
- Research Coordinator, Suicide Studies Research Unit, St Michael's Hospital, Toronto, Ontario; Doctoral Student, Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Corine Carlisle
- Assistant Professor, Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario; Clinical Head, Youth Concurrent Disorders Service, Centre for Addictions and Mental Health, Toronto, Ontario
| | - Rhonda J Rosychuk
- Professor, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
| | - Hong Lu
- Analyst, Institute for Clinical Evaluative Sciences, Toronto, Ontario
| | - Amanda Newton
- Assistant Professor, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
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Adegbite-Adeniyi C, Gron B, Rowles BM, Demeter CA, Findling RL. An update on antidepressant use and suicidality in pediatric depression. Expert Opin Pharmacother 2013; 13:2119-30. [PMID: 22984934 DOI: 10.1517/14656566.2012.726613] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION In 2003, public health advisories in North America and Europe regarding suicidality associated with selective serotonin reuptake inhibitors (SSRIs) led to the addition of black box warnings to antidepressant package inserts in 2004. Subsequently, a series of events appeared to result from these regulatory actions. AREAS COVERED This review provides an overview of the temporal associations of regulatory agencies' actions in North America and Europe with rates of depression diagnoses, pediatric antidepressant prescription rates, follow-up visits to physicians prescribing antidepressants, and rates of completed suicide and suicidal ideation in children and adolescents. In addition, evidence-based predictors of suicidal behavior and suicide risk, as provided by large, multisite studies of depressed children and adolescents, are outlined. Finally, this review considers key advancements in the study of young patients at risk for suicide and describes innovations in current research methodology, to more accurately identify suicidality and the relationship to antidepressant use within this vulnerable patient population. EXPERT OPINION Evaluating the role of antidepressants in those youths who do not respond to evidence-based psychotherapeutic interventions may be a useful future research direction. Until more data are available, however, closely monitored antidepressant treatment in combination with CBT may provide the most benefit.
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Affiliation(s)
- Clara Adegbite-Adeniyi
- University Hospitals Case Medical Center, Division of Child and Adolescent Psychiatry, Cleveland, OH 44106, USA.
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Rudorfer MV, Hillefors M. Assessing Psychiatric Adverse Effects during Clinical Drug Development. Pharmaceut Med 2012. [DOI: 10.1007/bf03262382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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21
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Epidemiology and nature of self-harm in children and adolescents: findings from the multicentre study of self-harm in England. Eur Child Adolesc Psychiatry 2012; 21:369-77. [PMID: 22447195 DOI: 10.1007/s00787-012-0269-6] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Accepted: 03/13/2012] [Indexed: 10/28/2022]
Abstract
We examined epidemiology and characteristics of self-harm in adolescents and impact of national guidance on management. Data were collected in six hospitals in three centres between 2000 and 2007 in the Multicentre Study of Self-harm in England. Of 5,205 individuals (7,150 episodes of self-harm), three-quarters were female. The female:male ratio in 10-14 year-olds was 5.0 and 2.7 in 15-18 year-olds. Rates of self-harm varied somewhat between the centres. In females they averaged 302 per 100,000 (95 % CI 269-335) in 10-14 year-olds and 1,423 (95 % CI 1,346-1,501) in 15-18 year-olds, and were 67 (95 % CI 52-82) and 466 (95 % CI 422-510), respectively, in males. Self-poisoning was the most common method, involving paracetamol in 58.2 % of episodes. Presentations, especially those involving alcohol, peaked at night. Repetition of self-harm was frequent (53.3 % had a history of prior self-harm and 17.7 % repeated within a year). Relationship problems were the predominant difficulties associated with self-harm. Specialist assessment occurred in 57 % of episodes. Self-harm in children and adolescents in England is common, especially in older adolescents, and paracetamol overdose is the predominant method. National guidance on provision of psychosocial assessment in all cases of self-harm requires further implementation.
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Hoffmann F, Glaeske G, Petermann F, Bachmann CJ. Outpatient treatment in German adolescents with depression: an analysis of nationwide health insurance data. Pharmacoepidemiol Drug Saf 2012; 21:972-9. [PMID: 22639197 DOI: 10.1002/pds.3295] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2011] [Revised: 03/27/2012] [Accepted: 04/25/2012] [Indexed: 11/05/2022]
Abstract
PURPOSE Data on medical treatment of adolescents with depression are scarce. This study aimed to examine outpatient health services utilisation of depressive disorders in adolescents. METHODS Data of a statutory health insurance company were analysed and outpatients from 12 to 18 years old with diagnosed depression during a 1-year period (2009) were identified. For this cohort, the prescription of antidepressants and psychotherapy was evaluated with respect to age and sex. RESULTS A total of 4295 patients (41.2% males; mean age, 15.5 years) matched the inclusion criteria. Of the patients, 29.7% consulted a child and adolescent psychiatrist. A total of 59.6% were treated with psychotherapy only, 9.6% were treated with a combination of psychotherapy and antidepressants, and 1.9% received only antidepressants. For 28.8% of patients, no specific depression-related treatment was prescribed. A total of 1357 packages of antidepressants were analysed, of which fluoxetine (24.4% of prescriptions), citalopram (14.0%), and mirtazapine (9.7%) were the most frequently prescribed substances. Regarding substance classes, selective serotonin reuptake inhibitors (SSRIs; 55.6%), tricyclic antidepressants (TCAs; 17.9%), and hypericum (St. John's wort; 8.5%) were most common. CONCLUSIONS Although the underlying data were coded for insurance purposes, which might result in some data impreciseness, this naturalistic study furnishes evidence that outpatient treatment of adolescents with depressive disorders in Germany only partly complies with guideline recommendations for first-line treatment: Although the prescriptions of SSRI for adolescent depression have risen over recent years, still, a quarter of antidepressant prescriptions for adolescents with depression were TCA or hypericum. Therefore, dissemination of knowledge on state-of-the-art treatment for adolescent depression remains a major educational goal.
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Affiliation(s)
- Falk Hoffmann
- Centre for Social Policy Research, Division Health Economics, Health Policy and Outcomes Research, University of Bremen, Bremen, Germany.
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Piening S, Haaijer-Ruskamp FM, de Vries JT, van der Elst ME, de Graeff PA, Straus SM, Mol PG. Impact of Safety-Related Regulatory Action on Clinical Practice. Drug Saf 2012; 35:373-85. [DOI: 10.2165/11599100-000000000-00000] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Purper-Ouakil D, Cohen D, Flament MF. Les antidépresseurs chez l’enfant et l’adolescent : mise au point des données d’efficacité et de tolérance. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.neurenf.2011.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Haw C, James A, Gralton E. Guidance on the Use of Antidepressants for Depression in Young People: A Survey of the Views of Consultants in Child and Adolescent Psychiatry. Child Adolesc Ment Health 2011; 16:79-85. [PMID: 32847216 DOI: 10.1111/j.1475-3588.2010.00580.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Committee on Safety of Medicines (CSM) and National Institute for Health and Clinical Excellence have issued guidance on antidepressant use in depression in young people. METHOD An anonymous survey was sent to 692 UK consultants in child and adolescent psychiatry; the response rate was 70.1%. RESULTS Almost all (95.1%) respondents said fluoxetine was their antidepressant of first choice (29.9% only prescribed fluoxetine), although use of sertraline and citalopram was common. The CSM advice had resulted in 68.4% switching to fluoxetine only, or mostly. CONCLUSIONS Clinicians appear to be adhering national guidance. Guidance needs to be regularly updated to reflect current evidence.
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Affiliation(s)
- Camilla Haw
- St Andrew's Healthcare, Billing Road, Northampton NN1 5DG, UK. E-mail:
| | - Anthony James
- Highfield Adolescent Unit, Warneford Hospital, Warneford Lane, Headington, Oxford OX3 7JX, UK
| | - Ernest Gralton
- St Andrew's Healthcare, Billing Road, Northampton NN1 5DG, UK. E-mail:
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Bergen H, Hawton K, Waters K, Cooper J, Kapur N. Epidemiology and trends in non-fatal self-harm in three centres in England: 2000-2007. Br J Psychiatry 2010; 197:493-8. [PMID: 21119156 DOI: 10.1192/bjp.bp.110.077651] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Self-harm is a common reason for presentation to a general hospital, with a strong association with suicide. Trends in self-harm are an important indicator of community psychopathology, with resource implications for health services and relevance to suicide prevention policy. Previous reports in the UK have come largely from single centres. AIMS To investigate trends in non-fatal self-harm in six general hospitals in three centres from the Multicentre Study of Self-harm in England, and to relate these to trends in suicide. METHOD Data on self-harm presentations to general hospital emergency departments in Oxford (one), Manchester (three) and Derby (two) were analysed over the 8-year period 1 January 2000 to 31 December 2007. RESULTS Rates of self-harm declined significantly over 8 years for males in three centres (Oxford: -14%; Manchester: -25%; Derby: -18%) and females in two centres (Oxford: -2% (not significant); Manchester: -13%; Derby: -17%), in keeping with national trends in suicide. A decreasing proportion and number of episodes involved self-poisoning alone, and an increasing proportion and number involved other self-injury (e.g. hanging, jumping, traffic related). Episodes involving self-cutting alone showed a slight decrease in numbers over time. Trends in alcohol use at the time of self-harm and repetition within 1 year were stable. CONCLUSIONS There were decreasing rates of non-fatal self-harm over the study period that paralleled trends in suicide in England. This was reflected mainly in a decline in emergency department presentations for self-poisoning.
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Affiliation(s)
- Helen Bergen
- Centre for Suicide Research, University of Oxford, UK
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2010. [DOI: 10.1002/pds.1850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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