Antidepressant Treatment Episode Research Articles

Concomitant medication use and its implications on the hazard pattern in pharmacoepidemiological studies: example of antidepressants, benzodiazepines and fracture risk

Background: Antidepressants and benzodiazepines are often co-prescribed and both associated with an increased fracture risk, albeit with distinctive hazard patterns. Timing of initiation of one with respect to the other and duration of use may influence the combined fracture hazard.
 The objective of our study was to describe patterns of concomitant use of benzodiazepine and antidepressants in terms of timing of initiation and duration and to illustrate the potential impact of various scenarios of timing of co-use on hip fracture hazard.
 Methods: Patients initiating antidepressant therapy (2002-2009) were identified from the Netherlands Primary Care Research Database. Concomitant benzodiazepine use was assessed according to the start time of benzodiazepine with respect to antidepressant therapy start. Duration of concomitant use was estimated relative to the length of antidepressant treatment episode. 
 Results: Among 16,087 incident antidepressant users, 39.0% used benzodiazepines concomitantly during their first antidepressant treatment episode. The time of initiation of benzodiazepine use was variable (64.4% starting before, 13.7% simultaneous and 21.9% after antidepressants). Duration of concomitant use in the three groups varied. 
 Conclusions: Co-prescribed medications with a common adverse event, may not only require accounting for concomitant use, but also the timing of start and duration of use as the overall hazard may vary accordingly.

Does Patient Adherence to Antidepressant Medication Actually Vary Between Physicians?

Previous research and improvement efforts have presumed that patients' nonadherence to antidepressant medication reflects physicians' quality of care. We used population-based health records to examine whether adherence to antidepressant medication actually varies between prescribing physicians. Electronic health records and insurance claims data from 5 integrated health systems in Washington, Idaho, Minnesota, Colorado, Hawaii, and California were used to identify 150,318 adults starting new episodes of antidepressant treatment for depression between January 1, 2010, and December 31, 2012. Early adherence was defined as any refill or dispensing of antidepressant medication in the 180 days following an initial antidepressant prescription. Patient-level demographic and clinical characteristics potentially associated with adherence were identified from health system records. Average probability of early adherence was 82% for psychiatrists and 74% for primary care physicians. Among individual physicians, the range of raw or unadjusted early adherence rates (5th to 95th percentiles) was from 33% to 100% for psychiatrists and from 0% to 100% for primary care physicians. After accounting for sampling variation and case mix differences, the range of adjusted early adherence rates (5th to 95th percentiles) was from 72% to 78% for psychiatrists and from 64% to 69% for primary care physicians. After accounting for sampling variation and case mix differences, early adherence to antidepressant medication varies minimally among prescribing physicians. Early discontinuation of antidepressant treatment is not an appropriate measure of individual physician performance, and efforts to improve adherence should emphasize system-level interventions rather than the performance of individual physicians.

Antidepressant Use by Youth with Minimal or Mild Depression: Evidence from 3 Health Systems.

Background:There is concern about the prevalence of prescribing antidepressant medications to youth without appropriate diagnoses or who have subthreshold (mild) depression.Methods:Electronic records data from 3 large healthcare systems identified youth aged ≤21 years starting a new episode of antidepressant treatment between January 1, 2009, and December 31, 2013. For those with a diagnosis of depression, Patient Health Questionnaire (PHQ9) scores at the time of treatment initiation were used to examine the distribution of symptom severity and patients' demographic and clinical characteristics.Results:Of the 15,460 episodes of treatment, a depression diagnosis was recorded in 95% of the cases. PHQ9 scores were available for 4,329 youth with a diagnosis of depression. Younger age, sex, previous treatment, co-occurring anxiety, treatment setting, concurrent psychotherapy, and site were significant predictors of completing a PHQ9. Among youth with a baseline score, 87% reported moderate or severe symptoms (PHQ9 score ≥ 10) and 13% reported mild or minimal symptoms (PHQ9 < 10). The proportion reporting PHQ9 < 10 when starting treatment decreased with age, ranging from 19% in those aged 13–14 years and 12% in those aged 18–21 years. Patients treated by psychiatrists were 1.54 times (95% Confidence Interval [CI], 1.21–1.97) more likely to have PHQ9 scores < 10 compared with primary care physicians. Patients with prior treatment history (odds ratio = 1.76; 95% CI, 1.45–2.13) and concurrent psychotherapy (odds ratio = 1.24; 95% CI, 1.02–1.52) were more likely to have PHQ9 < 10.Conclusions:In these health systems, prescribing of antidepressant medication to adolescents for minimal or mild depression is much less common than previous reported.

Long-Term Weight Change after Initiating Second-Generation Antidepressants.

(1) Objective: To examine the relationship between the choice of second-generation antidepressant drug treatment and long-term weight change; (2) Methods: We conducted a retrospective cohort study to investigate the relationship between choice of antidepressant medication and weight change at two years among adult patients with a new antidepressant treatment episode between January, 2006 and October, 2009 in a large health system in Washington State. Medication use, encounters, diagnoses, height, and weight were collected from electronic databases. We modeled change in weight and BMI at two years after initiation of treatment using inverse probability weighted linear regression models that adjusted for potential confounders. Fluoxetine was the reference treatment; (3) Results: In intent-to-treat analyses, non-smokers who initiated bupropion treatment on average lost 7.1 lbs compared to fluoxetine users who were non-smokers (95% CI: −11.3, −2.8; p-value < 0.01); smokers who initiated bupropion treatment gained on average 2.2 lbs compared to fluoxetine users who were smokers (95% CI: −2.3, 6.8; p-value = 0.33). Changes in weight associated with all other antidepressant medications were not significantly different than fluoxetine, except for sertraline users, who gained an average of 5.9 lbs compared to fluoxetine users (95% CI: 0.8, 10.9; p-value = 0.02); (4) Conclusion: Antidepressant drug therapy is significantly associated with long-term weight change at two years. Bupropion may be considered as the first-line drug of choice for overweight and obese patients unless there are other existing contraindications.

Antidepressants are not overprescribed for mild depression.

To evaluate overprescribing of antidepressant medication for minimal or mild depression. Electronic records data from 4 large health care systems identified outpatients aged 18 years or older starting a new episode of antidepressant treatment in 2011 with an ICD-9 diagnosis of depressive disorder (296.2, 296.3, 311, or 300.4). Patient Health Questionnaire-9 (PHQ-9) depression severity scores at time of treatment initiation were used to examine the distribution of baseline severity and the association between baseline severity and patients' demographic and clinical characteristics. Of 19,751 adults beginning treatment in 2011, baseline PHQ-9 scores were available for 7,051. In those with a baseline score, 85% reported moderate or severe symptoms (PHQ-9 score of 10 or more), 12% reported mild symptoms (PHQ-9 score of 5 to 9), and 3% reported minimal symptoms (PHQ-9 score of less than 5). The proportion reporting minimal or mild symptoms when starting treatment increased with age, ranging from 11% in those under age 65 years to 26% in those aged 65 and older. The proportion with minimal or mild symptoms was also moderately higher among patients living in wealthier neighborhoods and those treated by psychiatrists. Nevertheless, across all subgroups defined by sex, race/ethnicity, prescriber specialty, and treatment history, the proportions with minimal or mild symptoms did not exceed 18%. Secondary analyses, including weighting and subgroup analyses, found no evidence that estimates of baseline severity were biased by missing PHQ-9 scores. In these health systems, prescribing of antidepressant medication for minimal or mild depression is much less common than suggested by previous reports. Given that this practice may sometimes be clinically appropriate, our findings indicate that overprescribing of antidepressants for mild depression is not a significant public health concern.

Timing of adjunctive therapy in the treatment of depression: a chart review.

The objective of this study was to examine the evolution of antidepressant switch and adjunctive therapy. This chart review was conducted at 6 primary psychiatric clinics or hospitals, in Tokyo, Japan. A chart review of longitudinal prescriptions was conducted regarding 633 outpatients with major depressive disorder for up to 2 years after their first visit. Patients who had already received antidepressants prior to the visit were excluded. 22.6% (N=143) of the patients completed or continued the outpatient treatment over the 2 years while 27 (4.3%), 23 (3.6%), and 439 (69.4%) patients discontinued it due to hospitalization, referral to another clinic, and loss to follow-up, respectively. A total of 597 episodes of antidepressant treatment were identified. Among them, 482 episodes (80.7%) were associated with the suggested dose ranges while antidepressant drugs were under-dosed in 19.3% (N=115) of the episodes. 50 patients (7.9%) received adjunctive therapy; it was employed after a median of only one antidepressant had been tried. Psychiatrists may be hasty in prescribing an adjunctive therapy in the treatment of depression.

Social Inequalities in Early Antidepressant Discontinuation

This study aimed to test for social disparities in early discontinuation of antidepressant treatment and to explore associations with type of drug and composition of prescriber's clientele. The cohort was 14,518 Marseille residents (ages 18-64 years) covered by the National Health Insurance Fund who had a new episode of antidepressant treatment (specifically, no prescription claim in the six months before the index claim) prescribed by a private general practitioner in 2008 or 2009. Factors associated with early discontinuation (prescription filled or refilled fewer than four times in the six months after the index claim) were analyzed with multilevel models that were adjusted for patient morbidity and number of consultations with private general practitioners and psychiatrists. Sensitivity analyses were conducted with different definitions of new treatment and early discontinuation. Low income, type of antidepressant (tricyclics versus selective serotonin reuptake inhibitors), and prescribers' clientele composition (specifically, a high proportion of socioeconomically disadvantaged patients) were independently associated with an increased risk of early antidepressant discontinuation. A significant interaction was found between low income and gender. Low-income patients were more likely than other patients to receive tricyclic antidepressants. These results add further evidence of inequalities in care for major depression and suggest that women are at greater disadvantage than men. Educational programs for general practitioners should focus on the risks of antidepressant discontinuation among disadvantaged patients. Enhancing therapeutic education of low-income patients may improve their treatment adherence.

Social inequalities in antidepressant treatment

PurposeWe studied the relation between individual and neighborhood socioeconomic characteristics and the probability of:– new long-duration antidepressant treatment;– early antidepressant discontinuation.MethodsWe followed two cohorts of inhabitants of Marseille (aged 18–64 years) covered by the National Health Insurance Fund (NHIF) for 2.5 years. In the first cohort (316,412 individuals in 2008), we studied new long-duration antidepressant treatments (≥ 4 antidepressants prescription claims within 6 months after the index claim, and none in the 6 months before). The second cohort was restricted to the 14,518 individuals with a new episode of antidepressant treatment prescribed by a private GP in 2008–2009 to study early treatment discontinuation: &lt; 4 antidepressant prescription claims in the 6 months following the index claim. We developed a deprivation index at the neighborhood level (census block) and used multivariate multilevel logistic models adjusted for consultations with GPs and psychiatrists. In the second cohort, analyses were further adjusted on GPs characteristics. resultsFirst cohort: the probability of new long-duration antidepressant treatments was negatively associated with both individual low income and neighborhood deprivation. Second cohort: low income, and prescribers’ clientele composition (high proportion of disadvantaged patients) were independently associated with an increased risk of early discontinuation. A significant interaction was found between low income and gender. ConclusionsOur results add further evidence supporting the existence of inequalities in antidepressant treatment at both the individual, GP and neighborhood levels, and that these inequalities occur principally during the processes of care. Inequalities in antidepressant continuation are more pronounced among women. Further research is warranted to improve our understanding of their mechanisms.

Economic impact of antidepressant treatment duration in naturalistic conditions

To assess the economic impact of the duration of antidepressant drug treatment in a real-life setting. A historical fixed cohort study included 27 917 patients aged 18 and over with a new antidepressant treatment registered in the national insurance database. The economic impact concerned healthcare expenditure in the first 3 months after treatment discontinuation. Generalized linear models were used to compare two groups of treatment duration: <6 months and 6 months and over. After adjustment for care costs before and during treatment episode, gender, age, chronic diseases, welfare and prescriber specialty, total healthcare costs (in log) [-0.06 (-0.14;0.01) P = 0.11] and psychiatric care costs (in square root) [-0.08 (-0.41;0.25) P = 0.6] were similar in both groups. Non-psychiatric care costs were significantly lower in the 'long treatment duration' group compared with the 'short treatment duration' group [-11.4 (-15.8; -7.0) P < 0.0001]. The decreases in total and non-psychiatric care costs over the antidepressant treatment episode were larger in the 'long treatment duration' group compared with the 'short treatment duration' group. With regard to healthcare costs and global health, antidepressant drug treatments of short duration appear less effective than treatment of recommended duration.

Changes in patients' beliefs about their antidepressant during the acute phase of depression treatment

PurposeTo test hypotheses regarding medication beliefs in relation to adherence, side effects, and response during the acute phase of an antidepressant treatment episode. MethodsParticipants were 163 patients with unipolar major depression participating in the acute phase of a multi-stage trial of medication and psychotherapy. Before starting citalopram, patients underwent measures of treatment beliefs and depression. They continued taking citalopram until either responding, discontinuing due to side effects, or failing to respond within 14 weeks. Assessments of adherence, side effects and depression were made at weeks 2, 4, 6, 9, 12 and 14 (as applicable) and at trial exit. Beliefs were reevaluated at exit. ResultsPerceived need for medication increased between baseline and exit (P=.01) while perceived medication harmfulness dropped between baseline and exit (P<.0001). Adherence was related to baseline perceived need (P=.022), and side effects were related to baseline perceived harmfulness (P=.002). Change in depressive symptoms was significantly related to both baseline perceived need (P=.039) and mean adherence (P=.036) but not baseline perceived harmfulness (P=.184) or side effects (P=.102). At exit, perceived need was unrelated to change in depression severity (P=.565), while perceived harmfulness was related to prior side effects (P<.0001). ConclusionPatients’ medication perceptions become more pro-adherence as treatment proceeds. Their perceptions of antidepressant necessity predict their subsequent medication adherence and response, while their perceptions about medication harmfulness show strong prospective associations with actual side effects. Clinicians ought to adjust their prescribing decisions accordingly. Interventions that target beliefs ought to capitalize upon the apparently bidirectional association between harm perceptions and actual side effects.

Is customization in antidepressant prescribing associated with acute-phase treatment adherence?

OBJECTIVES: The objective was to explore whether prescribing variation is associated with duration of antidepressant use during the acute phase of treatment. Improving quality of care and increasing the extent to which treatment is patient-centered and customized are interrelated goals. Prescribing variation may be considered a marker of customization, and could be associated with better antidepressant treatment adherence. METHODS: A cross-sectional secondary data analysis examining the association between providers' antidepressant prescribing variation and patient continuity of antidepressant treatment. The data source was two states' Medicaid claims for dual-eligible Medicaid/Medicare patients. The sample included 383 patients with new episodes of antidepressant treatment, representing 70 providers with at least four patients in the sample. We tested two alternate measures of prescribing concentration: 1) share of prescriber's initial antidepressant prescribing accounted for by the two most common regimens, and 2) Herfindahl index. The HEDIS performance measure of effective acute-phase treatment (at least 84 out of 114 days with antidepressant) was the dependent variable. KEY FINDINGS: In multivariate analyses, the concentration measure based on the top two regimens was significant and inversely related to duration adequacy (p <.05). The Herfindahl index measure showed a trend towards a similar inverse relationship (p<.10). CONCLUSIONS: The findings provide some support for the hypothesized relationship between prescribing variation and adequate antidepressant treatment duration during the acute phase of treatment. Future work with more detailed, clinical longitudinal data could extend this inquiry to better understand the causal mechanisms using a more direct measure of customized care.

Impact of Duration of Antidepressant Treatment on the Risk of Occurrence of a New Sequence of Antidepressant Treatment

Despite the recommendation that antidepressant treatment should be continued for several months to reduce the risk of relapse/recurrence of depression, early discontinuation is frequent in naturalistic conditions. The study was aimed at exploring the impact of early discontinuation of antidepressant treatment on the risk of antidepressant re-initiation. A follow-up study of persons (n=35,053) starting antidepressant treatment was performed using a representative sample of the French Social Security Insurance national database. The risk of re-initiation of antidepressant treatment was higher if the duration of the index episode of antidepressant treatment was ≥ 6 months [hazard ratio (HR)=2.35; 95% CI 2.25-2.45) or 2-5 months (HR=1.65; 95% CI 1.59-1.71) compared to ≤ 1 month. The other characteristics independently associated with re-initiation of treatment were older age, female gender, low income, serious chronic illness, index prescription by a specialist and co-prescription of other psychotropic drugs. The lower risk of re-initiation of antidepressant treatment in persons with shorter-than-recommended duration of antidepressant treatment might be explained by overprescription of antidepressants in persons with sub-threshold symptoms.

Transitions from General Practitioner to Psychiatrist Care (or vice versa) during a First Antidepressant Treatment Episode

The aim of this study was to investigate how frequently patients transit from general practitioner (GP) to psychiatrist care and vice versa during a first antidepressant episode and antidepressant treatment changes associated with those transitions. Antidepressant episodes were constructed for patients (> or =18 years) initiating SSRI use in 2000 (N=10 158). Transition in care within a first treatment episode was investigated. Changes in antidepressant treatment were compared between transiting and non-transiting patients. 6.0% of patients who initiate SSRI use in GP practice transited to psychiatrist care, whereas 39.1% of those initiating use in psychiatrist care transited to GP care. Patients transiting from GP to psychiatrist care were more likely to switch to other antidepressants (RR=6.16, 95% CI: 4.90, 7.75) or to other doses (RR=4.48, 95% CI: 3.76, 5.34) than non-transiting patients. No significant differences in antidepressant treatment were found for patients transiting from psychiatric to GP care. Approximately 9% of SSRI initiators transit in care. Transitions from GP to psychiatric care lead to antidepressant treatment changes and could potentially be used in observational studies as a disease severity indicator.

Construction of drug treatment episodes from drug-dispensing histories is influenced by the gap length

Objectives When constructing drug treatment episodes using drug-dispensing databases, duration and the number of prescriptions belonging to a single treatment episode need to be defined. We investigated how different methods used to construct antidepressant treatment episodes influence their median estimated length. Study Design and Setting A follow-up study among adult antidepressant drug users, identified from the Dutch PHARMO RLS, starting selective serotonin reuptake inhibitor (SSRI) use in 2001 was conducted. The influence of varying lengths of the prescription overlap and the gap between prescriptions (number of days or percentage of prescription duration) on the median antidepressant treatment episode length were investigated. Results Of the 16,053 SSRI starters, 65.1% were female and mean age was 45.7 (SD: 17.2) years. Median antidepressant treatment episode length doubled when the gap length was expanded from 0 to 10 days. For short gap lengths the episode interquartile range was 40% to 200% larger when overlap was accounted for and when percentage of prescription duration gap length was used. Conclusion Differences in median episode length exist between methods that account for or disregard prescription overlap. These differences are of importance for studies that focus on drug exposure-outcome relationships and could have consequences for epidemiological analysis.

Does the Length of the First Antidepressant Treatment Episode Influence Risk and Time to a Second Episode?

Antidepressant treatment in primary care is inconsistent with treatment recommendations, and many patients discontinue treatment within 6 months. How this affects treatment outcomes is unknown. The aim of this study was to assess how length of the first antidepressant episode influences risk and time to a second treatment episode within 5 years.The study population included 9423 adults (67% women; mean age, 47.3 years) who initiated selective serotonin reuptake inhibitor use in 1998 or 1999. Based on the length of the first antidepressant treatment episode, patients were divided into early discontinuers (<6 months), continuing users (6-12 months), and persistent users (>12 months). The Cox proportional hazards model was used to estimate risk ratios (RRs) for the association between the length of the first antidepressant treatment episode and time to reinitiating antidepressant treatment.Time to a second treatment episode did not differ significantly between continuing users and early discontinuers (RR, 0.99; 95% confidence interval, 0.92-1.07). Persistent users showed a higher risk of experiencing a second treatment episode than early discontinuers (RR, 1.23; 95% confidence interval, 1.15-1.32).In conclusion, the risk of experiencing a second antidepressant treatment episode did not differ for those who used antidepressants for 6 to 12 months and those who discontinued early. In general, there is limited information on how length of an antidepressant treatment episode influences the risk of reinitiating treatment of patients in primary care. More research is needed to investigate the effectiveness of antidepressant drug treatment patterns in preventing relapse or recurrence in primary care populations.

P01-123 Factors associated with premature discontinuation of antidepressant drug treatment in France

Objectives:As practice guidelines recommend to maintain antidepressant treatments for a long duration after improvement of symptoms in order to prevent relapse or recurrence, our objectives were to explore the duration of the antidepressant drug treatment in France and to characterise the antidepressant users with a short duration of treatment.Methods:An observational retrospective cohort study was conducted in the community-dwelling population 18 year-old and over through claims databases of the public health insurance. A random sample of 34.663 outpatients who initiated an antidepressant treatment between the 1st January 2005 and the 31st December 2006 were selected. The dependent variable was the duration of the first episode of antidepressant treatment, categorised a priori in short duration [1-6 months[ versus long duration [6 months and more] according to guidelines. Characteristics independently associated with the treatment duration were investigated using logistic regressions.Results:Nearly two thirds of the individuals were females. Most patients were not on welfare. Three quarters of them did not present with chronic conditions. The duration of the antidepressant treatment complied with the international recommendations for only one patient of six. Adequate treatment duration was associated with being a female, being older, not being on welfare, presenting with a chronic condition and a treatment introduction by a psychiatrist or a hospital practitioner.Conclusion:The recommendations concerning the duration of an antidepressant treatment are rarely respected in a real-life setting in France. Further analyses should be conducted to characterise the patterns of prescription according to antidepressant classes and associated treatments.

Do Antidepressants Increase Suicide Risk?

Source: Simon G, Savarino J, Operskalski B, et al. Suicide risk during antidepressant treatment. Am J Psychiatry. 2006;163:41–47.Researchers from the Group Health Cooperative Center for Health Studies in Seattle, Wash, and Harvard Medical School in Boston, Mass, sought to determine the relationship between antidepressant use and suicidal behaviors using data from a mixed-model prepaid health plan serving approximately 500,000 members in Washington and Idaho. An episode of antidepressant use was defined as an outpatient antidepressant prescription filled by a member with a diagnosis of unipolar major depressive disorder, dysthymia, or depressive disorder NOS who had not filled a prescription for antidepressant medication in the previous 180 days. Using computerized record systems, 82,285 episodes of antidepressant treatment were identified among 65,103 health plan members during 10.5 years (1992–2003): 9520 members had 2 episodes of antidepressant use, and 1916 contributed more than 2 episodes. A total of 5107 episodes, or 6.2%, occurred among children 17 years or younger.Serious suicide events included deaths (n=31) and attempts leading to hospitalization (n=76). The highest risk of serious attempt was in the month before starting treatment as compared with subsequent months. In the months following treatment, the risk of a serious attempt was higher in the month following treatment than in the subsequent 5 months (OR=2.4; 95% CI, 1.6–3.8). The total number of serious attempts in adolescents was much smaller (n=17), but the pattern of risk over time was similar to that of adults. The absolute rate of attempt was 314 attempts per 100,000 children and adolescents compared with 78 attempts per 100,000 adults (z=3.18, P <.001).The risk of suicide death in the first month of treatment was not higher than in subsequent months (OR=1.2; 95% CI, 0.5–2.9). The number of deaths in adolescents (n=3) was too small to support trend analysis. The risk of both attempt and death was not lower in patients treated with newer drugs. Among those treated with newer antidepressants (n=56,570 episodes of treatment), risk of suicide attempt was greatest in the month before starting treatment, and risk in the first month of treatment was not higher than in the subsequent months. On the other hand, those treated with older antidepressants (n=25,715 episodes) were at highest risk of attempt in the first month of treatment.Dr. Schonwald has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of a commercial product/device. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Adolescents are a particularly high-risk group, given their developmental tendency to engage in impulsive, high-risk behaviors without long-term planning. The higher rate of absolute suicide attempts in younger patients may reflect these developmental propensities, but also serves to highlight the need for close monitoring of children and adolescents treated for depression.The FDA issued a public health advisory in October 2004, directing manufacturers of 10 newer antidepressant drugs to revise product labeling to include a boxed warning and statements that alert health care providers to an increased risk of suicidality in children and adolescents being treated with these agents.1 Subsequently, 2 FDA committees re-analyzed 24 drug company studies and identified 109 events of suicidal ideation, a finding 2.19 times more likely in patients treated with a selective serotonin reuptake inhibitor (SSRI) than in patients assigned to control groups. There were no suicides, and no unique trends for specific agents.2 Providers are now left with the struggle to balance the risk of untreated depression with that of increasing suicidal ideation.While it is not surprising that suicide attempts occur before medication is started (since an attempt often triggers treatment), these data reinforce the high risk of untreated depression. While suicide attempts may be increased in the month after treatment is started, this risk is not nearly as great as the risk of untreated depression.

Data Refute Link Between Suicide, Antidepressants

Data Refute Link Between Suicide, Antidepressants

Suicide Risk During Antidepressant Treatment

In March 2004 the U.S. Food and Drug Administration (FDA) warned physicians and patients regarding increased risk of suicide with 10 newer antidepressant drugs. Available data leave considerable uncertainty regarding actual risk of suicide attempt and death by suicide during antidepressant treatment. The authors used population-based data to evaluate the risk of suicide death and serious suicide attempt in relation to initiation of antidepressant treatment. Computerized health plan records were used to identify 65,103 patients with 82,285 episodes of antidepressant treatment between Jan. 1, 1992, and June 30, 2003. Death by suicide was identified by using state and national death certificate data. Serious suicide attempt (suicide attempt leading to hospitalization) was identified by using hospital discharge data. In the 6 months after the index prescription of antidepressant treatment, 31 suicide deaths (40 per 100,000 treatment episodes) and 76 serious suicide attempts (93 per 100,000) were identified in the study group. The risk of suicide attempt was 314 per 100,000 in children and adolescents, compared to 78 per 100,000 in adults. The risk of death by suicide was not significantly higher in the month after starting medication than in subsequent months. The risk of suicide attempt was highest in the month before starting antidepressant treatment and declined progressively after starting medication. When the 10 newer antidepressants included in the FDA advisory were compared to older drugs, an increase in risk after starting treatment was seen only for the older drugs. The risk of suicide during acute-phase antidepressant treatment is approximately one in 3,000 treatment episodes, and risk of serious suicide attempt is approximately one in 1,000. Available data do not indicate a significant increase in risk of suicide or serious suicide attempt after starting treatment with newer antidepressant drugs.

Gaps in antidepressant prescribing in primary care in the United Kingdom.

An important determinant for achieving efficacy results in clinical practice comparable to those demonstrated in clinical trials is whether or not patients take their medication as prescribed. Recent studies have shown that 30-60% of patients do not take their medications as prescribed. Gaps between antidepressant prescriptions raise questions about the possibility of periods of nonadherence to medication in clinical practice. The purpose of conducting this study was to assess the likelihood of experiencing a gap of > 15 days between antidepressant prescriptions for patients with a depression-related diagnosis and to assess whether this likelihood varied across different antidepressants with tricyclic antidepressants and selective serotonin reuptake inhibitors. Episodes of antidepressant treatment were constructed using the Doctors' Independent Network general practitioner medical records database. For all antidepressant agents considered, approximately 50% of patients had a gap between prescriptions and 15-25% of patients had a gap of > 15 days between prescriptions. A significant proportion of patients in a general practitioner setting in the UK have gaps recorded of > 15 days between antidepressant prescriptions. Gaps between prescriptions raise the question of whether patients may be at risk for clinical consequences associated with nonadherence to therapy, such as reduced effectiveness or treatment interruption symptomatology.