The public health impact of antidepressants: An instrumental variable analysis

doi:10.1016/j.jad.2011.05.037

Journal of Affective Disorders

Volume 134, Issues 1–3, November 2011, Pages 188-197

https://doi.org/10.1016/j.jad.2011.05.037 Get rights and content

Abstract

Background

There has been a marked increase in antidepressant medication prescription and use over the past three decades with unclear effects on the mental health status of the population. This study examined the impact of expansion of antidepressant use on prevalence and characteristics of depression and suicidal ideations in the community.

Method

Instrumental variable models were used to assess the impact of antidepressant treatments on the prevalence of depressive episodes, mixed anxiety and depression states and suicidal ideations in 22,845 participants of the 1993, 2000 and 2007 National surveys of psychiatric morbidity of Great Britain who were between 16 and 64 years of age.

Results

Increased prevalence of antidepressant treatment did not impact the prevalence of depressive episodes or mixed anxiety and depression states. However, antidepressant treatment was associated with decreased prevalence of severe and, to a lesser extent, mild depressive episodes and suicidal ideations and a corresponding increase in prevalence of moderate depressive episodes.

Limitations

The data were cross-sectional and based on self-report of symptoms in the past month and current medication use with no information on dose and duration of medication treatment.

Conclusions

Expansion of antidepressant treatments in recent years has not changed the community prevalence of depression overall, but it has reduced the prevalence of more severe depression and suicidal ideations. The findings call for better targeting and more judicious use of antidepressants in cases of more severe depressive episodes which are more likely to respond to such treatments.

Section snippets

Sample

The sample for this study was drawn from the psychiatric morbidity surveys of the general population of Great Britain conducted in 1993, 2000 and 2007. Overall 26,091 individuals selected from private households participated in these three surveys (McManus et al., 2009b). Delivery points for households were drawn randomly from postal sectors of the Small Area Postcode Address File, stratifying for socio-economic grouping within the English regions, Wales and Scotland. The response rate was 80%

Characteristics of the survey samples

There were some differences across the three survey waves with regard to age, gender and racial/ethnic distribution of the participants (Table 1). Participants of the 1993 sample were somewhat younger than those in the 2000 and 2007 samples and included more males. Also, the 2007 sample included a larger number of individuals from the racial/ethnic minorities. There were minor differences in the social class distribution of the samples. However, these differences did not follow a clear trend.

Discussion

The results of this study should be interpreted in the context of its limitations and the limitations of the survey data. First, the surveys were cross-sectional, therefore the course and outcome of treatments could not be assessed. Second, assessments of symptoms and diagnoses were based on individual self-reports elicited by lay interviewers using the CIS—R structured interview instrument. The diagnoses in such interviews do not necessarily correspond with clinical diagnoses (Brugha et al.,

Role of funding source

This research was not supported by any funding source.

Conflict of interest

The author has received research funding and consultant fees from Bristol-Myers Squibb.

References (46)

H.S. Akiskal et al.
Does the FDA proposed list of possible correlates of suicidality associated with antidepressants apply to an adult private practice population?
J. Affect. Disord.
(2006)
A. Cipriani et al.
Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis
Lancet
(2009)
K. Kroenke et al.
Interventions to improve provider diagnosis and treatment of mental disorders in primary care, a critical review of the literature
Psychosomatics
(2000)
J.A. Rassen et al.
Instrumental variables I: instrumental variables exploit natural variation in nonexperimental data to estimate causal relationships
J. Clin. Epidemiology
(2009)
Z. Rihmer et al.
Do antidepressants t(h)reat(en) depressives? Toward a clinically judicious formulation of the antidepressant–suicidality FDA advisory in light of declining national suicide statistics from many countries
J. Affect. Disord.
(2006)
B. Arroll et al.
Antidepressants versus placebo for depression in primary care
Cochrane Database of Systematic Reviews
(2009)
R.J. Baldessarini et al.
Ecological studies of antidepressant treatment and suicidal risks
Harv. Rev. Psychiatry
(2007)
J. Bhattacharya et al.
Estimating probit models with self-selected treatments
Stat. Med.
(2006)
T.S. Brugha et al.
Cross validation of a general population survey diagnostic interview: a comparison of CIS—R with SCAN ICD-10 diagnostic categories
Psychol. Med.
(1999)
T.S. Brugha et al.
Antidepressants may not assist recovery in practice: a naturalistic prospective survey
Acta Psychiatr. Scand.
(1992)

T.S. Brugha et al.

Trends in service use and treatment for mental disorders in adults throughout Great Britain

Br. J. Psychiatry

(2004)

W.M. Compton et al.

Changes in the prevalence of major depression and comorbid substance use disorders in the United States between 1991–1992 and 2001–2002

Am. J. Psychiatry

(2006)

G.A. Fava

Can long-term treatment with antidepressant drugs worsen the course of depression?

J. Clin. Psychiatry

(2003)

K.N. Fountoulakis et al.

Efficacy of antidepressants: a re-analysis and re-interpretation of the Kirsch data

Int. J. Neuropsychopharmacol.

(2011)

J.C. Fournier et al.

Antidepressant drug effects and depression severity: a patient-level meta-analysis

JAMA

(2010)

S.N. Ghaemi

Why antidepressants are not antidepressants: STEP-BD, STAR*D, and the return of neurotic depression

Bipolar Disord.

(2008)

K.M. Harris et al.

Who is the marginal patient? Understanding instrumental variables estimates of treatment effects

Health Serv. Res.

(1998)

R. Jenkins et al.

The National Psychiatric Morbidity surveys of Great Britain—strategy and methods

Psychol. Med.

(1997)

R. Jenkins et al.

The National Psychiatric Morbidity Surveys of Great Britain—strategy and methods

Int. Rev. Psychiatry

(2003)

R. Jenkins et al.

British psychiatric morbidity survey

Br. J. Psychiatry

(1998)

R. Jenkins et al.

The National Psychiatric Morbidity surveys of Great Britain—initial findings from the household survey

Psychol. Med.

(1997)

R. Jenkins et al.

The National Psychiatric Morbidity Surveys of Great Britain—initial findings from the household survey

Int. Rev. Psychiatry

(2003)

R. Jenkins et al.

The British Mental Health Survey Programme: achievements and latest findings

Soc. Psychiatry Psychiatr. Epidemiol.

(2009)

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Research reportThe public health impact of antidepressants: An instrumental variable analysis

Abstract

Background

Method

Results

Limitations

Conclusions

Section snippets

Sample

Characteristics of the survey samples

Discussion

Role of funding source

Conflict of interest

J. Affect. Disord.

Lancet

Psychosomatics

J. Clin. Epidemiology

J. Affect. Disord.

Antidepressants versus placebo for depression in primary care

Cochrane Database of Systematic Reviews

Ecological studies of antidepressant treatment and suicidal risks

Harv. Rev. Psychiatry

Estimating probit models with self-selected treatments

Stat. Med.

Cross validation of a general population survey diagnostic interview: a comparison of CIS—R with SCAN ICD-10 diagnostic categories

Psychol. Med.

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Acta Psychiatr. Scand.

Trends in service use and treatment for mental disorders in adults throughout Great Britain

Br. J. Psychiatry

Changes in the prevalence of major depression and comorbid substance use disorders in the United States between 1991–1992 and 2001–2002

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Can long-term treatment with antidepressant drugs worsen the course of depression?

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Psychol. Med.

The National Psychiatric Morbidity Surveys of Great Britain—strategy and methods

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British psychiatric morbidity survey

Br. J. Psychiatry

The National Psychiatric Morbidity surveys of Great Britain—initial findings from the household survey

Psychol. Med.

The National Psychiatric Morbidity Surveys of Great Britain—initial findings from the household survey

Int. Rev. Psychiatry

The British Mental Health Survey Programme: achievements and latest findings

Soc. Psychiatry Psychiatr. Epidemiol.

Research report
The public health impact of antidepressants: An instrumental variable analysis