Recent trends in the use of antidepressant drugs in Australia, 1990-1998

Prevalence of and Risk Factors for Depressive Symptoms and Antidepressant Use in Young Australian Women: A Cross-Sectional Study

Background: Despite the high prevalence of depression among adult women, the proportion of reproductive-aged women with moderate or severe depressive symptoms is uncertain, as is the proportion taking antidepressant medication. We report the prevalence of depressive symptoms in young Australian women, risk factors for depressive symptoms, and psychoactive drug use. Methods: An online survey was completed by population-based sample of 6,986 Australian women, aged 18-39 years, recruited from November 2016 to July 2017. Depressive symptoms were assessed by the Beck Depression Inventory-II, and psychotropic medication use was self-reported. Results: The prevalences of moderate and severe depressive symptoms were 15.0% (95% confidence interval [CI] 14.1%-15.8%) and 14.8% (95% CI 14.0%-15.7%), respectively. Housing insecurity was associated with over a twofold likelihood of moderate to severe depressive symptoms, whereas being parous or at least 25 years of age was protective. Use of any psychotropic medication was reported by 16.3% (95% CI 15.4%-17.2%). A previous cancer diagnosis was the strongest risk factor for current antidepressant use, whereas compared with being of European ancestry, being Asian or of another ancestry was associated with a lower likelihood of antidepressant use. Conclusion: The prevalence of moderate to severe depressive symptoms among young Australian women is alarming. Prevention strategies targeting the sociodemographic circumstances underpinning the identified risk factors are urgently needed.

Australian Mass Shootings: An Analysis of Incidents and Offenders

Mass shooting events are relatively underresearched, and most study comes from the United States. Despite significant international interest, little is known about other countries' experiences of these events. The current study examines Australian mass shooting incidents and offenders, with emphasis on mental illness, life strains, and offenders' life histories. Australia had 14 mass shootings between 1964 and 2014. Most offenders experienced acute life stressors and/or chronic strains leading up to the event; however, diagnosed mental illness was less commonly documented. These observations provide new information about mass shooting incidents and offenders, and can help to inform international policy development.

Pharmacological interventions for treatment-resistant depression in adults

BACKGROUND

Although antidepressants are often a first-line treatment for adults with moderate to severe depression, many people do not respond adequately to medication, and are said to have treatment-resistant depression (TRD). Little evidence exists to inform the most appropriate 'next step' treatment for these people.

OBJECTIVES

To assess the effectiveness of standard pharmacological treatments for adults with TRD.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) (March 2016), CENTRAL, MEDLINE, Embase, PsycINFO and Web of Science (31 December 2018), the World Health Organization trials portal and ClinicalTrials.gov for unpublished and ongoing studies, and screened bibliographies of included studies and relevant systematic reviews without date or language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with participants aged 18 to 74 years with unipolar depression (based on criteria from DSM-IV-TR or earlier versions, International Classification of Diseases (ICD)-10, Feighner criteria or Research Diagnostic Criteria) who had not responded to a minimum of four weeks of antidepressant treatment at a recommended dose. Interventions were: (1) increasing the dose of antidepressant monotherapy; (2) switching to a different antidepressant monotherapy; (3) augmenting treatment with another antidepressant; (4) augmenting treatment with a non-antidepressant. All were compared with continuing antidepressant monotherapy. We excluded studies of non-standard pharmacological treatments (e.g. sex hormones, vitamins, herbal medicines and food supplements).

DATA COLLECTION AND ANALYSIS

Two reviewers used standard Cochrane methods to extract data, assess risk of bias, and resolve disagreements. We analysed continuous outcomes with mean difference (MD) or standardised mean difference (SMD) and 95% confidence interval (CI). For dichotomous outcomes, we calculated a relative risk (RR) and 95% CI. Where sufficient data existed, we conducted meta-analyses using random-effects models.

MAIN RESULTS

We included 10 RCTs (2731 participants). Nine were conducted in outpatient settings and one in both in- and outpatients. Mean age of participants ranged from 42 - 50.2 years, and most were female. One study investigated switching to, or augmenting current antidepressant treatment with, another antidepressant (mianserin). Another augmented current antidepressant treatment with the antidepressant mirtazapine. Eight studies augmented current antidepressant treatment with a non-antidepressant (either an anxiolytic (buspirone) or an antipsychotic (cariprazine; olanzapine; quetiapine (3 studies); or ziprasidone (2 studies)). We judged most studies to be at a low or unclear risk of bias. Only one of the included studies was not industry-sponsored. There was no evidence of a difference in depression severity when current treatment was switched to mianserin (MD on Hamilton Rating Scale for Depression (HAM-D) = -1.8, 95% CI -5.22 to 1.62, low-quality evidence)) compared with continuing on antidepressant monotherapy. Nor was there evidence of a difference in numbers dropping out of treatment (RR 2.08, 95% CI 0.94 to 4.59, low-quality evidence; dropouts 38% in the mianserin switch group; 18% in the control). Augmenting current antidepressant treatment with mianserin was associated with an improvement in depression symptoms severity scores from baseline (MD on HAM-D -4.8, 95% CI -8.18 to -1.42; moderate-quality evidence). There was no evidence of a difference in numbers dropping out (RR 1.02, 95% CI 0.38 to 2.72; low-quality evidence; 19% dropouts in the mianserin-augmented group; 38% in the control). When current antidepressant treatment was augmented with mirtazapine, there was little difference in depressive symptoms (MD on Beck Depression Inventory (BDI-II) -1.7, 95% CI -4.03 to 0.63; high-quality evidence) and no evidence of a difference in dropout numbers (RR 0.50, 95% CI 0.15 to 1.62; dropouts 2% in mirtazapine-augmented group; 3% in the control). Augmentation with buspirone provided no evidence of a benefit in terms of a reduction in depressive symptoms (MD on Montgomery and Asberg Depression Rating Scale (MADRS) -0.30, 95% CI -9.48 to 8.88; low-quality evidence) or numbers of drop-outs (RR 0.60, 95% CI 0.23 to 1.53; low-quality evidence; dropouts 11% in buspirone-augmented group; 19% in the control). Severity of depressive symptoms reduced when current treatment was augmented with cariprazine (MD on MADRS -1.50, 95% CI -2.74 to -0.25; high-quality evidence), olanzapine (MD on HAM-D -7.9, 95% CI -16.76 to 0.96; low-quality evidence; MD on MADRS -12.4, 95% CI -22.44 to -2.36; low-quality evidence), quetiapine (SMD -0.32, 95% CI -0.46 to -0.18; I2 = 6%, high-quality evidence), or ziprasidone (MD on HAM-D -2.73, 95% CI -4.53 to -0.93; I2 = 0, moderate-quality evidence) compared with continuing on antidepressant monotherapy. However, a greater number of participants dropped out when antidepressant monotherapy was augmented with an antipsychotic (cariprazine RR 1.68, 95% CI 1.16 to 2.41; quetiapine RR 1.57, 95% CI: 1.14 to 2.17; ziprasidone RR 1.60, 95% CI 1.01 to 2.55) compared with antidepressant monotherapy, although estimates for olanzapine augmentation were imprecise (RR 0.33, 95% CI 0.04 to 2.69). Dropout rates ranged from 10% to 39% in the groups augmented with an antipsychotic, and from 12% to 23% in the comparison groups. The most common reasons for dropping out were side effects or adverse events. We also summarised data about response and remission rates (based on changes in depressive symptoms) for included studies, along with data on social adjustment and social functioning, quality of life, economic outcomes and adverse events.

AUTHORS' CONCLUSIONS

A small body of evidence shows that augmenting current antidepressant therapy with mianserin or with an antipsychotic (cariprazine, olanzapine, quetiapine or ziprasidone) improves depressive symptoms over the short-term (8 to 12 weeks). However, this evidence is mostly of low or moderate quality due to imprecision of the estimates of effects. Improvements with antipsychotics need to be balanced against the increased likelihood of dropping out of treatment or experiencing an adverse event. Augmentation of current antidepressant therapy with a second antidepressant, mirtazapine, does not produce a clinically important benefit in reduction of depressive symptoms (high-quality evidence). The evidence regarding the effects of augmenting current antidepressant therapy with buspirone or switching current antidepressant treatment to mianserin is currently insufficient. Further trials are needed to increase the certainty of these findings and to examine long-term effects of treatment, as well as the effectiveness of other pharmacological treatment strategies.

Serotonin Syndrome and the Anaesthetist

Serotonin syndrome results from excessive activation of serotonin (5-hydroxytryptamine; 5-HT) receptors in the nervous system, on the surface of platelets, and on the vascular endothelium. The clinical manifestations are a triad of altered conscious state, autonomic dysfunction, and neuromuscular excitability. Clinical diagnostic criteria remain poorly defined and unvalidated, and there are no available investigations to confirm the diagnosis. The syndrome is caused by the administration of one or more drugs possessing serotonergic activity. Severe forms of the syndrome usually result from overdose, but can be induced by monotherapy. The exact incidence of serotonin syndrome remains unknown, but is likely to be increasing due to increased prescription of selective serotonin reuptake inhibitor anti-depressants and tramadol, as well as recreational use of amphetamine-like substances. Serotonin syndrome may complicate the administration of drugs frequently used in anaesthetic practice, including pethidine and tramadol. Although the majority of cases improve with symptomatic and supportive care, severe cases need intensive care and frequently require mechanical ventilation. Neuromuscular excitability is likely to be the cause of rhabdomyolysis seen in severe cases and should be treated with benzodiazepines and muscle relaxants. Supportive therapies are required to treat hyperthermia and autonomic dysfunction. Cyproheptadine is the most commonly administered serotonergic antagonist, but is unavailable in parenteral form.

Psychological therapies for treatment-resistant depression in adults

BACKGROUND

Antidepressants are a first-line treatment for adults with moderate to severe major depression. However, many people prescribed antidepressants for depression don't respond fully to such medication, and little evidence is available to inform the most appropriate 'next step' treatment for such patients, who may be referred to as having treatment-resistant depression (TRD). National Institute for Health and Care Excellence (NICE) guidance suggests that the 'next step' for those who do not respond to antidepressants may include a change in the dose or type of antidepressant medication, the addition of another medication, or the start of psychotherapy. Different types of psychotherapies may be used for TRD; evidence on these treatments is available but has not been collated to date.Along with the sister review of pharmacological therapies for TRD, this review summarises available evidence for the effectiveness of psychotherapies for adults (18 to 74 years) with TRD with the goal of establishing the best 'next step' for this group.

OBJECTIVES

To assess the effectiveness of psychotherapies for adults with TRD.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (until May 2016), along with CENTRAL, MEDLINE, Embase, and PsycINFO via OVID (until 16 May 2017). We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing studies. There were no date or language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with participants aged 18 to 74 years diagnosed with unipolar depression that had not responded to minimum four weeks of antidepressant treatment at a recommended dose. We excluded studies of drug intolerance. Acceptable diagnoses of unipolar depression were based onthe Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or earlier versions, International Classification of Diseases (ICD)-10, Feighner criteria, or Research Diagnostic Criteria. We included the following comparisons.1. Any psychological therapy versus antidepressant treatment alone, or another psychological therapy.2. Any psychological therapy given in addition to antidepressant medication versus antidepressant treatment alone, or a psychological therapy alone.Primary outcomes required were change in depressive symptoms and number of dropouts from study or treatment (as a measure of acceptability).

DATA COLLECTION AND ANALYSIS

We extracted data, assessed risk of bias in duplicate, and resolved disagreements through discussion or consultation with a third person. We conducted random-effects meta-analyses when appropriate. We summarised continuous outcomes using mean differences (MDs) or standardised mean differences (SMDs), and dichotomous outcomes using risk ratios (RRs).

MAIN RESULTS

We included six trials (n = 698; most participants were women approximately 40 years of age). All studies evaluated psychotherapy plus usual care (with antidepressants) versus usual care (with antidepressants). Three studies addressed the addition of cognitive-behavioural therapy (CBT) to usual care (n = 522), and one each evaluated intensive short-term dynamic psychotherapy (ISTDP) (n = 60), interpersonal therapy (IPT) (n = 34), or group dialectical behavioural therapy (DBT) (n = 19) as the intervention. Most studies were small (except one trial of CBT was large), and all studies were at high risk of detection bias for the main outcome of self-reported depressive symptoms.A random-effects meta-analysis of five trials (n = 575) showed that psychotherapy given in addition to usual care (vs usual care alone) produced improvement in self-reported depressive symptoms (MD -4.07 points, 95% confidence interval (CI) -7.07 to -1.07 on the Beck Depression Inventory (BDI) scale) over the short term (up to six months). Effects were similar when data from all six studies were combined for self-reported depressive symptoms (SMD -0.40, 95% CI -0.65 to -0.14; n = 635). The quality of this evidence was moderate. Similar moderate-quality evidence of benefit was seen on the Patient Health Questionnaire-9 Scale (PHQ-9) from two studies (MD -4.66, 95% CI 8.72 to -0.59; n = 482) and on the Hamilton Depression Rating Scale (HAMD) from four studies (MD -3.28, 95% CI -5.71 to -0.85; n = 193).High-quality evidence shows no differential dropout (a measure of acceptability) between intervention and comparator groups over the short term (RR 0.85, 95% CI 0.58 to 1.24; six studies; n = 698).Moderate-quality evidence for remission from six studies (RR 1.92, 95% CI 1.46 to 2.52; n = 635) and low-quality evidence for response from four studies (RR 1.80, 95% CI 1.2 to 2.7; n = 556) indicate that psychotherapy was beneficial as an adjunct to usual care over the short term.With the addition of CBT, low-quality evidence suggests lower depression scores on the BDI scale over the medium term (12 months) (RR -3.40, 95% CI -7.21 to 0.40; two studies; n = 475) and over the long term (46 months) (RR -1.90, 95% CI -3.22 to -0.58; one study; n = 248). Moderate-quality evidence for adjunctive CBT suggests no difference in acceptability (dropout) over the medium term (RR 0.98, 95% CI 0.66 to 1.47; two studies; n = 549) and lower dropout over long term (RR 0.80, 95% CI 0.66 to 0.97; one study; n = 248).Two studies reported serious adverse events (one suicide, two hospitalisations, and two exacerbations of depression) in 4.2% of the total sample, which occurred only in the usual care group (no events in the intervention group).An economic analysis (conducted as part of an included study) from the UK healthcare perspective (National Health Service (NHS)) revealed that adjunctive CBT was cost-effective over nearly four years.

AUTHORS' CONCLUSIONS

Moderate-quality evidence shows that psychotherapy added to usual care (with antidepressants) is beneficial for depressive symptoms and for response and remission rates over the short term for patients with TRD. Medium- and long-term effects seem similarly beneficial, although most evidence was derived from a single large trial. Psychotherapy added to usual care seems as acceptable as usual care alone.Further evidence is needed on the effectiveness of different types of psychotherapies for patients with TRD. No evidence currently shows whether switching to a psychotherapy is more beneficial for this patient group than continuing an antidepressant medication regimen. Addressing this evidence gap is an important goal for researchers.

Pattern of psychotropic medication use over two decades in Australian women

OBJECTIVE

Few population-based studies have been used to investigate secular trends in psychotropic medication use. Therefore, the aim of this study was to examine psychotropic medication use over time using data from the Geelong Osteoporosis Study, an on-going, population-based, cohort study of Australian women.

METHODS

Of the 1494 women recruited at Time 1 (1993-1997), self-reported medication use from Time 2 (2004-2008) and/or Time 3 (2011-2014) was available for 889 women. Prevalence of antidepressant/antipsychotic/anxiolytic/sedative/anticonvulsant use by age and cohort strata was calculated using bootstrapping methods. Simultaneous age-cohort patterns were evaluated using logistic regression techniques.

RESULTS

The prevalence of any psychotropic medication use increased from 8.0% (95% confidence interval = [6.3, 9.8]) at Time 1 to 26.0% (95% confidence interval = [22.4, 29.4]) at Time 3, translating to a 4.3-fold increase in the likelihood of psychotropic medication use over the study period (odds ratio = 4.3, 95% confidence interval = [3.2, 5.8], p < 0.001). This increase was driven by the use of antidepressants (odds ratio = 6.4, 95% confidence interval = [4.2, 9.5], p < 0.001) and anticonvulsants (odds ratio = 4.4, 95% confidence interval = [1.8, 11.1]) and modest increases in the use of anxiolytic agents (odds ratio = 1.9, 95% confidence interval = [1.1, 3.1]) and sedatives (odds ratio = 1.7, 95% confidence interval = [1.6, 1.9]). The prevalence of any psychotropic medication use increased with increasing age (40-59.9 years: odds ratio = 1.9, 95% confidence interval = [1.5, 2.6]; 60-79.9 years: odds ratio = 2.6, 95% confidence interval = [1.9, 3.5], compared to the 20- to 39.9-year group). Use of selective serotonin reuptake inhibitors increased dramatically over the study period (odds ratio = 15.3, 95% confidence interval = [7.0, 33.4]).

CONCLUSION

Use of psychotropic medication has increased substantially over the past two decades, especially among older women. Further investigations into the correlates and outcomes of the increased use of psychotropic medications are warranted.

Clinical Outcomes of Concomitant Use of Warfarin and Selective Serotonin Reuptake Inhibitors: A Multidatabase Observational Cohort Study

BACKGROUND

Patients treated with warfarin are often coprescribed selective serotonin reuptake inhibitors (SSRIs) for coexisting depression. Some SSRIs are potent CYP2C9 inhibitors that may increase warfarin plasma concentrations and the risk of bleeding. We aimed to examine the effect of the putative CYP2C9-mediated warfarin-SSRI interaction on clinical outcomes.

METHODS

We conducted an observational cohort study among warfarin initiators who had a subsequent SSRI prescription in 5 US claims databases. Patients were followed for up to 180 days as long as they were exposed to both warfarin and their index SSRI groups. Cox regression models were used to estimate hazard ratios and 95% confidence intervals for bleeding events, ischemic or thromboembolic events, and mortality comparing patients treated with SSRIs that are potent CYP2C9 inhibitors (fluoxetine, fluvoxamine) with those treated with other SSRIs after propensity score matching.

FINDINGS

The eligible cohort comprised 52,129 patients. Hazard ratios were 1.14 (95% confidence interval [CI], 0.94-1.38) for bleeding events, 1.03 (95% CI, 0.87-1.21) for ischemic or thromboembolic events, and 0.90 (95% CI, 0.72-1.14) for mortality. Results were consistent across individual component outcomes, different warfarin stabilization periods, and subgroup analyses.

CONCLUSIONS

Patients concomitantly treated with warfarin and SSRIs that are potent CYP2C9 inhibitors had comparable rates of bleeding events, ischemic or thromboembolic events, and mortality as did patients cotreated with warfarin and other SSRIs, although small but potentially meaningful effects on bleeding cannot be completely excluded. SSRI inhibition of CYP2C9 does not appear to affect major safety or effectiveness outcomes of warfarin treatment in clinical practice, where patients may be closely monitored.

Relationship between prescribed psychotropic medications and co-ingested alcohol in intentional self-poisonings

BackgroundAcute alcohol consumption is a major risk factor for suicide, therefore investigating factors associated with alcohol-related self-harm warrant attention.AimsTo investigate the influence of prescribed psychotropic medications on the odds of co-ingesting alcohol preceding or during intentional efforts to self-poison.MethodA cross-sectional analysis of consecutive hospital presentations following intentional self-poisoning was conducted. A total of 7270 patients (4363 women) aged 18-96 were included.ResultsThe odds of alcohol co-ingestion were increased in those not prescribed any medication (odds ratio (OR) = 1.27, 99% CI 1.10-1.46, P<0.001) and in impulsive self-poisonings (OR = 1.39, 99% CI 1.11-1.74, P<0.001). Odds were decreased in those prescribed anticonvulsants (OR = 0.69, 99% CI 0.51-0.93), antipsychotics (OR = 0.55, 99% CI 0.45-0.66) and antidepressants (OR = 0.87, 99% CI 0.77-0.99).ConclusionsFindings indicate that being medicated for a psychiatric illness may reduce the likelihood of alcohol consumption during times of acute distress, hence perhaps may reduce the risk of intentional self-poisoning.

The antipsychotic story: changes in prescriptions and overdose without better safety

AIMS

Morbidity and mortality from drug overdose has decreased over three decades. This is credited to safer drugs and therefore better outcomes in overdose. We aimed to investigate changing prescriptions of antipsychotic medications and associated changes in antipsychotic overdoses over a 26-year period.

METHODS

All antipsychotic poisoning presentations to a tertiary referral toxicology unit between 1987 and 2012 were reviewed. Data were collected prospectively on demographics, ingestion information, clinical effects, complications and treatment. Rates of antipsychotic drug use in Australia were obtained from Australian government publications for 1990-2011 and linked to overdose admissions by postcode.

RESULTS

There were 3180 antipsychotic overdoses: 1235 first generation antipsychotics, 1695 'atypical' second generation antipsychotics and 250 lithium overdoses. Over 26 years, antipsychotic overdoses increased 1.8-fold, with first generation antipsychotics decreasing to one-fifth of their peak (≈80/year to 16) and second generation antipsychotics increasing to double this (≈160/year), olanzapine and quetiapine accounting for 78%. All antipsychotic overdoses had a median length of stay of 18.6 h, 15.7% admitted to intensive care unit, 10.4% ventilated and 0.13% died in hospital, which was the same for first generation compared to second generation antipsychotics. There was a 2.3-fold increase in antipsychotic prescriptions over the same period; first generation antipsychotics declined whereas there was a dramatic rise in second generation antipsychotics, mainly olanzapine, quetiapine and risperidone (79%).

CONCLUSION

Over 26 years there was an increase in antipsychotic prescribing associated with an increase in antipsychotic overdoses. Although the type of antipsychotics changed, the morbidity and mortality remained the same, so that antipsychotics are an increasing proportion of overdose admissions.

A Canadian Primary Care Sentinel Surveillance Network Study Evaluating Antidepressant Prescribing in Canada From 2006 to 2012

OBJECTIVE

To evaluate the prescribing patterns of antidepressants (ADs) by primary care providers to youth, adults, and seniors, from 2006 to 2012, using data from electronic medical records (EMRs).

METHOD

This was a retrospective cross-sectional database study that used primary care data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). Data on more than 600 000 Canadian primary care patients were used to determine the prevalence and incidence of AD prescribing to patients 15 years and older who had an encounter in the years of study (from 2006 to 2012). Each study year was evaluated independently.

RESULTS

The study population consisted of 86 927 patients in 2006 (mean age 48.1 years [SD 18.7], 38% male) and grew to 273 529 (mean age 49.6 years [SD 19.3], 40% male) in 2012. The prevalence of AD prescribing increased from 9.20% in 2006 to 12.80% in 2012 (P < 0.001). While the incidence rate of AD prescribing dropped from 3.54% in 2006 to 2.72% in 2008 (P < 0.001) the rate started to significantly rise again, reaching an incidence of 3.07% by 2012 (P < 0.001).

CONCLUSIONS

The prevalence of AD prescribing by primary care providers in Canada continued to rise from 2006 to 2012. Conversely, incidence has remained stable or declined during the 6-year study period. While many complex factors likely contribute to the observed prevalence and incidence rates, our findings suggest that the guidelines indicating the efficacy of long-term AD therapy for patients with highly recurrent or severe depression are being followed.

Prevalence and predictors of psychotropic medication use: results from the Northern Ireland Study of Health and Stress

BACKGROUND

To identify the predictors of psychotropic medication use and to determine rates and patterns of use in Northern Ireland (NI) among the general population and various subgroups.

METHOD

Analysis of data from the NI Study of Health and Stress, a representative household survey undertaken between 2004 and 2008 with 4340 individuals. Respondents were asked about prescribed psychotropic medication use in the previous 12 months along with a series of demographic questions and items regarding experience of traumatic life events. Mental health disorders were assessed using the World Health Organization's Composite International Diagnostic Interview.

RESULTS

Females, individuals aged 50-64 years old, those who were previously married, and those who had experienced a traumatic lifetime event were more likely to have taken any psychotropic medication. Use of any psychotropic medication in the population in the previous 12 months was 14.9%. Use among individuals who met the criteria for a 12-month mental health disorder was 38.5%. Almost one in ten individuals (9.4%) had taken an antidepressant.

CONCLUSIONS

Compared with other countries, NI has high proportions of individuals using psychotropic medication in both the general population and those who met the criteria for a 12-month mental disorder. However, these results still suggest possible under treatment of mental disorders in the country. In addition, rates of use in those with no disorder are relatively high. The predictors of medication use are similar to findings in other countries. Possible research and policy implications are discussed.

In fatal pursuit of immortal fame: Peer competition and early mortality of music composers

We investigate the impact of peer competition on longevity using a unique historical data set of 144 prominent music composers born in the 19th century. We approximate for peer competition measuring (a) the number or (b) the share of composers located in the same area and time, (c) the time spent in one of the main cities for classical music, and (d) the quality of fellow composers. These measures suggest that composers' longevity is reduced, if they located in agglomerations with a larger group of peers or of a higher quality. The point estimates imply that, all else equal, a one percent increase in the number of composers reduces composer longevity by ∼ 7.2 weeks. Our analysis showed that the utilized concentration measures are stronger than the personal factors in determining longevity, indicating that individuals' backgrounds have minimal impact on mitigating the effect of experienced peer pressure. The negative externality of peer competition is experienced in all cities, fairly independent of their population size. Our results are reaffirmed using an instrumental variable approach and are consistent throughout a range of robustness tests. In addition to the widely known economic benefits associated with competition, these findings suggest that significant negative welfare externalities exist as well.

Religious perspectives on the use of psychopharmaceuticals as an enhancement technology

The use of psychopharmaceuticals as an enhancement technology has been the focus of attention in the bioethics literature. However, there has been little examination of the challenges that this practice creates for religious traditions that place importance on questions of being, authenticity, and identity. We asked expert commentators from six major world religions to consider the issues raised by psychopharmaceuticals as an enhancement technology. These commentaries reveal that in assessing the appropriate place of medical therapies, religious traditions, like secular perspectives, rely upon ideas about health and disease and about normal human behavior. But unlike secular perspectives, faith traditions explicitly concern themselves with ways in which medicine should or should not be used to live a "good life".

Implementing guidelines for depression on antidepressant prescribing in general practice: a quasi-experimental evaluation

Background

Internationally, guidelines for depression recommend a stepped care approach, implying that antidepressant medication should not be offered as a first step treatment to patients with sub-threshold or mild depression. In the Netherlands, antidepressant prescribing rates in general practice as a first treatment step are considered to be high. The aim of this study was to evaluate the implementation of guideline recommendations on antidepressant prescribing.

Methods

A quasi-experimental study with a non-equivalent naturalistic control group and three years follow-up was performed in the general practice setting in the Netherlands. General Practitioners (GPs) participated in a national Quality Improvement Collaborative (QIC), focusing on the implementation of a guideline based model for a stepped care approach to depression. The model consisted of self-help and psychological treatment options for patients with milder symptoms as an alternative to antidepressants in general practice. Changes in antidepressant prescription rates of GPs were documented for a three-year period and compared to those in a control group of GPs, selected from an ongoing national registration network.

Results

A decrease of 23.3% (49.4%-26.1%) in antidepressant prescription rates for newly diagnosed patients with depressive symptoms was found within the intervention group, whereas no difference occurred in the reference group (50.3%-52.6%). The decrease over time was significant, compared to the usual care group (OR 0.44, 95% CI: 0.21-0.92).

Conclusions

An implementation program using stepped care principles for the allocation of depression interventions resulted in reduced antidepressant prescription rates in general practice. GPs can change prescribing behaviour within the context of a QIC.

Socioeconomic differences in antidepressant use in the PATH Through Life Study: evidence of health inequalities, prescribing bias, or an effective social safety net?

BACKGROUND

Depression is more common amongst those who are economically disadvantaged. However there is inconsistent evidence concerning the relationship between socioeconomic position and antidepressant use. Moreover, evidence of greater antidepressant use amongst those of lower socioeconomic position may reflect their greater psychiatric morbidity, a prescribing bias towards pharmacological treatments, or provide evidence of an effective social safety net. This study investigates these issues whilst addressing methodological limitations of earlier studies.

METHOD

Data were from a large, random community survey of Australian adults (N=4493) with linked administrative data for primary-care service use. Depression was measured using the Patient Health Questionnaire, with other measures of current mental health and history of depression included in analysis. Multiple personal indicators and a combined measure of social disadvantage were considered. A series of analyses systematically examined competing explanations for socioeconomic differences in depression and antidepressant treatment.

RESULTS

Markers of socioeconomic disadvantage were associated with a greater likelihood of antidepressant use. This finding was not attributable to the higher rates of depression amongst the disadvantaged. A similar pattern of results was evident for non-pharmaceutical treatments (primary care consultations). Socioeconomic position was not associated with use of complementary medications for depression, not covered by Australia's social safety net.

LIMITATIONS

Analysis did not consider specialist mental health services.

CONCLUSIONS

Socially disadvantaged respondents reported greater antidepressant use and service use after controlling for current depression symptoms. This pattern of findings suggests Australia's universal health-care system and social safety net may help address potential inequalities in health care.

Cognitive behavioural therapy as an adjunct to pharmacotherapy for primary care based patients with treatment resistant depression: results of the CoBalT randomised controlled trial

BACKGROUND

Only a third of patients with depression respond fully to antidepressant medication but little evidence exists regarding the best next-step treatment for those whose symptoms are treatment resistant. The CoBalT trial aimed to examine the effectiveness of cognitive behavioural therapy (CBT) as an adjunct to usual care (including pharmacotherapy) for primary care patients with treatment resistant depression compared with usual care alone.

METHODS

This two parallel-group multicentre randomised controlled trial recruited 469 patients aged 18-75 years with treatment resistant depression (on antidepressants for ≥6 weeks, Beck depression inventory [BDI] score ≥14 and international classification of diseases [ICD]-10 criteria for depression) from 73 UK general practices. Participants were randomised, with a computer generated code (stratified by centre and minimised according to baseline BDI score, whether the general practice had a counsellor, previous treatment with antidepressants, and duration of present episode of depression) to one of two groups: usual care or CBT in addition to usual care, and were followed up for 12 months. Because of the nature of the intervention it was not possible to mask participants, general practitioners, CBT therapists, or researchers to the treatment allocation. Analyses were by intention to treat. The primary outcome was response, defined as at least 50% reduction in depressive symptoms (BDI score) at 6 months compared with baseline. This trial is registered, ISRCTN38231611.

FINDINGS

Between Nov 4, 2008, and Sept 30, 2010, we assigned 235 patients to usual care, and 234 to CBT plus usual care. 422 participants (90%) were followed up at 6 months and 396 (84%) at 12 months, finishing on Oct 31, 2011. 95 participants (46%) in the intervention group met criteria for response at 6 months compared with 46 (22%) in the usual care group (odds ratio 3·26, 95% CI 2·10-5·06, p<0·001).

INTERPRETATION

Before this study, no evidence from large-scale randomised controlled trials was available for the effectiveness of augmentation of antidepressant medication with CBT as a next-step for patients whose depression has not responded to pharmacotherapy. Our study has provided robust evidence that CBT as an adjunct to usual care that includes antidepressants is an effective treatment, reducing depressive symptoms in this population.

FUNDING

National Institute for Health Research Health Technology Assessment.

Pharmacological treatment of unipolar depression during pregnancy and breast-feeding--a clinical overview

BACKGROUND

This overview is aimed at clinicians working with patients in the fertile age who suffer from depressive disorders. The study of adverse effects of antidepressants on the foetus is hampered by difficulty in distinguishing between the behavioural changes that are related to the disorder itself and changes that accompany its treatment with antidepressants. The current lack of solid scientific knowledge and the implications, mainly emotional, of treating pregnant or breast-feeding women often raise anxiety and cause concern among patients and clinicians.

METHODS

Currently available data are evaluated and clinical recommendations given.

RESULTS AND CONCLUSIONS

Citalopram and sertraline can be used during pregnancy, while some controversy remains over in utero exposure to paroxetine and fluoxetine, which might be associated with an increased risk of foetal cardiovascular malformation. Less data is available concerning fluvoxamine and escitalopram use but current data does not indicate a specific risk. Citalopram, paroxetine and sertraline can be used during breast-feeding, while fluoxetine probably should be avoided. Nortriptyline, amitriptyline and clomipramine can be used during pregnancy and lactation, although data are more abundant for SSRI treatment. Venlafaxine can be used during pregnancy, while caution is advised during breast-feeding. Other antidepressants should be avoided because of lack of data on their effect. A strongly indicated lithium therapy should be continued. Close monitoring of lithium levels throughout pregnancy is mandatory, as is detailed foetal echocardiography in weeks 18-22 of gestation. Lithium should not be used during breast-feeding. Electroconvulsive therapy (ECT) is a valid option if indicated, both during pregnancy and breast-feeding.

Severity of depression and response to antidepressants: GENPOD randomised controlled trial

BACKGROUND

Antidepressant prescribing is widespread. Nonetheless, response to antidepressants is variable. If it was possible to predict response to medication and thus tailor treatment accordingly, this would not only improve patient outcomes but may also have economic benefits.

AIMS

To test the hypothesis that individuals with more severe depression would benefit more from noradrenaline reuptake inhibitors (NARIs) than selective serotonin reuptake inhibitors (SSRIs) compared with individuals with less severe depression.

METHOD

Individuals recruited from UK primary care who met ICD-10 criteria for a depressive episode and scored 15 or more on the Beck Depression Inventory (BDI) were randomised to either an SSRI (citalopram 20 mg daily) or a NARI (reboxetine 4 mg twice daily). Randomisation was by means of a remote automated telephone system. The main outcome was depressive symptoms measured by the BDI total score 6 weeks after randomisation. (

TRIAL REGISTRATION

ISRCTN31345163.)

RESULTS

In total, 601 participants were randomised (citalopram: n = 298, reboxetine: n = 303). Ninety-one per cent were followed up at 6 weeks (citalopram: n = 274, reboxetine: n = 272). There was little evidence to support an interaction between treatment and severity of depression (interaction term: 0.02, 95% CI -0.59 to 0.62, P = 0.96). Adjustment for potential confounders (age, gender, employment status, history of depression, number of life events and social support) did not affect the findings (interaction term: 0.06, 95% CI -0.54 to 0.66, P = 0.85).

CONCLUSIONS

Treatment with NARIs does not confer any advantage over SSRI treatment for outcome in those with more severe depressive illness presenting in primary care.

Antidepressants utilization among elderly in Lombardy from 2000 to 2007: dispensing trends and appropriateness

PURPOSE

To investigate the prevalence and incidence of antidepressant (AD) use in the elderly during an 8-year period and to evaluate AD treatment appropriateness.

METHODS

A population-based dispensation study on community-dwelling elderly of a large area in Lombardy was performed. Data were drawn from the regional administrative database and from a general practice registry. For each year, prevalence of AD use (i.e., at least one recorded dispensation) and AD treatment (i.e., at least four recorded dispensations) was compared.

RESULTS

The prevalence of AD use and treatment doubled and tripled, respectively. The greatest shift occurred between 2000 and 2002 and was entirely due to SSRIs. The most pronounced increase was seen in females who accounted for 72% of all dispensations. The increase in prevalence was not mirrored by incident use, which slightly decreased (OR: 0.98; 95% CI: 0.98-0.98). The proportion of those who received a minimally adequate AD treatment grew over the years (OR: 1.63; 95% CI: 1.59-1.68). The increase in prevalence of AD treatment was most pronounced among older age groups (ORs between 1.02 and 1.06 for age classes ≥75 years relative to the 65-69 age class; P < 0.001) and was proportional to that of depressive disorders.

CONCLUSIONS

A dramatic rise in dispensations was observed. The increasing prevalence of minimally adequately treated subjects and a possible decrease in untreated depression may reflect an improvement in the pharmacological treatment of depression. The increase in prevalence and not in the incidence of dispensations could be related to an inappropriate prolongation of treatment duration.

Antidepressant use and colorectal cancer risk: a Danish population-based case-control study

Background:

Earlier research suggests that use of selective serotonin reuptake inhibitors (SSRIs), but not tricyclic antidepressants (TCAs), reduces the risk of colorectal cancer (CRC).

Methods:

We conducted a population-based case–control study to investigate the association between antidepressant use and CRC risk. Cases were diagnosed with a first primary CRC from 1991 through 2008. We selected 10 population controls matched to cases on sex, birth year, and residence from the Danish Civil Registration System using risk-set sampling. We estimated the odds ratios (ORs) and 95% confidence intervals (CIs) associating antidepressant use with colorectal cancer occurrence, controlling for potential confounders.

Results:

The study included 9979 cases and 99 790 controls. We found no notable reduction in CRC risk in ever users (⩾2 prescriptions) of TCAs (OR=0.94; 95% CI: 0.84, 1.05), SSRIs (OR=0.97; 95% CI: 0.90, 1.05), or other antidepressants (OR=0.95; 95% CI: 0.83, 1.07). Associations for recent and former use of antidepressants were also near null. Intensity of antidepressant use (number of pills divided by total duration of use), regardless of duration, was not associated with CRC risk.

Conclusions:

We found no evidence that antidepressant use substantially reduces the risk of colorectal cancer.

Antidepressant use and depressive symptomatology among older people from the Australian Longitudinal Study of Ageing

BACKGROUND

Depression is one of the leading contributors to the burden of non-fatal diseases in Australia. Although there is an overall increasing trend in antidepressant use, the relationship between use of antidepressants and depressive symptomatology is not clear, particularly in the older population.

METHODS

Data for this study were obtained from the Australian Longitudinal Study of Ageing (ALSA), a cohort of 2087 people aged over 65 years at baseline. Four waves of home interviews were conducted between 1992 and 2004 to collect information on sociodemographic and health status. Depressive symptoms were measured by the Center for Epidemiologic Studies - Depression Scale. Use of antidepressants was based on self-report, with the interviewer able to check packaging details if available. Longitudinal analysis was performed using logistic generalized estimating equations to detect if there was any trend in the use of antidepressants, adjusting for potential confounding factors.

RESULTS

The prevalence of depressive symptoms was 15.2% in 1992 and 15.8% in 2004 (p > 0.05). The prevalence of antidepressant users increased from 6.5% to 10.9% (p < 0.01) over this period. Among people with depressive symptoms, less than 20% were taking antidepressants at any wave. Among people without depressive symptoms, the prevalence of antidepressant use was 5.2% in 1992 and 12.0% in 2004 (p < 0.01). Being female (OR = 1.67, 95%CI: 1.25-2.24), having poor self-perceived health status (OR = 1.17, 95%CI: 1.04-1.32), having physical impairment (OR = 1.48, 95%CI: 1.14-1.91) and having depressive symptoms (OR = 1.62, 95%CI: 1.24-2.13) significantly increased the use of antidepressants, while living in community (OR = 0.51, 95%CI: 0.37-0.71) reduced the risk of antidepressant use.

CONCLUSIONS

Use of antidepressants increased, while depressive symptoms remained stable, in the ALSA over a 12-year period. Use of antidepressants was low for people with depressive symptoms.

Antidepressant dispensing trends in New Zealand between 2004 and 2007

OBJECTIVE

The aim of the present study was to explore antidepressant dispensing trends in New Zealand over a 3 year period (2004-2007) with a focus on trends by age, gender, ethnicity, District Health Board and type of antidepressant.

METHOD

Prevalence of antidepressant agents dispensed in the years ending June 2004-2005, 2005-2006 and 2006-2007 was calculated separately for the population aged 15-24, 24-44, 45-64 and 65-100 years, (> =65) by gender. The f rst occurrence of antidepressant dispensing for each individual in each year was extracted to calculate age-specific antidepressant dispensing rates standardized to the 2006 Census population for the New Zealand European/Other (NZEO) ethnic group.

RESULTS

The 12 month prevalence of antidepressant dispensing among the total population aged 15-100 years increased from 7.36% in 2004-2005 to 8.21% in 2005-2006 and to 9.39% in 2006-2007 Selective serotonin re-uptake inhibitor (SSRI) and tricyclic antidepressants (TCA) accounted for >90% of all antidepressants dispensed each year. SSRIs were more frequently prescribed to young adults (15-24 years) than TCAs, although this relation changed with increasing age. In women aged > =65, TCAs were more commonly dispensed than SSRIs, while among men in the same age group, dispensing patterns were similar for both agents. Age-specific dispensing rates were higher among female than male subjects, and the NZEO combined populations were dispensed significantly more antidepressant agents than Māori or Pacific peoples. Considerable regional variations in antidepressant dispensing were found by ethnicity and gender.

CONCLUSION

There are considerable variations in antidepressant dispensing in NZ, and the rate of dispensing has increased over the 3 years of the present study. Further work is required to investigate the different rates of antidepressant dispensing found between ethnic groups. Depression is strongly associated with suicide and the trend of increased dispensing of antidepressants found in the present study should continue to have a positive effect on suicide rates in NZ.

Explaining the rise in antidepressant prescribing: a descriptive study using the general practice research database

OBJECTIVE

To explore the reasons behind the recent increase in antidepressant prescribing in the United Kingdom. Design Detailed retrospective analysis of data on general practitioner consultations and antidepressant prescribing. Data source Data were obtained from the general practice research database, which contains linked anonymised records of over 3 million patients registered in the UK. Data were extracted for all new incident cases of depression between 1993 and 2005. Review methods Detailed analysis of general practitioner consultations and antidepressant prescribing was restricted to 170 practices that were contributing data for the full duration of the study.

RESULTS

In total, 189 851 people within the general practice research database experienced their first episode of depression between 1993 and 2005, of whom 150,825 (79.4%) received a prescription for antidepressants in the first year of diagnosis. This proportion remained stable across all the years examined. The incidence of new cases of depression rose in young women but fell slightly in other groups such that overall incidence increased then declined slightly (men: 7.83 cases per 1000 patient years in 1993 to 5.97 in 2005, women: 15.83 cases per 1000 patient years in 1993 to 10.06 in 2005). Antidepressant prescribing nearly doubled during the study period-the average number of prescriptions issued per patient increased from 2.8 in 1993 to 5.6 in 2004. The majority of antidepressant prescriptions were given as long term treatment or as intermittent treatment to patients with multiple episodes of depression.

CONCLUSIONS

The rise in antidepressant prescribing is mainly explained by small changes in the proportion of patients receiving long term treatment. Previous clinical guidelines have focused on antidepressant initiation and appropriate targeting of antidepressants. To address the costly rise in antidepressant prescribing, future research and guidance needs to concentrate on appropriate long term prescribing for depression and regular review of medication.

Rapid HPLC method for the simultaneous monitoring of duloxetine, venlaflaxine, fluoxetine and paroxetine in biofluids

A simple and rapid HPLC method is developed for the determination of two serotonin–norepinephrine-reuptake inhibitors (duloxetine and venlaflaxine) and two selective serotonin-reuptake inhibitors (fluoxetine and paroxetine) in human biofluids. Separation was performed on an Inertsil ODS-3 column (250 x 4.0 mm, 5 µm) with acetonitrile–ammonium acetate (0.05 M, 41:59 v/v) at 235 nm, within 7 min. SPE on Oasis® HLB cartridges was applied for the isolation of analytes from biofluids. The developed methodology was validated in terms of sensitivity, linearity, accuracy, precision, stability and selectivity. Relative standard deviation was less than 10.4%. Limit of detection was 0.2–0.6 ng/µl in blood plasma and 0.1–0.8 ng/µl in urine. The method was successfully applied to biofluids from a patient under duloxetine treatment.

Depression and occupational disability in five diagnostic groups: A review of recent research

PURPOSE

To compare the methodologies and results of research across five diagnostic groups in which there was expected to be a high prevalence of depression and occupational disability.

METHOD

A review of research published since 1994 was carried out concerning depression and occupational disability in five diagnostic groups: Major depressive disorder (MDD), spinal cord injuries (SCI), traumatic brain injuries (TBI), chronic back pain (CP) and myocardial infarction/coronary artery bypass grafting (MI/CABG).

RESULTS

Prospective longitudinal designs were mostly undertaken in MDD studies. Diagnostic interview schedules were utilized in most MDD studies whereas self-report inventories that tend to confound somatic and depressive symptoms were mostly used in CP, SCI, TBI and MI/CABG studies. In longitudinal MDD studies both depression and occupational disability were related to access to enhanced primary care treatment. On the other hand, CP research reported different results concerning the strength of depressive symptoms, cognitive and psychosocial factors in predicting occupational disability. Different trends across diagnostic groups were evident in relation to depression, occupational disability, co-morbidity, socio-demographic factors and psychosocial resources.

CONCLUSIONS

Co-morbid, socio-demographic and psychosocial factors provide a framework from which to identify those at greater risk of depression and occupational disability. However, more CP, SCI, TBI and MI/CABG studies with diagnostic schedules, prospective designs and longer follow-up are required.

Modern bioanalytical methods for the rapid detection of antidepressants: SNRIs and SSRIs in human biological samples

Serotonin–norepinephrine-reuptake inhibitors (SNRIs) and selective serotonin-reuptake inhibitors (SSRIs) belong to a new generation of antidepressants used in the treatment of depression and other mood disorders. SSRIs act as reuptake inhibitors primarily via the inhibition of the neuronal reuptake of serotonin (5-HT) in the CNS. SNRIs have additional inhibitory activity at noradrenaline-reuptake sites. Different analytical methods for the routine monitoring and toxicological screening of SNRIs and SSRIs have been developed. Rapid quantification is a necessity for clinical use, allowing the possibility of diagnostics. This review focuses on recent advances of the methods that concern the determination of SSRIs and SNRIs in human biological samples. Sample preparation methodologies are discussed, because sample pretreatment is the most limiting and crucial step in analysis of biological matrices. Furthermore, information concerning the mechanism of action, side effects and toxicity are also given.

Anti-depressants and suicide

Suicide takes the lives of around a million people each year, most of whom suffer from depression. In recent years there has been growing controversy about whether one of the best-selling anti-depressants - selective serotonin reuptake inhibitors (SSRIs) - increases or decreases the risk of completed suicide. Randomized clinical trials are not informative in this application because of small samples and other problems. We present what we believe are the most scientifically credible estimates to date on how SSRI sales affect suicide mortality using data from 26 countries for up to 25 years. We exploit just the variation in SSRI sales that can be explained by institutional differences in how drugs are regulated, priced, and distributed, as reflected by the sales growth of new drugs more generally. We find an increase in SSRI sales of 1 pill per capita (12% of 2000 sales levels) reduces suicide by 5%.

Methodology and challenges to recruitment to a randomized, double-blind, placebo-controlled trial of oral DHEA in postmenopausal women

OBJECTIVE

To report on the issues encountered in the recruitment of healthy naturally menopausal women in the community to a randomized placebo-controlled trial of dehydroepiandrosterone (DHEA) therapy for treatment of loss of sexual desire.

METHODS

Recruitment of women was achieved by advertising and media publicity. We have reported on the method by which women initially contacted us and the reasons for nonparticipation.

RESULTS

Nine hundred and eighteen women contacted us about participating in the study; 706 of these were telephoned screened, and 93 of these (10%) women were randomized to therapy. The main determinants for nonparticipation included ineligibility on phone screening (58%), withdrawal of interest either before or after screening (55%), and preexisting pathology after attending for screening (8%).

CONCLUSIONS

Despite ongoing interest by women to participate in research for therapies to treat low libido, concerns about the use of any hormonal treatment and the time poverty experienced by many women at midlife present new barriers to recruitment and need to be considered in assessing the feasibility of studies in this field.

Trends in antidepressant prescriptions among the elderly in Alberta during 1997 to 2004

OBJECTIVE

To analyze trends in antidepressant (AD) prescription rates among the elderly (aged 65 years and older) in Alberta during 1997 to 2004.

METHOD

Numerical data on AD prescriptions were obtained from Alberta Blue Cross. Age-standardized prescription rates were calculated according to type of AD.

RESULTS

The prescription rate for all ADs combined increased by 59% for men and 55% for women. This change was due entirely to serotonin reuptake inhibitors (SSRIs) and other recently-introduced ADs, that by 2004 accounted for 72% of AD prescriptions for men and 69% for women. For each year and type of AD, the prescription rate for women was almost double that for men.

CONCLUSIONS

In the elderly in Alberta, prescription rates for ADs increased markedly during 1997 to 2004, especially for SSRIs and other recently introduced ADs.

Physiological endpoints for potential SSRI interactions in fish

Selective serotonin reuptake inhibitors (SSRIs) are among the pharmaceutical compounds frequently detected in sewage treatment plant effluents and surface waters, albeit at very low concentrations, and have therefore become a focus of interest as environmental pollutants. These neuroactive drugs are primarily used in the treatment of depression but have also found broader use as medication for other neurological dysfunctions, consequently resulting in a steady increase of prescriptions worldwide. SSRIs, via inhibition of the serotonin (5-hydroxytryptamine, 5-HT) reuptake mechanism, induce an increase in extracellular 5-HT concentration within the central nervous system of mammals. The phylogenetically ancient and highly conserved neurotransmitter and neurohormone 5-HT has been found in invertebrates and vertebrates, although its specific physiological role and mode of action is unknown for many species. Consequently, it is difficult to assess the impact of chronic SSRI exposure in the environment, especially in the aquatic ecosystem. In view of this, the current knowledge of the functions of 5-HT in fish physiology is reviewed and, via comparison to the physiological role and function of 5-HT in mammals, a characterization of the potential impact of chronic SSRI exposure on fish is provided. Moreover, the insight on the physiological function of 5-HT strongly suggests that the experimental approaches currently used are inadequate if not entirely improper for routine environmental risk assessment of pharmaceuticals (e.g., SSRIs), as relevant endpoints are not assessed or impossible to determine.

Antidepressant drugs and memory: insights from animal studies

This is a selective review of the literature concerning the effects of antidepressant drugs on animal memory, which was performed with the aid of the PubMed database. Monoamine oxidase inhibitors tend to either have no effect on memory or result in its improvement. Studies with cyclic antidepressants have reported no effect or, more often, memory impairments. Pre-training administration of selective serotonin reuptake inhibitors (SSRIs) has been shown to have either no effect on memory or undermine it (with some isolated exceptions, in which improvements have been recorded), while post-training administration of SSRIs has been demonstrated to improve memory or have no effect. A small group formed by the remaining antidepressants has been shown to improve memory, with the exception of trazodone, which impairs memory. These findings are discussed in the light of knowledge regarding the actions of antidepressants on several neurotransmission systems. The possibility that the effects of antidepressants on memory are the core of the therapeutic effects of these drugs is also considered.

Developing the role of pharmacists as members of community mental health teams: perspectives of pharmacists and mental health professionals

BACKGROUND

People living with bipolar mood disorder and psychotic illnesses in Australia primarily access public-sector mental health care through community mental health teams (CMHTs). Adverse drug events are common among clients of CMHTs taking psychotropic medications.

OBJECTIVE

The study aimed to investigate and describe a potential role for pharmacists as members of CMHTs.

METHODS

Five study pharmacists were employed 1 day per week to work with 5 mental health teams over a 24-week period. The pharmacists conducted both client and team specific activities designed to optimize the use of medications. The pharmacists recorded their professional activities in diaries. Audiotaped focus groups were conducted with the pharmacists (n=1) and mental health team staff (n=3) at the conclusion of the study. Pharmacists' diaries and the transcripts of focus groups were thematically content analyzed.

RESULTS

Study pharmacists were perceived as valuable sources of unbiased and evidence-based drug information for both mental health team staff and their clients and caregivers. Mental health team staff particularly appreciated the provision of information about nonpsychotropic medications. Pharmacists' participation in clinical team meetings was used as an opportunity to present medication review findings and recommendations. Liaising between medication prescribers and dispensers working in primary and secondary care settings was deemed an important additional role; however, participating only 1 day per week was considered to delay rapport building and the establishment of collaborative working relationships with mental health team staff.

CONCLUSIONS

Including pharmacists as members of CMHTs addressed an unmet need for pharmaceutical services among clients and staff of CMHTs. Pharmacists' contributions were welcomed by mental health team staff. The study raised the issue of whether pharmacists should be considered as essential and legitimate members of interdisciplinary CMHTs.

Serotonin toxicity: a practical approach to diagnosis and treatment

Excess serotonin in the central nervous system leads to a condition commonly referred to as the serotonin syndrome, but better described as a spectrum of toxicity - serotonin toxicity. Serotonin toxicity is characterised by neuromuscular excitation (clonus, hyperreflexia, myoclonus, rigidity), autonomic stimulation (hyperthermia, tachycardia, diaphoresis, tremor, flushing) and changed mental state (anxiety, agitation, confusion). Serotonin toxicity can be: mild (serotonergic features that may or may not concern the patient); moderate (toxicity which causes significant distress and deserves treatment, but is not life-threatening); or severe (a medical emergency characterised by rapid onset of severe hyperthermia, muscle rigidity and multiple organ failure). Diagnosis of serotonin toxicity is often made on the basis of the presence of at least three of Sternbach's 10 clinical features. However, these features have very low specificity. The Hunter Serotonin Toxicity Criteria use a smaller, more specific set of clinical features for diagnosis, including clonus, which has been found to be more specific to serotonin toxicity. There are several drug mechanisms that cause excess serotonin, but severe serotonin toxicity only occurs with combinations of drugs acting at different sites, most commonly including a monoamine oxidase inhibitor and a serotonin reuptake inhibitor. Less severe toxicity occurs with other combinations, overdoses and even single-drug therapy in susceptible individuals. Treatment should focus on cessation of the serotonergic medication and supportive care. Some antiserotonergic agents have been used in clinical practice, but the preferred agent, dose and indications are not well defined.

Reasons for antidepressant prescriptions in Canada

PURPOSE

To describe reasons reported by physicians making recommendations for treatment with antidepressant medications.

METHODS

Data collected by IMS Health Canada in a database called the Canadian Disease and Therapeutic Index (CDTI) were used in this analysis. CDTI data are collected from a representative sample of office-based physicians who complete diaries in their practices during selected sampling periods. A drug recommendation is recorded each time a treatment is recommended. The data are weighted to produce national estimates of the frequency of such recommendations.

RESULTS

The frequency of recommendations for antidepressant treatment increased between 2000 and 2004. However, there was a slight decrease in 2005. Two types of antidepressant medications, tricyclic antidepressants (TCAs) and trazodone showed distinct patterns of use. TCAs were more commonly used for non-psychiatric indications than for psychiatric indications, especially for sleep- and pain-related reasons. Trazodone was frequently recommended for sleep problems. The proportion of recommendations for depressive disorders for antidepressants as a group remained stable over the 5-year study period.

CONCLUSIONS

About one-third of antidepressant recommendations are for reasons other than depression. It can no longer be assumed that the frequency of antidepressant use is a measure of the frequency of pharmacological depression treatment. However, prescription data may be useful for tracking trends.

Qualitative review of serotonin syndrome, ecstasy (MDMA) and the use of other serotonergic substances: hierarchy of risk

Growth of the antidepressant market and widespread use of the illicit drug ecstasy (methylenedioxymethamphetamine; MDMA) creates a need to delineate the potential harms associated with the concomitant use of ecstasy and serotonergic pharmaceutical drugs. One such harm is serotonin syndrome. The study aimed to synthesize the risk of serotonin syndrome associated with the concomitant use of ecstasy and other serotonergic substances in a clinically relevant hierarchy for psychiatrists and other medical practitioners. An extensive online database search was carried out of the literature on serotonin syndrome, in relation to illicit drugs and simultaneous use of other substances. Numerous licit and illicit substances implicated in serotonin syndrome, when used with ecstasy, have potential for increased toxicity and are presented in a resulting hierarchy of risk. Substances that inhibit serotonin re-uptake are less likely to lead to life-threatening elevations in serotonin when used with ecstasy. High doses or repeated use of stimulants such as methamphetamine and cocaine with ecstasy increase the risk of serotonin syndrome; as does the use of pharmaceutical amphetamine and ecstasy. Serotonin precursors also influence the course of serotonin syndrome when used with ecstasy. Substances that inhibit monoamine oxidase are most likely to lead to serious increases in serotonin when used with ecstasy. Findings highlight the importance of screening for the use of ecstasy and other serotonergic substances when prescribing antidepressant drugs.

Association of suicide and antidepressant prescription rates in Japan, 1999-2003

OBJECTIVE

We examined the relationship of increasing prescription volume of newer antidepressants, introduced in Japan in 1999, to national rates of suicide.

METHOD

The relationship between annual changes in rates of suicide (obtained from the Japanese Ministry of Health, Labor, and Welfare Vital Statistics Database) and prescription volume of the newer antidepressants paroxetine, fluvoxamine, and milnacipran (obtained from the database of IMS Japan K.K.), stratified by gender and age groups, was modeled statistically for the years 1999 through 2003. Effects of unemployment and alcohol consumption and the interaction of gender and age with antidepressant prescribing were assessed.

RESULTS

From 1999 through 2003 in Japan, total antidepressant prescriptions increased 57% among males and 50% among females. Approximately 80% of this increase involved the selective serotonin reuptake inhibitors (SSRIs). To reduce a limitation of ecological analysis, we compared annual change in prescription and suicide rates, which eliminates the effect of long-term (secular) linear trends. We found an inverse association between year-to-year changes in the suicide rate and prescription volume of newer antidepressants (fluvoxamine, paroxetine, and milnacipran) (beta = -1.34, p = .008) and SSRIs specifically (fluvoxamine, paroxetine) (beta = -1.41, p = .019). An increase of 1 defined daily dose of SSRI use/1000 population/day was associated with a 6% decrease in suicide rate. Exploratory analysis suggested a stronger association in males, who experienced a greater increase in antidepressant use. Changes in unemployment and alcohol consumption rates did not explain the association.

CONCLUSION

In Japan during 1999 through 2003, absent long-term linear trend effects, annual increases in prescribing of newer antidepressant medications, mainly SSRIs, were associated with annual decreases in suicide rates, particularly among males.

Agency and dependency within treatment: Drug treatment clients negotiating methadone and antidepressants

This paper explores how drug treatment clients exercise agency while finding their ability to act curtailed by the strictures of treatment itself. Drawing on qualitative interviews with 77 male and female drug treatment clients collected in an Australian study of drug treatment and mental health, the experience of methadone maintenance treatment (MMT) and that of commonly prescribed medications for depression (antidepressants) are examined. The ways that clients engage with MMT and antidepressants are detailed, illustrating how both types of treatment can make clients feel dependent, but can also motivate clients to modify their treatment regimens. These modifications are "tactical" responses generated within the constraints of treatment regulations and can also be against clinical recommendations e.g. stopping treatment. Rather than seeing this as "non-compliance", it is suggested that the negotiation of treatment is an inevitable response of clients trying to adapt to imperfect treatment conditions, who may have understandable anxieties about taking medication. The ways in which treatment providers might better acknowledge the capacities of MMT clients to engage with or modify treatment are discussed, as is the need to acknowledge drug treatment clients' anxieties about dependency and pharmaceutical drugs.

Measurement of changes in antihypertensive drug utilisation following primary care educational interventions

PURPOSE

To measure changes in drug utilisation following a national general practice education program aimed at improving prescribing for hypertension.

METHODS

A series of nationally implemented, multifaceted educational interventions using social marketing principles focusing on prescribing for hypertension, was commenced in October 1999, and repeated in September 2001 and August 2003. The target group was all primary care prescribers in Australia and interventions were both active (voluntary) and passive. Newsletter and prescribing feedback was mailed in October 1999, September 2001 (newsletter only) and August 2003. Approximately a third of general practitioners (GPs) in Australia undertook at least one active educational activity (clinical audit, educational visit or case study) during the period October 1999-April 2004. National dispensing data from 1996 to 2004 were analysed using time series methodology with a decay term for intervention effect, to assess trends in prescribing of various classes of antihypertensives. In particular, the program aimed to increase the prescribing of thiazide diuretics and beta blockers.

RESULTS

Consistent with key intervention messages, the program achieved an increase in low-dose thiazide and beta blocker prescribing. The rate of prescribing of low-dose thiazides doubled from 1.1 per 1000 consultations in October 1999 to 2.4 per 1000 in October 2003. Beta-blocker utilisation showed a more modest but significant increase over the time of the study, with the change in observed versus expected rate of prescribing increasing by 8% by April 2004. Therapeutic options for treating hypertension changed markedly in the time of the study with the advent of ACE inhibitor/Angiotensin II receptor antagonists and thiazide combination products. It is important, therefore, to interpret the results in light of these changes.

CONCLUSION

A national education program aimed at GPs was successful in improving prescribing for hypertension. Lessons learned will be applied in evaluation of future NPS programs and are also applicable to analysis of other interventions aimed at influencing prescribing behaviour.