Prescribing selective serotonin reuptake inhibitors as strategy for prevention of suicide

Advancing Global Health Through Primary Care Physician Education on Suicide Prevention

The rising global suicide rate presents a major public health concern, resulting in the loss of over 700,000 lives annually. Discrepancies in the impact of suicide among diverse populations underscore the necessity for targeted prevention strategies. Primary care providers (PCPs) play a crucial role in identifying and managing suicide risk, particularly in underserved areas with limited access to mental health care. Educating PCPs about evidence-based interventions and suicide prevention strategies has demonstrated effectiveness in reducing suicide rates. Landmark initiatives in Australia, Sweden, and Hungary have successfully lowered suicide rates by implementing educational programs for PCPs focused on suicide prevention. Denmark, previously afflicted by some of the highest rates globally in the 1980s, has significantly reduced its figures and now ranks among countries with the lowest rates in high-income nations. Collaborative programs involving PCPs and health workers in low-resource regions have also shown promising outcomes in suicide prevention efforts. Enhancing the expertise of PCPs in suicide prevention can fortify healthcare systems, prioritize mental health, and ultimately save lives, contributing to global health endeavors aimed at addressing the pervasive issue of suicide.

Catalytic Reaction Model of Suicide

Suicide is a devastating outcome of unresolved issues that affect mental health, general wellbeing and socioeconomic stress. The biology of suicidal behavior is still poorly understood, although progress has been made. Suicidal behavior runs in families and genetic studies have provided initial glimpses into potential genes that contribute to suicide risk. Here, we attempt to unify the biology and behavioral dimensions into a model that can guide research in this area. The proposed model envisions suicidal behavior as a catalytic reaction that may result in suicide depending on the conditions, analogously to enzyme catalysis of chemical reactions. A wide array of substrates or reactants, such as hopelessness, depression, debilitating illnesses and diminished motivation can mobilize suicidal thoughts and behaviors (STBs), which can then catalyze the final step/act of suicide. Here, we focus on three biological substrates in particular: threat assessment, motivation to engage in life and impulsivity. Genetic risk factors can affect each of these processes and tilt the balance toward suicidal behavior when existential crises (real or perceived) emerge such as loss of a loved one, sudden changes in social status or serious health issues. Although suicide is a uniquely human behavior, many of the fundamental biological processes are evolutionarily conserved. Insights from animal models may help to shape our understanding of suicidal behavior in man. By examining counterparts of the major biological processes in other organisms, new ideas about the role of genetic risk factors may emerge along with possible therapeutic interventions or preventive measures.

Toxicity of newer versus older antidepressants

Of all the controversies over the different medications used in psychiatry, there is probably least dispute about the effectiveness of antidepressants in controlling depressive illness. However, the choice of which antidepressant to use is bedevilled by the spectre of potential toxicity from adverse effects, interactions and overdose. The unwanted effects may vary from mild and tolerable to potentially lethal. At one time it was relatively easy to become familiar with the problems surrounding the original two main groups of antidepressants – the tricyclic antidepressants (TCAs) and the monoamine oxidase inhibitors (MAOIs). Recent years have seen the introduction of a number of newer drugs, with a wide range of chemical structures and differing pharmacological activities. They also have a new spectrum of adverse effects and interactions. It is worth reviewing the major differences between old and new antidepressants, and to identify the areas in which clinical caution must be exercised in order to avoid pitfalls and maximise clinical benefit.

Improving adherence in mood disorders: the struggle against relapse, recurrence and suicide risk

Medication nonadherence is a major obstacle to translating treatment efficacy from research settings into effectiveness in clinical practice for patients with affective disorders. Adherence to beneficial drug therapy is associated with lower mortality compared with poor adherence. Reduced adherence is associated with increased suicide risk, especially when lithium is discontinued. The aim of this paper is to review the prevalence, predictors and methods for improving medication adherence in unipolar and bipolar affective disorders. Studies were identified through Medline and PsycInfo searches of English language publications between 1976 and 2009. This was supplemented by a hand search and the inclusion of selected descriptive articles on good clinical practice. Estimates of medication nonadherence for unipolar and bipolar disorders range from 10 to 60% (median: 40%). This prevalence has not changed significantly with the introduction of new medications. There is evidence that attitudes and beliefs are at least as important as side effects in predicting adherence. The limited number of empirical studies on reducing nonadherence indicate that, if recognized, the problem may be overcome. Clinical data highlight the importance of extended courses of medication in improving the long-term prognosis of patients with affective disorders.

[Antidepressants and suicidality. Risk-benefit analysis]

Reanalyses of placebo-controlled trials reveal an increased risk of suicidal ideations or parasuicidal acts in children and adolescents under treatment with selective serotonin reuptake inhibitors (SSRI) or other antidepressants. Although no completed suicide was shown, these findings are the more important because, with the exception of fluoxetine, an evidence base for the efficacy of antidepressants is weak or lacking in this age group. For adults, there is no reason to doubt that antidepressants help to reduce suicides by shortening depressive episodes and preventing recurrence. A general and pronounced suicide-inducing effect of SSRI or other antidepressants can largely be excluded. On the other hand, in some vulnerable patients the risk of suicidal acts can increase, especially during the first days of antidepressant treatment. There is no evidence that this risk is higher with SSRI than with other antidepressants or nonpharmacological treatments. Safety in case of overdose is a strong argument favouring newer antidepressants over tri- and tetracyclic antidepressants in outpatients with unclear suicidality. The current widespread public discussions concering the risks of antidepressants is a risk in itself because confidence in treatment, compliance, and help seeking behaviour may get influenced negatively.

WITHDRAWN: Selective serotonin reuptake inhibitors (SSRIs) versus other antidepressants for depression

BACKGROUND

The relatively new class of antidepressant, the selective serotonin reputake inhibitors (SSRIs), may be better tolerated than the older tricyclic antidepressants. This review compares the efficacy of SSRIs with other antidepressants.

OBJECTIVES

To examine the relative efficacy of selective serotonin reuptake inhibitors (SSRIs) compared to other antidepressants.

SEARCH STRATEGY

The search strategy included a search of (a) Electronic bibliographic databases (MEDLINE, EMBASE); (b) reference lists of related reviews (c) reference lists of all located studies (d) contact with the manufacturer and (e) the Cochrane Group register of controlled trials

SELECTION CRITERIA

Randomised controlled trials comparing selective serotonin reuptake inhibitors with other kinds of antidepressants in the treatment of patients with depressive disorders. The outcome measures assessed included measures of the severity of depression.

DATA COLLECTION AND ANALYSIS

Data were collected from each study the main outcome measurefrom each study. These included: mean Hamilton depression rating scale, mean Montgomery & Asberg depression rating scale, Clinical Global Impression rating scale. An analysis of standardised mean difference of these scales was performed using Review Manager 3.1 software. The presence of heterogeneity of treatment effect was assessed

MAIN RESULTS

Ninety-eight trials contributed data to the analysis of the relative efficacy of SSRIs and related drugs with comparator antidepressants (Figure 3 & Appendix 3). Analysis of efficacy was based upon 5044 patients treated with an SSRI or related drug, and 4510 treated with an alternative antidepressant. The standardised effect size for SSRIs and related drugs together versus alternative antidepressants using a fixed effects model was 0.035 (95% CI -0.006 to 0.076; Q = 149.25, df = 97, p < 0.001).

AUTHORS' CONCLUSIONS

There are no clinically significant differences in effectiveness between selective serotonin reuptake inhibitors and tricyclic antidepressants. Treatment decisions need to be based on considerations of relative patient acceptability, toxicity and cost.

Is there evidence for negative 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 available means should be utilised to clarify the influence of antidepressants on suicidality, especially in view of the ongoing intensive debate about possible suicidality-inducing effects of antidepressants that may outweigh their traditionally hypothesised beneficial effects. This paper gives a systematic and comprehensive review of the empirical data which might indicate that antidepressants have negative effects on suicidality. First, principal methodological issues related to this research question are discussed. Thereafter, the results of controlled trials and epidemiological and cohort studies are presented. Altogether, there seems to be only a small amount of evidence from different research approaches that antidepressants, not only serotonin reuptake inhibitors (SSRIs), might induce, aggravate or increase the risk of suicidal ideation and suicide attempts. As to suicide, there are no hints in this direction. TCAs have a higher risk of fatal outcome in overdose compared to SSRIs, which, in case of mono-intoxication, carry almost no risk of lethal consequences. The ongoing discussion about suicidality-inducing effects should not prevent physicians from prescribing SSRIs and other antidepressants to their patients if they are clinically indicated. However, they should take into account potential risks and manage them by good clinical practice.

Treatment options in moderate and severe depression: decision analysis supporting a clinical guideline

BACKGROUND

Treatment options for depression include antidepressants, psychological therapy and a combination of the two.

AIMS

To develop cost-effective clinical guidelines.

METHOD

Systematic literature reviews were used to identify clinical, utility and cost data. A decision analysis was then conducted to compare the benefits and costs of antidepressants with combination therapy for moderate and severe depression in secondary care in the UK.

RESULTS

Over the 15-month analysis period, combination therapy resulted in higher costs and an expected 0.16 increase per person in the probability of remission and no relapse compared with antidepressants. The cost per additional successfully treated patient was 4056 UK pounds (95% CI1400-18300); the cost per quality-adjusted life year gained was 5777 UK pounds (95% CI1900-33 800) for severe depression and 14 540 UK pounds (95% CI 4800-79 400) for moderate depression.

CONCLUSIONS

Combination therapy is likely to be a cost-effective first-line secondary care treatment for severe depression. Its cost-effectiveness for moderate depression is more uncertain from current evidence. Targeted combination therapy could improve resource utilisation.

Antidepressants reduce the risk of suicide among elderly depressed patients

Treatment with selective serotonin reuptake inhibitors (SSRIs) may increase the risk of impulsive acts including suicide, while data from epidemiological studies suggest that the effect of SSRIs in the elderly may be beneficial. We aimed to evaluate the association between exposure to antidepressants and suicidality in a cohort of elderly patients suffering from major depressive disorder (MDD). This was a retrospective matched case-controlled evaluation over a 10-year period. All records of admissions of patients with MDD (ICD-10) were assessed. The index group comprised all patients who had attempted suicide in the month prior to admission. The case-controlled group was the next admission of a patient suffering from MDD, matched for sex and age who had not attempted suicide in the month prior to admission. The index group during the 10-year period (1995-2004) consisted of 101 patients suffering from MDD who were hospitalized following a suicide attempt. Mean age for the group was 76.5+/-6.6 years; there were 42 men and 59 women. The control group patients (N=101) were matched for age (mean 76.6+/-6.9 years) and sex. The proportion of patients exposed to an antidepressant was significantly greater in the control group, than in the group of patients who had attempted suicide (58 vs 42%, odds ratio 1.94 (95% CI: 1.1-3.4), p=0.019). SSRIs were prescribed in 29% of patients in the control group vs 21% of patients in the index group (p=0.03). It is of interest to note that concomitant prescription of benzodiazepines also conferred a protective effect. In conclusion, elderly depressed patients treated with antidepressants may be at reduced risk of attempting suicide. These findings need support from prospective randomized trials.

Pharmacoeconomic evaluation of antidepressants : a critical appraisal of methods

In recent years, there has been much debate regarding the real cost effectiveness of new antidepressants. This review is an attempt to identify key contentious methodological issues that can impact the reliability, validity and quality of the research on this subject. There are inherent complexities between inputs and outcomes related to depression, and the choice of pharmacoeconomic methodology requires a crucial balance between the study design and its ability to capture relevant information. Knowledge of the real efficiency of antidepressants should always be ascertained with reference to the real-world setting. Studies that show a corresponding balance between internal and external validity, coupled with sound methodology and standardised reporting, have the potential to translate pharmacoeconomics research into real-world, time-relevant decision-making.

Lower suicide risk with long-term lithium treatment in major affective illness: a meta-analysis

OBJECTIVE

To compare suicide rates with vs. without long-term lithium treatment in major affective disorders.

METHOD

Broad searching yielded 22 studies providing suicide rates during lithium maintenance; 13 also provide rates without such treatment. Study quality was scored, between-study variance tested, and suicide rates on vs. off lithium examined by meta-analyses using random-effects regression methods to model risk ratios.

RESULTS

Among 5647 patients (33 473 patient-years of risk) in 22 studies, suicide was 82% less frequent during lithium-treatment (0.159 vs. 0.875 deaths/100 patient-years). The computed risk-ratio in studies with rates on/off lithium was 8.85 (95% CI, 4.12-19.1; P<0.0001). Higher rates off-lithium were not accounted for by treatment-discontinuation.

CONCLUSION

Suicide risk was consistently lower during long-term treatment of major affective illnesses with lithium in all studies in the meta-analysis, including the few involving treatment-randomization.

Assessing the economic impact of psychiatric disorders: where to begin?

Over the past decade, psychiatric disorders have increasingly been regarded as serious public health concerns, with debilitating symptoms as well as high social and economic costs to patients, caregivers, third party payers and society. In this article, we review findings from recent research on psychiatric disorders, while providing a framework for assessing their pharmacoeconomic impact. In particular, we consider the prevalence of psychiatric disorders, their far-reaching impacts, and their associated treatment patterns. These categories present a starting point for analysing the pharmacoeconomic consequences of psychiatric disorders and underlie an expert opinion in this context

Treating the suicidal patient with bipolar disorder. Reducing suicide risk with lithium

Bipolar disorder is associated with increased mortality because of complications of commonly comorbid substance use and stress-sensitive medical disorders as well as accidents and very high rates of suicide. Long-term lithium treatment may be associated with reduced suicidal risk. We review and summarize findings that help to quantify relationships between the presence versus the absence of lithium maintenance and suicides or attempts in patients with bipolar or other major affective disorders. Results from 33 studies (1970-2000) yielded 13-fold lower rates of suicide and reported attempts during long-term lithium treatment than without it or after it was discontinued. Although greatly reduced, these rates remain above those estimated for the general population. Evidence for substantial, if incomplete, protection against suicide with lithium is supported by more compelling evidence than that for any other treatment provided for patients with mood disorders. Studies of commonly used, but incompletely evaluated, alternative treatments are required, and further protection against premature mortality can be anticipated with better protection against bipolar depression.

The economics of selective serotonin reuptake inhibitors in depression: a critical review

The prevalence of depression and the high costs associated with its treatment have increased interest in pharmacoeconomic evaluations of drug treatment, particularly in the 1990s as the use of selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs) expanded substantially. This review presents results from specific studies representing the key study designs used to address the pharmacoeconomics of SSRI use: retrospective administrative database analyses, clinical decision analysis models, and randomised clinical trials. Methodological considerations in interpreting results are highlighted. In retrospective administrative database analyses, most comparisons have been made between SSRIs and tricyclic antidepressants (TCAs). A few studies have addressed differences between SSRIs. The studies focused on healthcare cost (to payer) and cost-related outcomes (e.g. treatment duration, drug switching). Although SSRIs are generally associated with higher drug acquisition costs than are TCAs, total healthcare costs are at least offset, if not decreased, by reductions in costs associated with use of SSRIs. Although studies from the early 1990s show some advantage for fluoxetine, the results are limited by use of data from shortly after the introduction of paroxetine and sertraline; studies from the mid- 1990s on that compare drugs within the SSRI class show general equivalence in terms of cost. Important methodological advances are occurring in retrospective studies, with selection bias and other design limitations being addressed statistically. Clinical decision analysis models permit flexibility in terms of ability to specify different alternative treatment scenarios and varying durations. Sensitivity analysis aids interpretability, although model inputs are limited by data availability. Results from short term (1 year duration or less) studies comparing SSRIs and TCAs suggest that SSRIs are more cost effective or that there is no difference. Longer term studies (lifetime Markov models) focus more on the impact of maintenance antidepressant therapy and show more mixed results, generally favouring SSRIs over TCAs. The results indicate that the effect of SSRIs is mainly through prevention of relapse. Important assumptions of these models include fewer serious adverse effects and lower treatment discontinuation rates with SSRIs. Naturalistic clinical trials provide greater generalisability than traditional randomised clinical trials. One naturalistic trial found that nearly half of TCA-treated patients switched to another antidepressant within 6 months; only 20% of SSRI-treated patients switched. Cost differences between groups were minimal. These studies indicate few differences in medical costs, depression outcomes and health-related quality of life between TCAs and fluoxetine, although fewer fluoxetine-treated patients switched treatment.

Deliberate self poisoning with antidepressant drugs: a comparison of the relative hospital costs of cases of overdose of tricyclics with those of selective-serotonin re-uptake inhibitors

BACKGROUND

Debate continues over the relative merits of tricyclics and selective serotonin re-uptake inhibitors (SSRIs) as first line antidepressant treatment for depression. SSRIs are safer in overdose but more expensive than tricyclics. This report compared the hospital costs of cases of overdose with both groups of drug.

METHODS

Records of all persons aged over thirteen years presenting to a general hospital in one year were analysed for demographic information and details of their attendance.

RESULTS

There were 1165 episodes of self-poisoning, 151 involving tricyclics as the sole antidepressant and 69 SSRIs as the sole antidepressant. Those taking SSRIs had a shorter (1.96 vs. 2.59 days) and less expensive ( pound330 vs. pound567) stay. A large proportion of this difference in cost was due to a small number of admissions to the Intensive Care Unit.

LIMITATIONS

This study used only hospital costs, so excluding costs associated with primary care.

CONCLUSIONS AND CLINICAL RELEVANCE

If there were similar cost differences countrywide, the difference in hospital costs of self poisoning with SSRIs and tricyclics would represent an additional pound3.87 million per year due to self poisoning with tricyclics across the whole of England and Wales. This is a small proportion of the estimated pound100 million cost of switching to first-line prescribing of SSRIs for depression.

The need for an iterative process for assessing economic outcomes associated with SSRIs

Pharmacotherapeutic advances in the treatment of depression have included the development of the selective serotonin reuptake inhibitors (SSRIs), thereby providing alternatives to tricyclic antidepressants. Concurrent with these events have been significant structural (e.g. pharmaceutical formularies) and regulatory (e.g. required pharmacoeconomic evaluations) changes in the delivery, financing, and oversight of healthcare programmes throughout the world. International cost-containment initiatives are increasingly mandating a demonstration of value for money, defined in terms of a measurable health and/or financial outcome, and, in the case of medicines, attributable to a given expenditure, for a given pharmacotherapeutic option. We examine the inherent strengths and weaknesses of 5 study designs used to discern and contrast financial outcomes stemming from the use of antidepressant pharmacotherapy for the treatment of depressive illness [randomised controlled trials (RCTs); meta-analyses; decision-analytical models (DAMs); retrospective database investigations; randomised naturalistic inquiry]. We argue that the economic appraisal of pharmacotherapy requires an iterative process extending from the developmental (RCTs; meta-analyses; DAMs) through to the postmarketing phase (database reviews; naturalistic inquiry), thereby resulting in a portfolio of evidence as to the safety, efficacy and effectiveness of a given pharmacotherapeutic category (e.g. SSRIs) and/or a specific medication. Database reviews, while nonrandomised, and prospective naturalistic inquiry afford greater insight into the patterns of use and financial merits of prescribing specific pharmacotherapeutic options for the treatment of depression within the context of clinical practice as compared with RCTs, meta-analyses and DAMs. The portfolio of evidence to date indicates that the first-line use of SSRIs in the treatment of depression is clinically warranted, and represents value for money.

The treatment of depression in UK general practice: selective serotonin reuptake inhibitors and tricyclic antidepressants compared

BACKGROUND

Antidepressants are commonly prescribed by general practitioners as treatment for depression. Controversy exists as to the effectiveness in everyday use of the older tricyclic antidepressants (TCAs) when compared to the newer selective serotonin reuptake inhibitors (SSRIs).

AIM

To investigate the patterns of current prescribing of antidepressants for the treatment of depression and compare TCAs with the newer SSRIs.

METHOD

The study population was patients attending 151 computerised general practices from throughout the United Kingdom between 1991 and 1996. Patients with new prescriptions for antidepressants and a diagnosis of depression were identified. Age and gender distributions, prescribed doses and drop-out rates were investigated.

RESULTS

During the study period 9.8% of patients received a prescription for an antidepressant, there was a 40% increase in the prescribing rate of TCAs and a 460% increase in SSRI prescribing. TCAs were initially prescribed in sub-therapeutic doses. More than 50% of patients ceased taking their antidepressants within 6 weeks of starting treatment. Fluoxetine and paroxetine were more likely to be prescribed for a therapeutic period than were other antidepressants.

CONCLUSIONS

General practitioners should prescribe a therapeutic dose of antidepressant for a recognised therapeutic period to ensure that patients with depression receive the most effective treatment.

Fatal toxicity associated with antidepressant use in primary care

BACKGROUND

New selective serotonin reuptake inhibitors (SSRIs) are perceived to be much safer in use than older tricyclic antidepressants (TCAs). However, previous assessments of association with fatal toxicity were made too soon after the introduction of the new drugs to permit accurate estimation.

AIM

To determine the level of association of antidepressant drugs with fatal poisoning in the treatment of depression.

METHOD

National data for England and Wales for three years (1993 to 1995) for fatal poisonings associated with antidepressants were obtained and, together with national primary care data on prescribing, were used to calculate fatality association by antidepressant drug.

RESULTS

There were substantial variations between drugs in the level of association with fatal poisoning. Assuming an average treatment episode lasted three months, one fatality is associated with 11,800 treatment episodes of antidepressant use (95% CI = 11,120 to 12,580) when only single substance fatalities are considered. For SSRIs as a group the association was one in 411,800 (95% CI = 243,300 to 1.34 million) and for TCAs one in 8130 (95% CI = 7650 to 8670). However, for one of the newer TCAs, lofepramine, the single substance fatality rate associated with its use was one in 233,700 (95% CI = 124,500 to 1.89 million), which is not statistically significantly different from the SSRIs (P = 0.35).

CONCLUSIONS

Estimated death rates associated with specific antidepressants should be compared with caution because drugs may be used selectively in patients with differing severity of depression. The proportion of these fatalities that could be prevented by switching to safer antidepressants is unclear when so few deaths are recorded as accidental; when there is intent to do self-harm the potential for switching to other means is unknown. However, this approach to relative toxicity may remain the best available since it is unlikely that a randomised trial will ever be conducted with a large enough sample size to obtain experimental data. Fatalities from antidepressant poisoning are very rare but if safety is paramount then lofepramine or an SSRI are justifiable treatment choices.

Comparison of trends in method-specific suicide rates in Australia and England & Wales, 1968-97

OBJECTIVE

To compare secular trends in method-specific suicide rates among young people in Australia and England & Wales between 1968 and 1997.

METHODS

Australian data were obtained from the Australian Bureau of Statistics, and for England & Wales from the Office for National Statistics. Overall and method-specific suicide rates for 15-34 year old males and females were calculated using ICD codes E950-9 and E980-9 except E988.8.

RESULTS

In both settings, suicide rates have almost doubled in young males over the past 30 years (from 16.8 to 32.9 per 100,000 in Australia and from 10.1 to 19.0 in England & Wales). Overall rates have changed little in young females. In both sexes and in both settings there have been substantial increases in suicide by hanging (5-7 fold increase in Australia and four-fold increase in England & Wales). There have also been smaller increases in gassing in the 1980s and '90s. In females, the impact of these increases on overall rates has been offset by a decline in drug overdose, the most common method in females.

CONCLUSIONS

Rates of male suicide have increased substantially in both settings in recent years, and hanging has become an increasingly common method of suicide. The similarity in observed trends in both settings supports the view that such changes may have common causes. Research should focus on understanding why hanging has increased in popularity and what measures may be taken to diminish it.

Suicide by antidepressant intoxication identified at autopsy in Vienna from 1991-1997: the favourable consequences of the increasing use of SSRIs

In the area of Vienna, any person dying under questionable circumstances is examined at the Institute of Forensic Medicine, where the cause of death is determined by means of autopsy and chemical analysis. Our study on fatal intoxications was performed in the period between 1991 and 1997, when selective serotonin reuptake inhibitors (SSRIs) were establishing themselves on the market, reaching the top of prescription statistics. Tricyclic antidepressants (TCAs) were involved in 30 single- and 127 multiple-substance intoxications, with amitriptyline and doxepin being the most frequently used drugs. SSRIs were involved in five multiple-substance intoxications. The f-value, which refers to the number of deaths per million defined daily doses prescribed, was found to be significantly (P</=0.001) higher in TCAs than in SSRIs. The f-value for the total group of all antidepressants declined significantly (P</=0.05) during the observation period of 7 years. In conclusion, SSRIs turned out to be less toxic than TCAs, and the increasing use of new antidepressants did not coincide with an increased number of deaths caused by these drugs.

SSRIs versus other antidepressants for depressive disorder

OBJECTIVES

To examine the relative efficacy of selective serotonin reuptake inhibitors (SSRIs) compared to other antidepressants.

SEARCH STRATEGY

The search strategy included a search of (a) Electronic bibliographic databases (MEDLINE, EMBASE); (b) reference lists of related reviews (c) reference lists of all located studies (d) contact with the manufacturer and (e) the Cochrane Group register of controlled trials

SELECTION CRITERIA

Randomised controlled trials comparing selective serotonin reuptake inhibitors with other kinds of antidepressants in the treatment of patients with depressive disorders. The outcome measures assessed included measures of the severity of depression.

DATA COLLECTION AND ANALYSIS

Data were collected from each study the main outcome measurefrom each study. These included: mean Hamilton depression rating scale, mean Montgomery & Asberg depression rating scale, Clinical Global Impression rating scale. An analysis of standardised mean difference of these scales was performed using Review Manager 3. 1 software. The presence of heterogeneity of treatment effect was assessed

MAIN RESULTS

Ninety-eight trials contributed data to the analysis of the relative efficacy of SSRIs and related drugs with comparator antidepressants (Figure 3 & Appendix 3). Analysis of efficacy was based upon 5044 patients treated with an SSRI or related drug, and 4510 treated with an alternative antidepressant. The standardised effect size for SSRIs and related drugs together versus alternative antidepressants using a fixed effects model was 0. 035 (95% CI -0.006 to 0.076; Q = 149.25, df = 97, p < 0.001).

REVIEWER'S CONCLUSIONS

There are no clinically significant differences in effectiveness between selective serotonin reuptake inhibitors and tricyclic antidepressants. Treatment decisions need to be based on considerations of relative patient acceptability, toxicity and cost.

Level 1 psychiatric emergency services. The tools of the crisis sector

Psychiatric emergency services have become an increasingly important element in the mental health system. Many approaches to delivering these services have been described but no unifying constructs have emerged. This article reviews the range of psychiatric emergency settings including their structure and functions, the evidence of their benefits to the system, and the controversies surrounding their use. Categorization by capability is proposed as a means of improving the quality and consistency of assessment and treatment. Regional consolidation is proposed as a means of accomplishing these improvements while containing costs.

Assessing new health technologies: lessons to be learned from drugs

Balancing the interests of producers, consumers and purchasers (governments) increases the complexity of evidence-based evaluation of non-drug health technologies.

Costs of antidepressant overdose: a preliminary study

There is ongoing debate regarding the relative cost effectiveness of different classes of antidepressants. Although factors such as tolerability and discontinuation rates have been taken into account, there has been little consideration of the cost of overdose. In the current study we examined the cost of antidepressant overdose at four teaching hospitals over a four-week period and found that the cost of selective serotonin reuptake inhibitor overdose was less than half that of tricyclic anti-depressant overdose. The cost of overdose is often ignored and should be considered in future analyses of the cost effectiveness of different antidepressant prescribing policies in primary care.

Adverse effects associated with selective serotonin reuptake inhibitors and tricyclic antidepressants: a meta-analysis

BACKGROUND

The use of antidepressant medications and the resulting costs have increased dramatically in recent years, partly because of the introduction of selective serotonin reuptake inhibitors (SSRIs). An assessment of the clinical and economic aspects of SSRIs compared with the older tricyclic antidepressants (TCAs) was initiated to generate information for purchasers of these drugs as well as clinicians. One component of this study was an examination of the adverse effects associated with the use of these drugs.

METHODS

Searches of bibliographic databases (for January 1980 through May 1996) and manual scanning of both peer-reviewed publications and other documents were used to identify double-blind, randomized controlled trials involving at least one SSRI and one TCA. For the study of adverse effects, only trials that had at least 20 patients in each trial arm and that reported rates of adverse effects in both arms were retained. In total 84 trials reporting on 18 adverse effects were available. Meta-analyses were undertaken to calculate pooled differences in rates of adverse effects. The question of whether the method of eliciting information from patients about adverse effects made a difference in the findings was also examined. Finally, differences in drop-out rates due to adverse effects were calculated.

RESULTS

The crude rates of occurrence of adverse effects ranged from 4% (palpitations) to 26% (nausea) for SSRIs and from 4% (diarrhea) to 27% (dry mouth) for TCAs. The differences in the rates of adverse effects between the 2 types of drugs ranged from 14% more with SSRIs (for nausea) to 11% more with TCAs (for constipation). The results did not depend on the method of eliciting information from patients. There were no statistically significant differences between drug classes in terms of drop-outs due to adverse effects.

INTERPRETATION

SSRIs and TCAs are both associated with adverse effects, although the key effects differ between the drug classes. Further explanation of the adverse effects and their relation to discontinuation of medication will require better studies involving prospective collection of quality-of-life data.

Antidepressants and suicide mortality

BACKGROUND

This paper presents a nationwide analysis of suicide mortality in Finland from 1990 to 1995, when the total use of antidepressants, especially that by selective serotonin reuptake inhibitors (SSRIs) expanded in the country.

METHODS

Suicide rate was analysed by various methods including that by intake of antidepressants. Various antidepressants were compared by calculating fatal toxicity indices (FTI) by relating number of fatal poisonings by a drug to its consumption.

RESULTS

The expanded use of antidepressants coincided with an increased number of deaths caused by these drugs. The proportion of suicides committed by use of antidepressants among all suicides increased from 5.6% to 8.4%. The total suicide rate, however, declined significantly. This was mainly accounted for by the reduced suicide rates by hanging and carbomonoxide poisoning, which outnumbered the increased figures of suicides by poisoning. On the whole, 82% of suicides by antidepressants were committed by use of tricyclics. Use of doxepin and amitriptyline remained steady, and their FTIs were constantly high. The lowest FTIs were associated with fluoxetine, citalopram, mianserin and moclobemide.

LIMITATIONS

The method ignores causality between the increased use of SSRIs and suicide mortality. Various factors affecting risk of suicide or choice of a method remain outside the scope of the data.

CONCLUSION

The increased use of SSRIs coincided with a significant decline in suicide mortality. However, suicides by use of antidepressants showed an upward trend. Therefore, in suicide prevention, risks and benefits of antidepressants should be considered in choosing treatment for depressive patients.

Evidence into practice. Prescribing selective serotonin reuptake inhibitors

This descriptive analysis examines prescribing trends of antidepressants in English primary care, providing analysis of NHS reimbursement data for groups of antidepressants between 1989 and 1994. Prescribing trends seem unaffected by the release of information on the effectiveness and cost-effectiveness of antidepressant drugs. We found that simple distribution of the results of health technology assessments may not be sufficient to influence practice.

Fluoxetine. A pharmacoeconomic review of its use in depression

Depressive illness is a common, often unrecognised and untreated condition with substantial associated costs, particularly indirect costs (e.g. lost productivity and absenteeism). The improved tolerability profile of fluoxetine and associated lower discontinuation rates, the relative safety of the drug in overdosage and its similar efficacy compared with tricyclic antidepressants have provided the main rationale for using this agent in depressed patients. Pharmacoeconomic analyses of fluoxetine have mainly sought to determine whether its higher acquisition cost in comparison with tricyclic antidepressants can be offset by reductions in other costs and whether the use of this agent as first-line therapy can be justified. Studies have also attempted to determine whether the selective serotonin reuptake inhibitors (SSRIs) can be distinguished from one another on pharmacoeconomic grounds; overall efficacy and tolerability of these agents appear to be similar, although tolerability data are conflicting. Most analyses have been of a retrospective database or clinical decision analytic model design; two prospective trials (one conducted in a naturalistic setting) have been conducted. These studies have mainly considered direct treatment costs only from the perspective of the healthcare payer. Available evidence suggests that overall total direct healthcare costs for patients who start antidepressant therapy with fluoxetine are similar to, or lower than, those for patients who start therapy with tricyclic agents or other SSRIs. Offsetting of the higher acquisition cost of fluoxetine compared with that of tricyclic agents may be accounted for by lower in- and outpatient costs with fluoxetine, a possible lower risk of absenteeism from work and lower mean total medical costs associated with acute overdosage. Between-treatment differences in drug use patterns may also, in part, explain the observed differences in total healthcare costs between fluoxetine and other antidepressants. In particular, patients beginning therapy with fluoxetine are more likely to receive treatment regimens that meet minimum recommended guidelines for dosage and duration and are less likely to require treatment switching/augmentation than those receiving tricyclic antidepressants or other SSRIs as initial therapy. In addition, fewer fluoxetine than tricyclic antidepressant recipients discontinue therapy early, and fewer fluoxetine recipients require upward dosage titration or concomitant anxiolytic/ hypnotic medications than patients receiving other SSRIs. In conclusion, fluoxetine is a well established antidepressant which possesses tolerability and safety advantages over the tricyclic agents. The available cost analyses show that these benefits can be obtained without additional overall cost to the healthcare provider. Cost advantages observed to date for fluoxetine over other SSRIs require confirmation.

Economic comparisons of the pharmacotherapy of depression: an overview

As many countries find that their health care expenditure is taking up an increasing proportion of their financial resources, economic aspects of care processes have become more important in the choice of optimal strategies. This review of the economic studies of the comparative treatment of depression shows that nearly every aspect of treatment has important economic consequences. Cost-of-illness studies have documented the high burden on society of this disorder, and the associated loss of productivity and work. Comparative cost-effectiveness/utility studies, the majority of which are based on modelling techniques, have consistently shown a better cost-effectiveness ratio of the newer antidepressants over more traditional tricyclic antidepressants (TCAs), when all therapy-related costs are taken into account.

Effect of lithium maintenance on suicidal behavior in major mood disorders

We reviewed evidence of a possible antisuicide action of lithium maintenance treatment in mood disorders. Of 28 published studies involving over 17,000 patients with major affective illnesses, most yielded supportive evidence: risk of suicides and attempts averaged 3.2 versus 0.37 per 100 patient-years without versus with lithium (8.6-fold difference). In a new study of 284 bipolar I- and II-disordered patients, corresponding rates (2.2 vs. 0.39/100 patient-years) differed by 5.6-fold (p < 0.001); moreover, after discontinuing lithium, rates of suicidal acts rose by 7-fold (16-fold within the first year), and fatalities increased by nearly 9-fold. Lithium maintenance treatment in recurring major mood disorders has strong evidence of antisuicide effects not demonstrated with any other mood stabilizer. Close association of suicide and depression in bipolar disorder emphasizes the need for improved identification and treatment of bipolar depression.

Putting trials on trial--the costs and consequences of small trials in depression: a systematic review of methodology

STUDY OBJECTIVE

To determine why, despite 122 randomised controlled trials, there is no consensus about whether the selective serotonin reuptake inhibitors or tricyclic and related antidepressants should be used as first line treatment of depression.

DESIGN

Systematic review of all RCTs comparing selective serotonin reuptake inhibitors and tricyclic or heterocyclic antidepressants.

MAIN RESULTS

The shortcomings identified in the 122 trials were as follows: (1) there was inadequate description of randomisation, (2) the outcomes used were mainly observer rated measurements of depression, and studies failed to use quality of life measures or perform economic evaluations, (3) doses of tricyclic antidepressants were inadequate, (4) generalisability of studies was poor (including a reliance on secondary care settings and inadequate follow up), and (5) there were statistical shortcomings such as low statistical power, failure to use intention to treat analyses, and the tendency to make multiple comparisons.

CONCLUSIONS

Future RCTs should be designed to inform policy makers and address these methodological shortcomings.

Constraints on antidepressant prescribing and principles of cost-effective antidepressant use. Part 2: Cost-effectiveness analyses

Cost-effectiveness studies are a useful tool in drug-choice decisions. They are appropriate when alternative therapies have different levels of effectiveness, as with antidepressants. The calculation of cost effectiveness is similar to that used by some authors to determine whether a drug should be included in a formulary, so it clearly has immediate practical application and potential acceptability. However, the actual acceptability of cost-effectiveness studies has been hampered by a lack of conformity over study objectives, methodology and use of available data, and this significantly affects results. Studies that focus on the same location and setting, and conducted at the same time, frequently provide different results in their conclusions, depending on the assumptions and viewpoints, and the effects of sampling error. For example, dosage can affect purchase price calculations, but also compliance and efficacy, which are important considerations. Moreover, conclusions based on cost disadvantages of new drugs are not appropriate for planning for the future, since a drug's market price tends to fall with time and increasing demand. Appropriate use of outcome measures is important, and treatment failures, as well as successes, should be considered. Cost-effectiveness analysis has been used to demonstrate an important point: even when the appropriate use of antidepressants and specialty care increases medical costs, it improves value for money. A variety of drugs for one indication should be available to the prescriber, as the most cost-effective one may differ between patient subpopulations. Many costs of morbidity, adverse effects and secondary effects of antidepressants remain to be properly quantified, but are likely to have an important influence on cost effectiveness. These costs are likely to be higher for tricyclic antidepressants than the newer reversible inhibitors of monoamine oxidase and selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors. Costing in some areas of health is relatively straightforward. Depression is among the most difficult areas to cost because of its gradation in severity, its chronic and recurrent nature, and its subtle effects on working capacity. Quantification of differences resulting from the use of different drugs has many pitfalls. Until now, each cost analysis of depression has differed from the last, and most have placed excessive reliance on poorly substantiated and hypothetical assumptions. More in-depth studies are required to define the most cost-effective policies for recommendation to healthcare decision-makers and antidepressant drug prescribers. Compliance, adverse effects, and safety in overdose are important factors. The impact of indirect costs also needs to be addressed.

The generalisability of pharmacoeconomic studies

Authors of pharmacoeconomic analyses understandably want their findings to apply as broadly as possible. Also, decision-makers may have to interpret the results of analyses conducted in healthcare settings other than their own. The validity of transferring or generalising results from one setting to another raises important issues for health-economic evaluation. Pharmacoeconomic analyses attempt to model the costs and benefits of alternative treatments in normal clinical practice. Usually, no single clinical study directly provides all the required information, and a variety of data sources is generally included in each analysis. Different data sources present different problems in terms of their relevance to decision-makers. At one extreme, an analysis based purely on trial outcomes and resource use may be precise, but not reflect normal practice; at the other extreme, an analysis using practice data may appear relevant, but be exposed to biases and confounding. Reviews of published studies suggest that general standards have been inadequate in the past. Reapplying such analyses in different localities may simply replicate inadequate findings. The 'perfect' should not become the enemy of the merely 'good'. Models can be helpful in decision-making, provided that they accurately communicate uncertainties in modelling and data. Even so, there will be limits to the generalisability of pharmacoeconomic models, since the required analysis differs between jurisdictions, and because of variations in normal clinical practice. The transferability of research findings re-opens the issue of credibility in pharmacoeconomics. Methodological standardisation, reporting standards and researcher independence are recognised as important factors for enhancing credibility. Where possible, pharmacoeconomic analyses should reflect the findings of systematic reviews of health outcomes to avoid the risk of biased selection of the evidence. In addition, the application of findings to individual healthcare settings must be considered, since cost effectiveness may vary markedly by setting and perspective.

Cost-effectiveness of antidepressant treatment reassessed

BACKGROUND

A recent simulation concluded that the serotonin-specific reuptake inhibitor (SSRI) paroxetine was more cost-effective than the tricyclic antidepressant (TCA) imipramine, despite substantially higher medication acquisition costs.

METHOD

We replicated the previous model and revised key assumptions which drove the results. The revised model was subjected to sensitivity analysis.

RESULTS

Most scenarios in the revised model showed that the TCA is equally or more cost-effective than the SSRI. Model revision producing these results were changes in assumptions about switched treatment success rates, treatment length and initial treatment success. The revised model appears sensitive to drug acquisition and delivery costs and costs of treatment failure.

CONCLUSIONS

Based on the model, a policy of using TCAs as first-choice antidepressant treatment, with SSRIs reserved for those patients not doing well initially, appears more cost-effective than the reverse sequence. Given limitations in current knowledge about key parameters to include in a simulation model, large prospective random-assignment cost-effectiveness studies are needed.

Which antidepressant? A commentary from general practice on evidence-based medicine and health economics

BACKGROUND

With increasing demand for health care, evidence-based medicine combined with health economics offers a method of optimizing allocation of limited resources. Depression is an illness that has a high prevalence with important medical, social and economic implications. More than 90% of depression is diagnosed and treated in general practice.

AIM

To review the effectiveness of an evidence-based approach combined with health economics in deciding whether a tricyclic antidepressant (TCA) or a selective serotonin reuptake inhibitor (SSRI) should be used in the treatment of depression in general practice.

METHOD

An evidence-based strategy tested the two treatments against the criteria of appropriateness, efficacy, effectiveness and value for money.

RESULTS

Although both drugs were equally efficacious, their relative effectiveness and value for money could not be accurately defined.

CONCLUSION

An evidence-based approach does not make clear whether SSRIs or TCAs should be used for the treatment of depression in general practice. Research questions arising from general practice should be addressed in a relevant setting and should yield answers that will complement and support a more pragmatic system of medicine rather than seek to direct it.

Are decisions taken by health care professionals rational? A non systematic review of experimental and quasi experimental literature

Systematic overviews of the effectiveness and cost effectiveness of health care interventions are increasingly available, and yet there has been relatively little attention upon putting their important findings into practice. Furthermore, close attention to the decision making behaviour of health professionals in situations of uncertainty indicates that this may not always be 'rational'. This paper examines developments in the understanding of rationality in decision making from outside the health care setting, particularly the interesting work on 'regret theory', and begins to apply this framework to health care.

Sertraline. A pharmacoeconomic evaluation of its use in depression

Depression is a common condition that is often unrecognised, misdiagnosed and/or undertreated. It is associated with substantial direct, indirect and intangible costs. The indirect costs of lost earnings/productivity and premature death account for the majority of these costs; drug costs account for only about 1 to 2% of total costs and about 10 to 12% of direct costs. Thus, better recognition and appropriate treatment of depression would increase the direct costs associated with this illness, but would also have the potential to greatly reduce indirect costs and consequently the overall cost of depression. Because of their higher acquisition costs relative to tricyclic antidepressants (TCAs), there has been much debate about whether the use of sertraline or other selective serotonin reuptake inhibitors (SSRIs) for first-line treatment of depression can be justified. While these agents have similar efficacy to TCAs, they are better tolerated and have a lower risk of death on overdosage. Despite the large economic burden of depression on society, pharmacoeconomic data on sertraline and antidepressant drugs in general are scarce. Most of the available studies on sertraline are limited to considerations of direct costs and do not assess costs from a societal perspective. In addition, a number of studies have significant methodological problems which limit determination of meaningful conclusions. Nonetheless, data from 2 more recent studies with fewer methodological problems than earlier studies indicated that sertraline was more cost-effective than TCAs because of fewer psychiatrist consultations, and less costly than fluoxetine because of fewer absences from work and fewer medical consultations. The cost-utility ratio of maintenance therapy of depression with sertraline appears to fall within the range of accepted cost-utility ratios of common healthcare interventions. Thus, studies to date have generally shown that overall treatment costs with sertraline and other SSRIs are no greater than those for TCAs; this is despite the lower acquisition costs of the latter agents. Therefore, it is clear from these data that it is misleading to classify antidepressant agents as expensive or inexpensive based solely on their acquisition costs. Sertraline, therefore, can be considered as a first-line alternative to TCAs and other SSRIs for the treatment of depression on both clinical and pharmacoeconomic grounds.

Selective serotonin reuptake inhibitors. Assessment for formulary inclusion

Depression is a common and significant health problem associated with impairment in a patient's ability to function in their role (e.g. student, worker, home-maker), and may have a fatal outcome in the case of suicide. Recently there has been progress in developing new antidepressant medications, such as the selective serotonin reuptake inhibitors (SSRIs). These agents, while no more effective than the tricyclic antidepressant (TCA) drugs, are generally better tolerated than traditional medications used to treat depression. Further, because of their adverse effect profiles, they are generally better tolerated, and safer in overdose, than the TCAs. In response to concerns about aggregate healthcare costs, formularies are being employed to control the direct costs of prescription drugs. When direct drug costs alone are considered, the TCAs are initially less expensive than the SSRIs. However, compared with those taking SSRIs, patients taking TCAs withdraw from treatment more frequently, have more accidents, experience more adverse effects that require treatment, and are more likely to die from an overdose (if it occurs). Furthermore, unsuccessful treatment may be due to noncompliance, which is frequently related to adverse effects. Medications have effects on indirect costs. For example, adverse effects may impair productivity and lead to accidents in the home and at work. There are increased hospital and indirect costs of drugs used in overdose. Medication non-compliance may lead to failure to recover from depression, which results in ongoing expense to the state in the form of disability benefit payments. The largest cost savings are often associated with indirect costs, such as reduced benefit payments and improved productivity and earnings when treatment is successful. Taking all these considerations together, it does not appear that TCAs, taken over time, are any less expensive than the newer antidepressant medications.

Are SSRIs a cost-effective alternative to tricyclics?

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are more expensive than tricyclics. Reports have suggested that SSRIs are cost-effective because they are better tolerated and safer in overdose.

METHOD

A systematic review of all randomised controlled trials (RCTs), meta-analyses, and cost-effectiveness studies comparing SSRIs and tricyclic antidepressants (TCAs).

RESULTS

None of the RCTs provided an economic analysis and there were methodological problems in the majority which would preclude this approach. Meta-analyses suggest that clinical efficacy is equivalent but slightly fewer patients prescribed SSRIs drop out of RCTs. Cost-effectiveness studies have been based on crude 'modelling' approaches and over-estimate the difference in attrition rates and the cost of treatment failure. It appears impossible to evaluate the economic aspects of suicide because of its rarity.

CONCLUSIONS

There is no evidence to suggest that SSRIs are more cost-effective than TCAs. The debate will only be concluded when a prospective cost-effectiveness study is done in the setting of a large primary care based RCT.

Paroxetine. A pharmacoeconomic evaluation of its use in depression

There has been intense debate about whether the use of paroxetine or other selective serotonin reuptake inhibitors (SSRIs) as alternatives to tricyclic antidepressants for first-line treatment of depression can be justified, considering their higher acquisition costs. The rationale for using paroxetine in the treatment of depression lies in its more favourable tolerability profile than tricyclic antidepressants and its lower risk of death on overdosage. Depression is one of the most common psychiatric disorders and is associated with substantial direct, indirect and intangible costs. Indirect costs account for the majority of costs associated with depression, while drug costs account for only 9 to 25% of direct costs. Therefore, increased recognition and treatment of depression has the potential to greatly reduce the overall cost of this disease. Pharmacoeconomic data on paroxetine and other SSRIs in the treatment of depression are scarce. Available studies are limited to considerations of direct costs alone and are primarily based on retrospective data from clinical trials. Nevertheless, in terms of costs per successfully-treated patient, available data suggest that the treatment costs associated with paroxetine are similar to those of amitriptyline and possibly less than those of imipramine. Paroxetine treatment costs also appear to be similar to those of amitriptyline and imipramine in terms of expected costs per patient. While one group of investigators suggested that the overall cost of administering paroxetine may also be less than that for fluoxetine and sertraline when drug costs and labour costs associated with dosage adjustment are taken into account, more data are required before conclusions on the relative pharmacoeconomic merits of SSRIs can be made. Despite the lower risk of death from overdosage with SSRIs, switching from an established tricyclic antidepressant to a newer tricyclic or related antidepressant in an attempt to avoid suicide appears to be more cost effective than switching to an SSRI. Thus, evidence available to date indicate that despite higher acquisition costs paroxetine and other SSRIs are no more costly than tricyclic antidepressants when total costs per successfully treated patient or expected costs per patient are considered. With its favourable tolerability profile and low risk of death on overdosage, paroxetine should therefore be considered as an effective alternative to tricyclic antidepressant agents as a first-line treatment of depression.(ABSTRACT TRUNCATED AT 400 WORDS)

Dealing with uncertainty: will science solve the problems of resource allocation in the U.K. NHS?

In spite of the huge efforts which internationally address the development and assessment of health technologies, the majority of health care interventions have not been formally evaluated for their effectiveness and their likely impact upon health status is largely unknown. This has led to a situation where it is unclear on what basis a health care system might be judged, or for that matter on what basis decisions on the specification of individual services might be made. It has frequently been argued that the only way to build an adequate understanding of the effectiveness of different interventions is through systematically locating and synthesising the available evidence from research, and such systematic overviews are increasingly available in many areas. However, such overviews produce few clear conclusions, and even when the results of systematic overviews show unequivocal benefits for patients, implementing the findings of such reviews remains problematic. Research evidence provides useful information on marginal benefits for patients, though areas where the absolute benefit is high appear to be very rare. The most common finding appears to be uncertainty. Interpreting research evidence is complex, and even very clear findings may prove hard to operationalise. Good quality research will help, but will not solve, the problems of resource allocation in the NHS or in other health systems.

Antidepressant prescription by British child psychiatrists: practice and safety issues

OBJECTIVES

To evaluate the pattern of prescribing antidepressant (AD) drugs by British child psychiatrists with particular emphasis on the impact of newer-type (heterocyclic and selective serotonin reuptake inhibitor) agents on this practice and to assess the safety of AD use for children in terms of clinicians' reports of adverse effects.

METHOD

A short postal survey asking specific questions about these aspects of their clinical practice was sent to 350 British child psychiatrists.

RESULTS

The response rate was 71%. A clear majority of the 238 respondents (85%) who provided analyzable reports had prescribed ADs, the most popular of these being amitriptyline and imipramine, although nearly one third of prescribers also used newer agents occasionally and the selective serotonin reuptake inhibitors specifically, very rarely indeed. British child psychiatrists issued only one or two new prescriptions for AD medication per year. ADs were being used for a wide range of child and adolescent psychiatric disorders beyond the product data sheet-recommended indications of "depression" and "nocturnal enuresis." High rates of mostly mild adverse effects were reported in children treated with older-type ADs; however, the use of newer ADs did not appear to have influenced this picture when the reports of prescribers of only older ADs were compared with reports of those who also prescribed newer agents.

CONCLUSIONS

Despite a willingness to use this form of treatment, British child psychiatrists tend to use it very sparingly compared to practices revealed in American studies. The preferential and infrequent use of older AD agents may account for the high rates of adverse effects reported. These practices do not allow clinicians to become familiar with, and thus more comfortable about, using newer agents.

Relative mortality from overdose of antidepressants

OBJECTIVE

To compare the fatal toxicities of antidepressant drugs in 1987-92.

DESIGN

Retrospective epidemiological review of prescription data of the Department of Health, Scottish Office Home and Health Department, and Welsh Health Common Services Authority (excluding data from most private general practices and most hospitals), and mortality data from the Office of Population Censuses and Surveys and General Register Office in Scotland.

SETTING

General practice, England, Scotland, and Wales.

MAIN OUTCOME MEASURES

Deaths per million prescriptions and deaths per defined daily dose.

RESULTS

81.6% (1310/1606) of deaths from antidepressant overdose were due to two drugs, amitriptyline and dothiepin. The overall average of deaths per million prescriptions was 30.1. The overall rate for tricyclic drugs was 34.14 (95% confidence interval 32.47 to 38.86; P < 0.001), monoamine oxidase inhibitors 13.48 (6.93 to 22.19; P < 0.001), atypical drugs 6.19 (4.04 to 8.80; P < 0.001), and selective serotonin reuptake inhibitors 2.02 (0.64 to 4.17; P < 0.001). The numbers of deaths per million prescriptions of amoxapine, dothiepin, and amitriptyline were significantly higher than expected, while nine drugs had a significantly lower number of deaths per million prescriptions than expected. Analysis of deaths per defined daily dose showed a similar pattern.

CONCLUSIONS

Safety in overdose should be considered in risk-benefit and cost-benefit considerations of antidepressants. A switch in prescribing, from drugs with a high number of deaths per million prescriptions to drugs with a low number, could reduce the numbers of deaths from overdose. Although this form of suicide prevention can be implemented easily and immediately, its introduction needs to be considered against the higher costs of some of the newer drugs.