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A MENTAL health expert has questioned the rising rate of antidepressant prescribing in Australia and called for a more rigorous system of patient follow-up, after a study revealed that the prevalence of self-poisoning has not changed in 26 years.
Professor Philip Mitchell, head of the school of psychiatry at the University of NSW, told MJA InSight that “around 9% of the population are now taking antidepressants and this is excessive”.
He said research had consistently shown that people at a higher risk for suicide presented with similar social determinants, including unemployment and being single, and these factors were not corrected by putting more patients on medication.
Professor Mitchell was commenting on a study published this week by the MJA that examined the in-hospital mortality and morbidity associated with self-poisoning from different drug classes in the greater Newcastle region between 1987 and 2012. (1)
The authors found there were 17 266 admissions of patients poisoned by 34 342 substances. Of these substances, 16 723 were drugs only available on prescription.
The outcomes measured in the study were hospital length of stay (LOS), types of drugs ingested, intensive care unit (ICU) admission, need for ventilation, in-hospital deaths, and rates of antidepressant drug use. The median LOS was 16 hours; 12.2% of patients were admitted to ICU, 5.7% were ventilated, and 0.45% died in hospital.
The authors found that over the 26-year study period, the patient demographic, and social and psychiatric factors remained stable, but case fatality decreased, as did ICU admission, ventilation and LOS.
The most frequently ingested substances were alcohol, benzodiazepines, paracetamol, antidepressants and antipsychotic drugs. Over the study period, there was a substantial fall in some highly toxic drugs ingested (tricyclic antidepressants, barbiturates and theophylline), but increases in the ingestion of less toxic, atypical antipsychotic drugs, serotonin specific reuptake inhibitors, and paracetamol.
A greater than six-fold increase in community antidepressant use was accompanied by only minor changes in overall and total antidepressant self-poisoning rates, the authors wrote.
They said their study demonstrated how prospective databases could generate useful information regarding relative toxicity and patient management.
The authors recommended a more widespread and coordinated collection of information on self-poisoning and suicide, including a national coronial register of drug-related deaths, data collection of poisonings reported to poison control centres, and a systematic use of clinical databases to record poisoning hospital admissions.
Professor Nicholas Buckley, professor of clinical pharmacology at the University of Sydney and a coauthor of the study, told MJA InSight that it was encouraging to find that the newer antidepressants and higher overall prescription rates were not having negative effects.
“However, there is no apparent benefit either, so reasons to prescribe or not prescribe antidepressants should probably be based on measures other than the potential for self-harm”, he said.
Professor Buckley believed an important message that came out of the research was that solving the problem of self-poisoning should not solely rely on psychiatric solutions.
He said investing in postmarketing surveillance and data collection mechanisms was a “no-brainer” because these solutions required minimal effort and “focused on the agents involved in poisoning, rather than just trying to ‘fix’ the people who take the poisons”.
Professor Mitchell agreed, telling MJA InSight that the results of the study were reassuring from a pharmacological perspective, particularly for the general public.
“This should ease some community concerns about the dangers of antidepressant drugs”, Professor Mitchell said.
“These newer antidepressants do appear to be less toxic and lethal than the older tricyclic medications. It’s now near impossible to commit suicide with these antidepressants.”
Despite the apparent improved safety of newer medications, a more rigorous follow-up system was needed across Australia to monitor how patients were responding to their treatment, Professor Mitchell said.
Professor Helen Christensen, professor of mental health at the University of NSW and chief scientist at the Black Dog Institute, welcomed the study, telling MJA InSight that it highlighted how “suicidal behaviour and depression are not necessarily tethered together”.
However, she said that research into mental illness now needed to go further than investigating pharmacological treatments.
“Interventions for suicide and self-harm must extend beyond antidepressant medication”, Professor Christensen said.
“While [antidepressant] medication is good for depression, it ultimately does not target the mechanisms involved in suicidal behaviour directly.”
(Photo: Catalin Petolea / shutterstock)
There are non-psychiatric methods to reduce suicide that are very simple and effective. AIHW data shows a substantial reduction in death rates from suicide over the last 25 years – this has been due to 3 factors in Australia – gun control, catalytic converters in cars (reducing car exhaust gas poisonings), and psychiatric medication that are safer in overdose. There has been ‘method substitution’ but the total effect has still been greatly reduced suicide rates
Most antidepressants are prescribed for ‘depression’ although a small percentage are not. Conversely, many people with depression do not take antidepressants, and indeed many people receiving them do not meet diagnostic criteria for major depression.
http://www.ncbi.nlm.nih.gov/pubmed/20105349
What our paper shows however is that having a much larger number of people on safer antidepressants did not lead to either more or less overdoses. Whether or not people feel instinctively like it should have made a difference one way or the other, it simply didn’t.
Our paper has shown no reduction in deliberate self-harm, but these episodes are less likely to result in a fatal outcome. These arguments do not mean I think we should be complacent about fixing mental health or other societal problems. However, preventing a suicide in a depressed unemployed person is a good thing in itself. It is also a very good outcome for the mental health of their friends and family, on whom the suicide would have a devastating effect.
There is no mention of drug combinations used to commit suicide. I am interested in this aspect, especially tricyclics and anticonvulsants. The recent article published in AFP by one of the Gold Coast chronic pain clinics suggests these are a potent combination as cause for completed suicide, suicidal attempts and suicidal thoughts. Are doctors being careful enough in what they prescribe in combination?
The comment from ApenName and That suggest that a 9% of the population taking antidepressants is not excessive as some may be taking them for other reasons. He / she has to be kidding !! I find that rate of antidepressant use outrageous. It appears any patient who presents as being unhappy or dissatisfied with their life, or upset that their dog has died gets a script for antidepressants. I can see no other logical answer for this ridiculous rate of over-prescribing, and find it extraordinary that any doctor would consider it reasonable.
I REALLY hope that Prof Mitchell has been misquoted, or had his message distorted.
1. “people at a higher risk for suicide presented with similar social determinants, including unemployment and being single, and these factors were not corrected by putting more patients on medication.” Tha’t interesting. The same social determinants pertain to reckless driving, but no one complains that orthopos should stop treating people. It is beyond the scope of care to directly treat those things, but that does not mean that the treatment does not work.
2. “around 9% of the population are now taking antidepressants and this is excessive”. Really? Got data? Antidepressants are not just used for depression, but are also used to treat depression and PMS, amongst other things.
3. “However, there is no apparent benefit either, so reasons to prescribe or not prescribe antidepressants should probably be based on measures other than the potential for self-harm.” This comment was by someone else, but puhleeese. No apparent benefit? As the drugs are safer, people will be more inclined to overdose on them, for example, to communicate distress. What would be interesting is knowing the rate of violent suicide and attempts over the last 26 years. But even then correlation would not mean causation.
“Professor Buckley believed an important message that came out of the research was that solving the problem of self-poisoning should not solely rely on psychiatric solutions.” Well that was not a message that came from the research. People already know that poverty and social dislocation increase the risk of mental illness, and that addressing those things would be a good thing
Why do we persist in publishing material that has been widely acknowledged for over a decade, if not two;eg, safety of SRIs, untethering of depression from suicide. Yes, Australia made a large strategic error in persisting with the ‘medical model ‘ of suicidal behaviour at the turn of the century. By 2010, that had been recognized and was being addressed. Is it only physicians/psychiatrists who are not yet aware of this!
We have had an increasing anxiety about the amount of opioids of all types in the community. This anxiety is well placed in my opinion . Opioids are however an important class of drug which are effective in a minority of well chosen patients but need to be managed with care and respect. These do not seem to feature in this paper as much as I would have suspected. The level of alcohol and indeed benzodiazepines however, are still a cause for concern though. Opioids are often combined with paracetamol and NSAIDs and this might be a hidden factor. Interesting paper and timely.