Use of antidepressants among people committing suicide in Sweden

Particular aspects of adverse event assessment in post marketing surveillance

The main feature of observational studies is the representation of naturalistic treatment conditions. In contrast to clinical trials, they allow the evaluation and quantification of adverse event profiles of drugs under “real life” conditions. The price for this unquestionable chance is the proneness to distorting factors, which may aggravate the interpretation of the study results. Analysis of observational study results therefore has to control for potentially influential factors and reconsider possible alternatives explaining observed associations. The most important distorting factors, which should be taken into account during analysis and interpretation are under-reporting, event selection, bias, confounding and misusage? Authors and readers of such study results should be aware of this possible sources of error, in order to derive optimal benefit from this study approach.

Antidepressants and suicide among young women in Sweden 1999-2013

OBJECTIVE

To establish whether the young women (15-24 year old) who committed suicide in Sweden (1999-2013) received antidepressant treatment or not, and to what extent, prior to and/or at the time of suicide. To investigate the belief that increased prescription of antidepressants would drastically reduce the number of suicides.

METHODS

An analysis of data from the Swedish Prescribed Drug Register, the Causes of Death Register, with registers cross checked, and from the National Board of Forensic Medicine.

RESULTS

This analysis shows a covariance between increased prescription of antidepressants and an increasing trend in the number of suicides among young women. In the period 1999-2003 antidepressants were found in toxicological analyses done in 23% of the young women who committed suicide, and in 39% of cases for 2009-2013.

CONCLUSION

An increasingly larger proportion of young women who later committed suicide, had in the last few years been treated with antidepressants, prior to and at the time of the suicide. The previous assumptions that treatment with antidepressants would lead to a drastic reduction in suicide rates, are incorrect for the population of young women. On the contrary, it was found that an increasing tendency of completed suicides follow the increased prescription of antidepressants.

Treatment resistant depression: causes and consequences

The Joint winners of the second Merck Essay Prize for 1994 were Drs Andrew Smith and Swaran Singh. Their essays are published below. The number of entries was 15.

Antidepressant prescribing prior to suicide: role of doctors

The pharmacological treatment of depression and the time elapsed since last seen by a doctor were investigated among 507 adults who subsequently killed themselves. The proportion of people consulting a general practitioner or psychiatrist prior to suicide was lower than reported by the British government in the Health of the Nation document. General practitioners prescribed relatively low doses of antidepressants. Nineteen out of the 115 people receiving antidepressants used the drugs to kill themselves. Our findings emphasise the importance of prescribing adequate doses of antidepressants and underline the need for safer prescribing.

The relationship between the prescription of pyschotropic drugs and suicide rates in adults in England and Wales

BACKGROUND

A few studies have demonstrated an inverse relationship between the general population and suicide rates and antidepressant prescribing rates. Correlations between general population suicide rates and prescribing rates of other psychotropic drugs have also been observed. There have not been any studies during the last decade.

METHODS

The relationship between adult suicide rates and prescription rates of psychotropic drugs by the broad British National Formulary (BNF) categories, for individual psychotropic drug groups within the BNF categories (e.g. selective serotonin reuptake inhibitors) and for individual psychotropic drugs was examined over a 12-year period (1995-2006) was examined using Spearman's rank correlation. All data were ascertained from the archives of the Office for National Statistics.

RESULTS

There was an absence of significant correlations between adult suicides rates and rates of prescriptions of psychotropic drugs in the broad BNF categories, individual psychotropic drug groups and individual psychotropic drugs.

DISCUSSION

The findings may be due to methodological errors. Should the findings be accurate, then the following approaches require consideration to reduce suicide rates further: (i) development of strategies to ensure continued prescription of psychotropic drugs at the current level; (ii) development of strategies to improve non-pharmacological measures, including improved mental health services provision for adults, improved assessment of suicide risk, increased availability of psychosocial interventions and restricting the availability of methods of suicide; and (iii) development of strategies to implement improvement in distal risk (e.g. societal socio-economic status) and protective (e.g. societal educational attainment) factors for suicide at a societal level.

Diagnoses and prescriptions of antidepressants in suicides: Register findings from the Friuli Venezia Giulia Region, Italy, 2002-2008

OBJECTIVE

To explore to what extent and under which diagnoses individuals who committed suicide had received psychiatric in-patient care, and how many had previously committed non-lethal self-harm. To investigate the antidepressant treatment received by these individuals.

METHODS

Case-control study based on a health register.

RESULTS

Psychiatric hospitalisation was found in 31.2% of the cases and 2.3% of the controls, and was a strong predictor for suicide with an odds ratio (OR) = 19.5. This did not differ significantly between diagnostic categories (except anxiety disorders with OR = 5.3). Non-lethal self-harm in the study period was committed by 14.3% of the cases and 0.14% of the controls, and was twice as common in female cases than in male cases. Previous self-harm was a very strong independent predictor for suicide with OR = 53.1 when a single episode of self-harm had occurred, and OR = 98.0 for repeated episodes (adjusted for age, gender and hospitalisation). Only 16.1% of the cases were currently on antidepressant medication at the time of suicide.

CONCLUSIONS

Few of the suicides had previously been psychiatric in-patients. Even fewer had current prescriptions for antidepressants. This suggests that better diagnosis and treatment of psychiatric patients is an important suicide preventive intervention.

Application of proteomics in diagnosis of ADHD, schizophrenia, major depression, and suicidal behavior

This report focuses on the application of different proteomic techniques in diagnosis and treatment of psychiatric disorders such as major depression, suicidal behavior, schizophrenia, and attention deficit/hyperactivity disorder (ADHD). Firstly, we briefly describe different analytic approaches that can be applied for the discovery of specific biomarkers for diagnosing the above disorders, as well as for monitoring the effect of their treatment. Secondly, we discussed the types of biomarkers in general used in biomedicine for characterizing different disorders and diseases. Next, the potential applications of these biomarkers for diagnosing and managing major depression, suicidal behavior, schizophrenia, and ADHD are discussed in details. Forensic aspects of these biomarkers for the above disorders are also considered. Finally, we discuss the potential of specific biomarkers for distinguishing between comorbid psychiatric disorders in clinical setup as well as their potential for understanding mechanisms underlying the disorders and in discovery of new treatment strategies.

Disopyramide and mianserin intoxication: a unique fatal case--review of the literature

Lethal occurrence is exceptional after disopyramide or mianserin poisoning. A case of intentional lethal intoxication with these drugs was reported, as well as a review of the literature. Pre- and postmortem blood concentrations of disopyramide or mianserin were assessed in a woman who died from acute cardiac failure after ingestion. The premortem blood concentration of disopyramide alone was considered lethal, and a toxic premortem concentration of mianserin was observed that may have increased cardiovascular failure induced by disopyramide because the metabolism of both drugs is mediated via cytochrome P450. Moreover, it was shown that the postmortem redistribution of disopyramide was limited, as pre- and postmortem concentrations were 48 and 65 mg/L, respectively. As regards mianserin, redistribution was observed after death with pre- and portmortem concentrations at 0.23 and 0.79 mg/L, respectively. This case illustrates that if postmortem blood concentration of disopyramide is known, the premortem concentration can be deduced.

The relationship between the prescription of psychotropic drugs and suicide rates in older people in England and Wales

BACKGROUND

Several studies have reported an inverse correlation between general population and elderly suicide rates and antidepressant prescribing rates. Correlations between general population and elderly suicide rates and prescribing rates of other psychotropic drugs have also been reported. All studies of elderly suicide rates have used data over a decade old.

METHODS

The relationship between elderly suicide rates and prescription rates of psychotropic drugs by the broad British National Formulary (BNF) categories, for individual psychotropic drug groups within the BNF categories (e.g. SSRIs), and for individual psychotropic drugs was examined over a 12-year period (1995-2006) using Spearman's rank correlation. All data were ascertained from the archives of the National Statistics Office.

RESULTS

There was an absence of significant correlations between elderly suicides rates and rates of prescriptions of psychotropic drugs in the broad BNF categories, individual psychotropic drug groups and individual psychotropic drugs.

DISCUSSION

The findings may be due to methodological flaws. However, if they are genuine, then the following approaches require consideration to further reduce suicide rates: (1) development of strategies to ensure continued prescription of psychotropic drugs at the current level; (2) development of strategies to improve non-pharmacological measures, including improved mental health services provision for older people, improved assessment of suicide risk, increased availability of psychosocial interventions and restricting the availability of methods of suicide; and (3) development of strategies to implement improvement in distal risk (e.g. societal socio-economic status) and protective (e.g. societal educational attainment) factors for suicide at a societal level.

Antidepressant Utilization and Suicide in Europe: An Ecological Multi-National Study

BACKGROUND

Research concerning the association between use of antidepressants and incidence of suicide has yielded inconsistent results and is the subject of considerable controversy. The first aim is to describe trends in the use of antidepressants and rates of suicide in Europe, adjusted for gross domestic product, alcohol consumption, unemployment, and divorce. The second aim is to explore if any observed reduction in the rate of suicide in different European countries preceded the trend for increased use of antidepressants.

METHODS

Data were obtained for 29 European countries between 1980 and 2009. Pearson correlations were used to explore the direction and magnitude of associations. Generalized linear mixed models and Poisson regression distribution were used to clarify the effects of antidepressants on suicide rates, while an autoregressive adjusted model was used to test the interaction between antidepressant utilization and suicide over two time periods: 1980-1994 and 1995-2009.

FINDINGS

An inverse correlation was observed in all countries between recorded Standardised Death Rate (SDR) for suicide and antidepressant Defined Daily Dosage (DDD), with the exception of Portugal. Variability was marked in the association between suicide and alcohol, unemployment and divorce, with countries depicting either a positive or a negative correlation with the SDR for suicide. Every unit increase in DDD of an antidepressant per 1000 people per day, adjusted for these confounding factors, reduces the SDR by 0.088. The correlation between DDD and suicide related SDR was negative in both time periods considered, albeit more pronounced between 1980 and 1994.

CONCLUSIONS

Suicide rates have tended to decrease more in European countries where there has been a greater increase in the use of antidepressants. These findings underline the importance of the appropriate use of antidepressants as part of routine care for people diagnosed with depression, therefore reducing the risk of suicide.

Can we really prevent suicide?

Every year, suicide is among the top 20 leading causes of death globally for all ages. Unfortunately, suicide is difficult to prevent, in large part because the prevalence of risk factors is high among the general population. In this review, clinical and psychological risk factors are examined and methods for suicide prevention are discussed. Prevention strategies found to be effective in suicide prevention include means restriction, responsible media coverage, and general public education, as well identification methods such as screening, gatekeeper training, and primary care physician education. Although the treatment for preventing suicide is difficult, follow-up that includes pharmacotherapy, psychotherapy, or both may be useful. However, prevention methods cannot be restricted to the individual. Community, social, and policy interventions will also be essential.

The European Psychiatric Association (EPA) guidance on suicide treatment and prevention

Suicide is a major public health problem in the WHO European Region accounting for over 150,000 deaths per year. SUICIDAL CRISIS: Acute intervention should start immediately in order to keep the patient alive.

DIAGNOSIS

An underlying psychiatric disorder is present in up to 90% of people who completed suicide. Comorbidity with depression, anxiety, substance abuse and personality disorders is high. In order to achieve successful prevention of suicidality, adequate diagnostic procedures and appropriate treatment for the underlying disorder are essential.

TREATMENT

Existing evidence supports the efficacy of pharmacological treatment and cognitive behavioural therapy (CBT) in preventing suicidal behaviour. Some other psychological treatments are promising, but the supporting evidence is currently insufficient. Studies show that antidepressant treatment decreases the risk for suicidality among depressed patients. However, the risk of suicidal behaviour in depressed patients treated with antidepressants exists during the first 10-14 days of treatment, which requires careful monitoring. Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and insomnia is recommended. Treatment with antidepressants of children and adolescents should only be given under supervision of a specialist. Long-term treatment with lithium has been shown to be effective in preventing both suicide and attempted suicide in patients with unipolar and bipolar depression. Treatment with clozapine is effective in reducing suicidal behaviour in patients with schizophrenia. Other atypical antipsychotics are promising but more evidence is required. TREATMENT TEAM: Multidisciplinary treatment teams including psychiatrist and other professionals such as psychologist, social worker, and occupational therapist are always preferable, as integration of pharmacological, psychological and social rehabilitation is recommended especially for patients with chronic suicidality. FAMILY: The suicidal person independently of age should always be motivated to involve family in the treatment. SOCIAL SUPPORT: Psychosocial treatment and support is recommended, as the majority of suicidal patients have problems with relationships, work, school and lack functioning social networks.

SAFETY

A secure home, public and hospital environment, without access to suicidal means is a necessary strategy in suicide prevention. Each treatment option, prescription of medication and discharge of the patient from hospital should be carefully evaluated against the involved risks. TRAINING OF PERSONNEL: Training of general practitioners (GPs) is effective in the prevention of suicide. It improves treatment of depression and anxiety, quality of the provided care and attitudes towards suicide. Continuous training including discussions about ethical and legal issues is necessary for psychiatrists and other mental health professionals.

Treatment of Veterans with depression who died by suicide: timing and quality of care at last Veterans Health Administration visit

OBJECTIVE

To examine the recency and quality of the last Veterans Health Administration (VHA) visit for patients with depression who died by suicide.

METHOD

We obtained services and pharmacy data for all 1,843 VHA patients with diagnosed depressive disorders (DSM-IV criteria) who died by suicide from April 1999 through September 2004. We ascertained the location and timing of their final VHA visit. For visits occurring within 30 days of suicide, we examined 3 quality indicators: (1) evidence that mental illness was a focus of the final visit, (2) adequacy of antidepressant dosage, and (3) recent receipt of mental health services.

RESULTS

Just over half of the patients (51%) with depression diagnoses had a VHA visit within 30 days of suicide. A minority of these patients (43%) died by suicide within 30 days of a final visit with mental health services, although 64% had received such services within 91 days of their suicide. Among the 57% of patients who died by suicide within 30 days and who were seen in non-mental health settings for their final visit, only 34% had a mental health condition coded at the final visit, and only 41% were receiving adequate dosages of antidepressant (versus 55% for those last seen by mental health services) (P < .0005).

CONCLUSIONS

Veterans Health Administration patients with depression who died by suicide within 30 days of their final visit received relatively high rates of mental health services, but most final visits still occurred in non-mental health settings. Increased referrals to mental health services, attention to mental health issues in non-mental health settings, and focus on antidepressant treatment adequacy by all providers might have reduced suicide risks for these patients.

Antidepressant medication prevents suicide in depression

OBJECTIVE

Ecological studies have demonstrated a substantial decrease in suicide in parallel with an increasing use of antidepressants. To investigate on the individual level the hypothesis that antidepressant medication was a causal factor.

METHOD

Data on the toxicological detection of antidepressants in 18 922 suicides in Sweden 1992-2003 were linked to registers of psychiatric hospitalization as well as registers with sociodemographic data.

RESULTS

The probability for the toxicological detection of an antidepressant was lowest in the non-suicide controls, higher in suicides, and even higher in suicides that had been psychiatric in-patients but excluding those who had been in-patients for the treatment of depression.

CONCLUSION

The finding that in-patient care for depression did not increase the probability of the detection of antidepressants in suicides is difficult to explain other than by the assumption that a substantial number of depressed individuals were saved from suicide by postdischarge treatment with antidepressant medication.

Decrease in suicide among the individuals treated with antidepressants: a controlled study of antidepressants in suicide, Sweden 1995-2005

OBJECTIVE

Ecological studies have demonstrated a substantial decrease in suicide in parallel with an increase in the use of antidepressants. Causality cannot, however, be inferred from such studies. The aim of this study was to test on the individual level the hypothesis that treatment with antidepressant medication has been a substantially contributing cause of the decrease in suicide.

METHOD

Time trends in the detection of antidepressants and five 'control medications' in the forensic toxicological screening of 16 937 suicides and 33 426 controls in Sweden 1995-2005.

RESULTS

The expected number of antidepressant-positive suicides in 2005 was 409 if the hypothesis was true and 603 if it was false. The observed number in 2005 was 420. The control medications were detected to the extent that was expected if not preventing suicide.

CONCLUSION

The observed trend in the number of suicides with antidepressants was well predicted by the hypothesis that the increased use of antidepressants has been a substantially contributing cause of the decrease in suicide.

Antidepressant use and suicide prevention: a prescription database study in the region Friuli Venezia Giulia, Italy

OBJECTIVE

To investigate the possible impact of the increased use of antidepressants on suicide rates in the Italian region of Friuli Venezia Giulia (FVG).

METHOD

Individual-based data on antidepressants in FVG from 1997 to 2006 were obtained from the regional prescription database, and linked to data on suicide for the same period obtained from the regional health information system. Age and sex were considered.

RESULTS

The number of users of antidepressants increased almost fivefold during the study period. Selective serotonin reuptake inhibitors accounted for 71% of the individual users in 2006. The number of defined daily doses (DDD) per patient increased almost sevenfold. In parallel, the suicide rate decreased by one-third in men as well as in women, and in subjects under and over the age of 60 years.

CONCLUSION

Suicide rates in FVG have declined in agreement with the hypothesis that the use of antidepressants may prevent suicide.

Toxicologic findings in suicide: a 10-year retrospective review of Kentucky medical examiner cases

Toxicologic analysis is an integral component in the investigation of suicide and requires correlation with a detailed scene inspection, with an extensive exploration into the decedent's medical and social background to uncover suicidal ideation or intent and a postmortem examination of the body. In this review, the authors analyzed 2864 cases classified as suicide upon autopsy and toxicologic examinations between 1993 and 2002 in the Kentucky Division of Medical Examiner's Services. Blood and urine were collected in 95.0% and 72.3% of cases, respectively. A total of 32.5% of the victims had negative blood toxicologic results, and 52.7% of urine toxicology screens yielded no drugs. Analysis of the data indicated that 3 times as many women had taken antidepressants and more than twice as many had consumed opioids. Drug toxicity ("overdose") ranked as the third (9.9%) leading cause of suicide after firearm injury (67.5%) and hanging (13.7%). Women succumbed to drug toxicity more than men (27.5% versus 5.9%). Of the overdose deaths, 66.5% had a negative blood alcohol concentration (BAC), while antidepressants, opioids, and benzodiazepines were detected in blood in 54.4%, 37.4%, and 29.2% of the subjects, respectively. The collection of these data serves the goals of public health and clinicians in devising strategies for suicide prevention.

Evidence for beneficial effects of antidepressants on suicidality in depressive patients: a systematic review

The role of antidepressants in suicide prevention is a major public health question, given the high prevalence of both depression and depression-related suicidality. Therefore all means available should be utilised to clarify the influence of antidepressants on suicidality. This paper gives a comprehensive overview of the positive effects of antidepressants on suicidality. In the first section, principal methodological issues related to suicidology in general as well as to clinical and epidemiological studies that investigate the influence of antidepressants on suicidality are discussed. In the second section, the results of controlled clinical studies on the efficacy of antidepressants in suicidality are presented. The third section reports on the results of other types of studies, especially epidemiological studies. Altogether, there seems to be reasonable evidence from different research approaches that antidepressants are able to reduce suicidal ideation and also suicidal behaviour in depressive patients. While the evidence for the beneficial effect on suicidal ideation comes from randomised control group studies, some of which used a placebo arm, the evidence for the prophylactic effect on suicidal behaviour, especially suicide, was primarily obtained from well-designed epidemiological studies.

Do antidepressants prevent suicide?

As in many developed countries, the use of antidepressants in Denmark has been substantially increasing during recent years, coinciding with a decreasing suicide rate. We aimed to investigate the relationship between treatment with antidepressants and suicide on individualized data from a nationwide study comprising an observational cohort study with linkage of registers of all prescribed antidepressants and recorded suicides in Denmark during the period 1995-99. A total of 438 625 patients who purchased at least one prescription of antidepressants and 1073 862 individuals from the general population were included in the study. Patients who continued treatment with selective serotonin reuptake inhibitors (SSRIs) (i.e. who purchased SSRIs twice or more) had a decreased rate of suicide compared with patients who purchased SSRIs once only [rate ratio (RR)=0.63; 95% confidence interval (CI)=0.56-0.71]. Furthermore, the rate of suicide decreased consistently with the number of prescriptions. Similarly, among patients treated with newer antidepressants other than SSRIs, the rate of suicide was decreased compared with the rate for patients who purchased other newer antidepressants once only (RR=0.70; 95% CI=0.52-0.94). Continued antidepressant treatment with SSRIs or other newer antidepressants is found to be associated with a reduced risk of suicide.

Suicide in severe depression related to treatment: depressive characteristics and rate of antidepressant overdose

The objective of the present study was to assess the association between depressive characteristics and completed suicide despite adequate antidepressant therapy in severe depression and to investigate the frequency of lethal antidepressant overdoses. A record evaluation of 98 suicide victims with a primary severe depression had been performed. These had been admitted to the Department of Psychiatry, Lund University Hospital between 1956 and 1969 and followed up to 1998. Psychomotor retardation was related to completed suicide after ECT. The estimated frequency of lethal intoxication with antidepressants was low: 3% of the suicides.

Treatment of suicide attempters prior to hospital admission

OBJECTIVE

Numerous authors have reported serious shortcomings in the treatment of suicidal patients. This study examined the treatment suicide attempters admitted to a psychiatric hospital in Switzerland had received prior to the suicide attempt.

METHOD

Thirty-one patients were admitted to this hospital within a year, representing 36 suicide attempts, which corresponds to 6.5% of the annual admission number. Three of these patients were admitted twice, and one patient was admitted three times. Information on previous treatment was collected in personal interviews and included medication, and its dosage, at 1 month and 2 weeks prior to the suicide attempt, and whether the patient had received psychotherapy. In addition, details of the psychosocial event and the means of the suicide attempt were recorded.

RESULTS

Twenty-one patients had been prescribed psychotropic drugs in 24 events, but only in 17 events concerning 15 patients, antidepressants were prescribed prior to hospitalisation. Antipsychotics and benzodiazepines were prescribed in 6 and 21 events, respectively (including 8 events with hypnotics). None of the patients was treated with lithium. In 19 events, 16 patients had received psychotherapy prior to admission. In 32 events, psychotropic drugs were used for the suicide attempt.

CONCLUSION

The findings confirm the undertreatment of patients attempting suicide reported by other authors. In spite of the majority of patients being under psychiatric care, no adequate pharmacotherapy had been prescribed particularly for depressed patients.

Antidepressant drug use and suicide prevention

Depression has been identified as occurring in the majority of people who commit suicide. Effective antidepressant medications have been available for over half a century. It seems logical to conclude that treatment of depression with antidepressants would have a suicide preventive effect. This has been difficult to demonstrate due to the infrequency of suicide and methodological problems in prospectively testing the hypothesis. Pooled data from controlled clinical trials of antidepressants have not demonstrated a suicide preventive effect, but patient selection and the brief time of most trials limits the power of the data. Some reports from either long-term or very large databases have provided evidence that antidepressants prevent suicide. All but one study using aggregated data from naturalistic settings have shown inverse relationships between use of antidepressants and suicide rates in various populations. Definite conclusions cannot be drawn from naturalistic studies since unknown confounders cannot be excluded. The number of geographically widespread studies reporting positive results with varying methods leads us to conclude, however, that antidepressants do exert a suicide preventive effect.

Selective serotonin reuptake inhibitor antidepressants and the risk of suicide: a controlled forensic database study of 14,857 suicides

OBJECTIVE

To test the hypothesis that selective serotonin reuptake inhibitor (SSRI) antidepressants may have a suicide emergent effect, particularly in children and adolescents.

METHOD

Detections of different antidepressants in the forensic toxicological screening of 14 857 suicides were compared with those in 26,422 cases of deaths by accident or natural causes in Sweden 1992-2000.

RESULTS

There were 3411 detections of antidepressants in the suicides and 1538 in the controls. SSRIs had lower odds ratios than the other antidepressants. In the 52 suicides under 15 years, no SSRIs were detected. In 15-19-year age group, SSRIs had lower relative risk in suicides compared with non-SSRIs.

CONCLUSION

The hypothesis that treatment of depressed individuals with SSRIs leads to an increased risk of suicide was not supported by this analysis of the total suicidal outcome of the nationwide use of SSRIs in Sweden over a period of 9 years, either in adults or in children or adolescents.

Depression, antidepressants and suicidality: a critical appraisal

Regulatory agencies in the United Kingdom and United States have been critically examining the possible link between suicidality and antidepressant use in children and adults, which has resulted in an FDA directive to the manufacturers of all antidepressant medications to add a 'black box' warning that describes the increased risk of suicidal behaviour in children and adolescents who take antidepressants. A crucial issue in this debate, as we discuss here, is the assessment of the capacity of antidepressants to increase suicidality over and above what is caused by the underlying disorder, major depression, which is itself the principal cause of suicide.

Association between mortality from suicide in England and antidepressant prescribing: an ecological study

BACKGROUND

Antidepressant prescribing has been increasing in England. Studies in other countries suggest that while this may be associated with reduced suicide rates, it may also be associated with increased fatal poisoning from antidepressant drugs. We therefore conducted an ecological study to assess the association between prescription rates for antidepressants and suicide or fatal antidepressant-related poisoning in England.

METHODS

The Office for National Statistics provided information on the number of suicides, antidepressant-related poisoning deaths and populations for England between 1993 and 2002. The Department of Health supplied data on prescriptions for all antidepressants dispensed in England. Associations between prescriptions and deaths were assessed using Spearman's rank correlation coefficient.

RESULTS

There were 46,747 suicides, 3,987 deaths involving tricyclic antidepressants and 430 involving selective serotonin re-uptake inhibitors and other antidepressants. Increased antidepressant prescribing was statistically associated with a fall in suicide rates (Spearman's rs = -0.73, p = 0.02) and fatal poisoning involving tricyclic antidepressants (rs = -0.64, p = 0.05). In contrast, increased prescribing of selective serotonin re-uptake inhibitors and other antidepressants was statistically associated with an increase in fatal poisoning involving these drugs (rs = 0.99, p < 0.001).

CONCLUSION

Increased prescribing of antidepressants may indicate improved diagnosis and treatment of depression in primary care. Our analysis suggests that this was accompanied by lower suicide rates. A decrease in poisoning deaths involving tricyclic antidepressants may suggest a change in preference for using serotonin reuptake inhibitors and other antidepressant drugs for high-risk patients. This may also partially explain the increase in deaths involving these drugs. Due to the ecological nature of the design, we cannot say conclusively whether reduced suicide rates are a direct consequence of increased antidepressant prescribing rates. To confirm these associations, individual level data on prescribing and suicide is needed.

Adolescent suicide in Quebec and prior utilization of medical services

BACKGROUND

Psychopathology is the main risk factor for adolescent suicide but several studies have shown that only a small proportion of suicide victims receive mental health care during the months preceding their suicide. The goal of this study is to describe the utilization of medical services by Quebec adolescent suicide victims during the year preceding their suicide.

METHODS

All suicides of persons aged 19 or less that occurred during a five-year period were retrieved from the Quebec Coroner's database. Corresponding medical services utilization data were retrieved from the Quebec physician payment database (RAMQ) and the Quebec hospitalization database (MED-ECHO). Data were analyzed in terms of types and intensity of medical services (physical or psychiatric), types of providers (general practitioners, psychiatrists, and other medical specialists), and timing of interventions relative to the date of suicide.

RESULTS

78% of all Quebec adolescent suicide victims utilized medical services during the year before their suicide. However, only 12% of all victims received medical attention for psychiatric problems, and only 9.9% met with a psychiatrist during that same period of time. General practitioners and non-psychiatric medical specialists provided medical attention for psychiatric problems to only 5.6% and 0.7% of those future suicide victims with whom they met in outpatient settings, and the intensity of their interventions was low.

INTERPRETATION

These results suggest that the level of recognition and treatment of psychopathology in Quebec adolescents who later commit suicide is low, despite the fact that a large proportion of them meet with physicians during the year preceding their suicide. This suggests that information and training programs pertaining to adolescent suicide and psychopathology should be implemented for GPs and non-psychiatric medical specialists as well.

Fatal intoxications in a Swedish forensic autopsy material during 1992-2002

Compilations of substances detected in fatal intoxications are important in order to observe changes in intoxication patterns, to monitor effects of preventive work and to discover new trends in drug usage. The aim of the present study was to describe the current pattern of substances detected in fatal intoxications in Sweden. Fatal intoxications investigated at the Department of Forensic Chemistry, Linköping, Sweden, during 1992-2002, were analysed. All suicides, uncertain cases and accidents where the cause of death were fatal intoxications (ICD-9: E950, E980 and E859) were included and substances detected in more than 50 fatal intoxications (in femoral blood) were listed. For each substance, a cut off value was set, above which concentrations were considered toxic. Fatal intoxications were detected by forensic-chemical analyses in 12% (6998/60,314) of the forensic autopsies during the study period. Among the suicides, an average of 3.8 substances were detected per case, the corresponding figure for uncertain cases and accidents were 3.5 and 4.1 substances, respectively. Ethanol was by far the most frequently detected substance, detected in 43% (3039) of the fatal intoxications, of which 32% (960) had toxic concentrations, followed by propoxyphene, detected in 27% (1863) of the fatal intoxications of which 74% (1370) had toxic concentrations. The number of cases where ethanol and propoxyphene were detected decreased during the study period. Moreover, other CNS-active drugs such as antidepressants, analgesics and anxiolytics were also frequently detected. The drugs with high proportions of cases with toxic concentrations detected were propoxyphene, amitriptyline, zolpidem, carisoprodol, alprazolam, thioridazine, methadone and ketobemidone. Selective serotonin reuptake inhibitors (SSRI) and tricyclic antidepressants (TCA) were detected in 12% (833) and 10% (665), respectively. A significantly (P <0.001) higher proportion of cases where TCA were detected had toxic concentrations when compared with cases where SSRI were detected (64% versus 31%).

Reducing the burden of affective disorders: is evidence-based health care affordable?

BACKGROUND

Affective disorders remain the leading cause of disability burden despite the availability of efficacious treatment. A wider dissemination of evidence-based health care is likely to impact this burden, however the affordability of such a strategy at the population level is unknown. This study calculated the cost-effectiveness of evidence-based health care for depression, dysthymia and bipolar disorder in the Australian population, and determined whether it was affordable, based on current mental health-related expenditure and outcomes for these disorders.

METHODS

Cost-effectiveness was expressed in costs per years lived with disability (YLDs) averted, a population health summary measure of disability burden. Data from the Australian National Survey of Mental Health and Wellbeing, in conjunction with published randomized trials and direct cost estimates, were used to estimate the 1-year costs and YLDs averted by current health care services, and costs and outcomes for an optimal strategy of evidence-based health care.

RESULTS

Current direct mental health-related health care costs for affective disorders in Australia were 615 million dollars (1997-98 Australian dollars). This treatment averted just under 30,000 YLDs giving a cost-effectiveness ratio of 20,633 dollars per YLD. Outcome could be increased by nearly 50% at similar cost with implementation of an evidence-based package of optimal treatment, halving the cost-effectiveness ratio to 10,737 dollars per YLD.

LIMITATIONS

The method to estimate YLDs averted from the literature requires replication. The costs of implementing evidence-based health care have not been estimated.

CONCLUSIONS

Evidence-based health care for affective disorders should be encouraged on both efficacy and efficiency grounds.

Suicidal behaviour in bipolar disorder: risk and prevention

Bipolar (manic-depressive) disorder is a common and severe illness. It is also potentially fatal as a result of accidents and increased mortality associated with comorbid substance use and medical illnesses, but its highest lethality results from suicide. Suicide rates, averaging 0.4% per year in men and women diagnosed with bipolar disorder, are >20-fold higher than in the general population. Suicidal acts often occur early in the illness course and in association with severe depressive and dysphoric-agitated mixed phases of illness, especially following repeated, severe depressions. Systematic consideration of risk and protective factors enhances assessment of potentially suicidal patients. Short-term interventions employed empirically to manage acute suicidality include close clinical supervision, rapid hospitalisation and use of electroconvulsive treatment. Several plausible therapeutic interventions have limited evidence of long-term effectiveness against mortality risks associated with any psychiatric disorder, including antidepressant, antimanic, antipsychotic and electroconvulsive, as well as psychosocial, treatments. However, in bipolar disorder and other major affective disorders, lithium maintenance treatment is a notable exception, with strong and consistent evidence that it reduces suicidal risk. The growing range of drugs being introduced to treat acute and long-term phases of bipolar disorder, including antiepileptic drugs, atypical antipsychotics and relatively safe, modern antidepressants, require research assessment for their ability to limit premature mortality from suicide and other causes. For now, however, more can be done to improve treatment in major affective illnesses by application of current knowledge in a systematic fashion, with close and sustained clinical follow-up of patients at risk, hopefully with a resulting reduction of mortality rates.

The prospectively observed course of illness among depressed patients who commit suicide

OBJECTIVE

These analyses were conducted to describe the course of illness among patients with major affective disorders who commit suicide.

METHOD

Twenty-nine patients who entered a long-term, high-intensity follow-up study of major affective disorders and who later committed suicide within 1 year of their last follow-up interview were individually matched to other patients by age, sex, the presence or absence of lifetime drug or alcohol abuse, time to last interview and polarity. Those who suicided were compared with their controls by depressive and substance abuse morbidity during follow-up, treatment resistance, treatment compliance, suicidal behavior and psychosocial adjustment.

RESULTS

Among the various measures used to characterize the course of illness during a mean follow-up of 4.3 years, only those pertaining to suicidal behavior robustly separated the suicide group from their controls. Suicidal behavior in the remote past seemed as predictively important as suicidal behavior during follow-up.

CONCLUSION

Of the various features monitored over time in patients with major affective disorder, suicidal behavior itself was the clearest correlate of risk for completed suicide.

A global view of suicidal behaviour

Suicidal behaviour is a major public health problem. There is no one explanatory theory of suicidal behaviour, and various combinations of sociological and biological/medical interventions are required to reduce associated mortality and morbidity. The importance of primary prevention varies from community to community, and may have an impact at the population level. However, individual suicidal persons always require optimum assessment and management and that is usually provided by primary care and emergency physicians. This paper provides an overview of issues to be addressed in the assessment and management of suicidal patients.

Psychopharmacological treatment and psychiatric morbidity in 390 cases of suicide with special focus on affective disorders

OBJECTIVE

The aim of this study was, on the basis of data from health-care registers, to describe the adequacy of psychopharmacological treatment in suicides.

METHOD

Data on consecutive suicides in a Danish County (Funen) in the period of 1 April 1991-31 December 1995 were identified in the Danish Psychiatric Central Register, the National Patient Register, the National Health Insurance and Odense University Pharmacoepidemiological Database.

RESULTS

Twenty-five per cent of the suicides previously hospitalized due to affective disorders and 3% of the suicides without psychiatric hospitalizations at all, received an apparently adequate treatment with antidepressants the month before suicide.

CONCLUSION

The most striking finding was the insufficiency of treatment with antidepressants in the group of suicides without psychiatric hospitalization, in particular in light of the fact that depression is assumed to be present in at least 50% of all suicides.

Unmet needs in the pharmacological management of depression

Newer antidepressants, such as the selective serotonin reuptake inhibitors (SSRIs), selective noradrenaline reuptake inhibitors (NRIs) and drugs acting on both serotonin and noradrenaline, represent a clinically significant advance over the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors. Nevertheless, all current pharmacological treatments for depression fall somewhat short of the 'ideal', and unmet needs remain in the pharmacological management of depression. In general, current antidepressants differ little in terms of efficacy. However, in terms of tolerability, SSRIs appear to offer clear advantages over older therapies. For example, the proportion of patients who discontinue treatment because of adverse events and the risk of fatal toxicity both appear to be lower with SSRIs, compared with TCAs. Some adverse events, however, such as sexual dysfunction and nausea (typical serotonergic side effects), tend to be more frequent with SSRIs. Also, individual SSRIs appear to differ in the likelihood that they will be associated with these side effects. However, no clear advantage emerges for any one SSRI over another, and the current recommendation is that the anticipated side-effect profile should be tailored to the patient. Current pharmacoeconomic data do not appear to favour any antidepressant over another, with no cost benefits associated with prescribing TCAs instead of SSRIs.The refinement of current drugs arising from the introduction of their active enantiomers may translate into clinical benefit, bringing closer the 'ideal' antidepressant. Potential benefits of a single enantiomer versus the racemate in the management of depression include: a reduction in the total dose, while maintaining desired outcomes, as well as a possible greater efficacy, dose for dose,simpler assessment of dose-response relationships,a reduction in pharmacokinetic and pharmacodynamic variability between patients, anda reduction in any toxicity arising from the inactive stereoisomer. However, these benefits remain to be proved in clinical trials and naturalistic studies. Further refinement of the benefit:risk ratio of current 'gold standard' drugs may go some way to addressing the shortfalls in existing antidepressant therapy. Copyright 2001 John Wiley & Sons, Ltd.

Modelling suicide risk in affective disorders

BACKGROUND

The lifetime risk of suicide in affective disorders is commonly quoted as 15%. This stems from hospital populations of affective disorders.

AIMS

To model the lifetime prevalence of suicide using data on completed suicides from one English Health District and community-based rates of prevalence of affective disorders.

METHODS

A secondary analysis of a primary data set based on 212 suicides in North Staffordshire was undertaken. The population rates of psychiatric morbidity were obtained from the National Comorbidity Survey.

RESULTS

The model suggests a lifetime prevalence rate of suicide for any affective disorder at 2.4%, with a rate for those uncomplicated by substance abuse, personality disorder or non-affective psychosis at 2.4%, and a rate for uncomplicated cases who had no mental health service contact at 1.1%.

CONCLUSIONS

Lifetime prevalence rates of suicide in subgroups of affective disorders may be lower than the traditional rates cited for hospital depression. This has implications for primary care projects designed to investigate the occurrence of and the prevention of suicide.

Suicides are seldom prescribed antidepressants: findings from a prospective prescription database in Jämtland county, Sweden, 1985-95

OBJECTIVE

This study presents data relating to prospectively monitored treatment and post-mortem toxicology of individuals who committed suicide.

METHOD

A case-control study of prospectively monitored pharmacological treatment in suicides and controls. Psychiatric records and post-mortem toxicology were also studied.

RESULTS

Fifty-nine subjects who committed suicide purchased twice the number of prescriptions as the 118 controls. Sixteen cases received psychiatric in-patient care compared to four of the controls. In the last 3 months prior to suicide, 38 cases (64%) were dispensed drugs: anxiolytics-hypnotics in 17 cases (29%), antipsychotics in six cases (10%) and antidepressants in seven cases (12%). More psychiatrists than GPs prescribed antidepressants. About one-third of psychotropic drugs were retrieved in post-mortem toxicology.

CONCLUSION

There is a frequent use of psychotropics and psychiatric care among suicides; however, few used antidepressants and complied. Many suicides are still misdiagnosed and are not adequately treated.

Preventing suicide and premature death by education and treatment

Suicide is a leading cause of mortality. It is, in principle, preventable - given the fact that we possess effective treatments for depressive illness, the major contributor to such mortality. Nonetheless, complex logistic problems have prevented the institution of successful suicide prevention programs. The present review summarizes the author's work on the island of Gotland in Sweden, where the small size of the population permitted the institution of an educational and treatment program aimed at the general medical practitioners. The program was successful in reducing suicide rates by 60%. This was accompanied by reduction of different indices measuring depressive morbidity. Prevention was successful for as long as the program was instituted. The author provides his reflections on the public health implications of his data - particularly for Eastern Europe which is experiencing widespread stress in the workplace and in economic situations. More hypothetically, he presents his views on a serotonin-mediated 'male suicide syndrome'.

Deliberate self-harm and antidepressant drugs. Investigation of a possible link

BACKGROUND

It is not clear if the frequency of deliberate self-harm (DSH) is the same in patients taking different pharmacological classes of antidepressant drugs.

AIMS

To compare the frequency of DSH in patients who had been prescribed a tricyclic antidepressant (TCA) or a selective serotonin reuptake inhibitor (SSRI) prior to the DSH event.

METHOD

This was a prospective study in 2776 consecutive DSH cases attending an accident and emergency department. The incidence of DSH in TCA-treated cases and SSRI-treated cases is expressed as number of DSH events per 10 000 prescriptions of each antidepressant.

RESULTS

Significantly more DSH events occurred following the prescription of an SSRI than that of a TCA (P<0.001). The occurrence of DSH was highest with fluoxetine and lowest with amitriptyline.

CONCLUSIONS

Merely prescribing safer-in-overdose antidepressants is unlikely to reduce the overall morbidity from DSH.

Completed suicide: an update for the general psychiatrist

Objectives: To review the most recent information on completed suicide for the general adult psychiatrist.

Methods: Literature review.

Results: Suicide is the result of a complex interaction of multiple variables. Prediction is highly dependent on clinical evaluation. Predictive factors identify groups better than individuals. Prevention has both clinical and political implications.

Conclusions: Reduced access to lethal methods (historically, from barbiturates to modified vehicle exhaust systems and paracetamol), attention to social factors (such as alcohol availability and employment levels) and clinical vigilance, coupled with adequate treatment of psychiatric disorders and close follow-up, should help to reduce suicide rates. Wider cultural issues (eg. religion) are poorly understood and require further research.

Pragmatic randomised controlled trials in psychiatry

BACKGROUND

Randomised controlled trials (RCTs) are the most important method of evaluating new treatments and treatment policies. Despite this, there are relatively few large pragmatic RCTs in psychiatry.

AIMS

To explore the main advantages of large pragmatic RCTs and the obstacles to performing them in psychiatry.

METHOD

A narrative review of literature on pragmatic RCTs with examples drawn from psychiatry and other medical specialities.

RESULTS

Obstacles to performing pragmatic RCTs in psychiatry include the complexity of psychiatric interventions, the complexity of outcomes used in psychiatry and the difficulties of blinding subjects and investigators to some psychiatric interventions.

CONCLUSIONS

Researchers need to frame questions in a form that is relevant to clinicians and to convince clinicians to cooperate in simple large pragmatic trials.

The place for the tricyclic antidepressants in the treatment of depression

OBJECTIVE

The new generation antidepressants have been an important advance in the treatment of depression. Since their introduction, their use has become widespread and the role of the older tricyclic antidepressants (TCAs) has been suggested only as a second-line choice. This assumption is questioned and the role of the TCAs as a first-line treatment for severe depression is discussed.

METHOD

The relevant literature concerning the efficacy, tolerability and safety of the antidepressant drugs is reviewed, particularly those studies which compare the newer antidepressant agents with the TCAs.

RESULTS

The newer agents are equally as efficient as the tricyclics in the treatment of mild to moderate depression. There are indications that the TCAs are more efficacious for severe depression. The tolerability of the drugs appear about equivalent in terms of discontinuation rates; however, the side effects are different and clinicians need to be mindful of drug interactions and the potential of the serotonin syndrome with the selective serotonin re-uptake inhibitors (SSRIs), problems not found with the TCAs. The TCAs are potentially lethal in overdose; however, appropriate clinical management appears to be a more important issue than the toxicity of the medication.

CONCLUSIONS

The newer antidepressant agents are important advances in the treatment of depression. However, the TCAs still have an important place as the first-line treatment for patients with severe (melancholic/endogenous) depression.

Suicide in the course of the treatment of depression

Five different mechanisms have been proposed whereby antidepressant treatment might lead to suicide: first by simply ameliorating depressions more rapidly; second by an action intrinsic to the specific antidepressant effects; third by toxicity in overdose; fourth by side-effects of specific antidepressants; and finally by virtue of treatment inefficacy. Evidence from randomized control trials (RCT), controlled case studies and epidemiological studies on this question is reviewed and it is concluded that antidepressants can be implicated in some cases of suicide during treatment. Modifications of clinical trial methods and pharmacogenetic studies would yield a richer data set to explore this issue further.

Selective serotonin reuptake inhibitors have broadened the utilisation of antidepressant treatment in accordance with recommendations. Findings from a Swedish prescription database

BACKGROUND

With the advent of the selective serotonin reuptake inhibitors (SSRIs), the use of antidepressants has increased drastically in Sweden. The use of tricyclic antidepressants (TCAs) has, however, decreased.

METHODS

We surveyed a prescription database in the Swedish county of Jämtland and compared prescription patterns for patients prescribed SSRIs with those prescribed TCAs.

RESULTS

The incidence of treatments of antidepressants increased from 0.76% to 1.33% during the period 1991-1996. There were no significant differences between SSRIs and TCAs with regard to patients having only one prescription dispensed within three months from the index prescription, or patients who switched class of antidepressant. Only a minority of the treatments were continued for at least six months, but significantly more SSRI than TCA treatments (42% and 27%). A second treatment period suggesting recurrence was three-times more common in the TCA group than in the SSRI group.

CONCLUSION

Provided that the increased use of SSRIs is mainly for depression, these drugs appear, despite a lower efficacy in severe depression, to have enabled a broader utilisation of antidepressants with regard to incidence, dosage and duration, in accordance with recommendations. Further analyses of this phenomenon relative to diagnostic criteria and outcome measures are required.

Suicide attempts preceding completed suicide

BACKGROUND

This study investigated three questions with major implications for suicide prevention: the sensitivity of the history of previous suicide attempt(s) as an indicator of suicide risk, the time interval from a preceding suicide attempt to the fatal one, and switching of suicide methods by those eventually completing suicide.

METHOD

The lifetime history of suicide attempts and the methods the victims (n = 1397) used were examined in a nationwide psychological autopsy study comprising all suicides in Finland within a 12-month research period in 1987-1988.

RESULTS

Overall, 56% of suicide victims were found to have died at their first suicide attempt, more males (62%) than females (38%). In 19% of males and 39% of females the victim had made a non-fatal attempt during the final year. Of the victims with previous attempts, 82% had used at least two different methods in their suicide attempts (the fatal included).

CONCLUSIONS

Most male and a substantial proportion of female suicides die in their first suicide attempt, a fact that necessitates early recognition of suicide risk, particularly among males. Recognition of periods of high suicide risk on the grounds of recent non-fatal suicide attempts is likely to be important for suicide prevention among females. Subjects completing suicide commonly switch from one suicide method to another, a finding that weakens but does not negate the credibility of restrictions on the availability of lethal methods as a preventive measure.