Infrequent use of antidepressants in depressed individuals (an interview and prescription database study in a defined Swedish population 2001-2002).

PURPOSE: To investigate whether antidepressants are over-used, under-used, or misused, by determining to what extent the depressed individuals in a defined population are treated with antidepressant medication and, from the other end, to what extent prescribed antidepressants are aimed for the treatment of depression. SUBJECTS AND METHOD: From an individual based prescription database in the County of Jämtland, 2048 individuals representative for the general population were selected. The presence of current depression in these individuals was screened by a mailed self-screening questionnaire. Individuals with depression according to the questionnaire were interviewed by a psychiatrist using a structured interview (SCAN) to confirm the diagnosis. Their use of antidepressants was obtained from the prescription database. RESULTS: Sixty-two (4.5%) out of 1375 were diagnosed with depression and 17 (27%) of these were taking an antidepressant. In addition 44 individuals, currently not depressed, were taking antidepressants. Twenty-five of these were interviewed per telephone and it was found that the indications for 18 of them were continuation treatment of depression, and for seven of them pain, sleep disturbance or anxiety. CONCLUSION: Antidepressants appear to be under-used in the population. Only one in four of the depressed individuals was treated with antidepressant medication. Those who had antidepressant medication without being currently depressed had, with few exceptions, either continuation treatment for depression in remission or treatment on other approved indications.

Indications for and outcome of antidepressant medication in a general population: a prescription database and medical record study, in Jämtland county, Sweden, 1995.

OBJECTIVE: To examine the indications for prescribing antidepressants and the clinical outcome when they are prescribed for the treatment of depression, and compare tricyclic antidepressants (TCAs) and selective serotonin re-uptake inhibitors (SSRIs) in these respects. METHOD: A naturalistic study of a prospective prescription monitoring database and medical records. RESULTS: Depression was the indication for 23% of the tricyclic treatments and for 82% of the SSRI treatments. A successful treatment of the depression was found in 20% of the TCA cases and 41% of the SSRI cases (NS). CONCLUSION: This study provides evidence that the main use of SSRIs in 1995 is the treatment of depression. The study implies that SSRIs have a more favourable outcome in "real life" than TCAs.

Suicides are seldom prescribed antidepressants: findings from a prospective prescription database in Jämtland county, Sweden, 1985-95.

OBJECTIVE: This study presents data relating to prospectively monitored treatment and post-mortem toxicology of individuals who committed suicide. METHOD: A case-control study of prospectively monitored pharmacological treatment in suicides and controls. Psychiatric records and post-mortem toxicology were also studied. RESULTS: Fifty-nine subjects who committed suicide purchased twice the number of prescriptions as the 118 controls. Sixteen cases received psychiatric in-patient care compared to four of the controls. In the last 3 months prior to suicide, 38 cases (64%) were dispensed drugs: anxiolytics-hypnotics in 17 cases (29%), antipsychotics in six cases (10%) and antidepressants in seven cases (12%). More psychiatrists than GPs prescribed antidepressants. About one-third of psychotropic drugs were retrieved in post-mortem toxicology. CONCLUSION: There is a frequent use of psychotropics and psychiatric care among suicides; however, few used antidepressants and complied. Many suicides are still misdiagnosed and are not adequately treated.

Selective serotonin reuptake inhibitors have broadened the utilisation of antidepressant treatment in accordance with recommendations. Findings from a Swedish prescription database.

BACKGROUND: With the advent of the selective serotonin reuptake inhibitors (SSRIs), the use of antidepressants has increased drastically in Sweden. The use of tricyclic antidepressants (TCAs) has, however, decreased. METHODS: We surveyed a prescription database in the Swedish county of Jämtland and compared prescription patterns for patients prescribed SSRIs with those prescribed TCAs. RESULTS: The incidence of treatments of antidepressants increased from 0.76% to 1.33% during the period 1991-1996. There were no significant differences between SSRIs and TCAs with regard to patients having only one prescription dispensed within three months from the index prescription, or patients who switched class of antidepressant. Only a minority of the treatments were continued for at least six months, but significantly more SSRI than TCA treatments (42% and 27%). A second treatment period suggesting recurrence was three-times more common in the TCA group than in the SSRI group. CONCLUSION: Provided that the increased use of SSRIs is mainly for depression, these drugs appear, despite a lower efficacy in severe depression, to have enabled a broader utilisation of antidepressants with regard to incidence, dosage and duration, in accordance with recommendations. Further analyses of this phenomenon relative to diagnostic criteria and outcome measures are required.

Oral contraceptive use: interview data versus pharmacy records.

BACKGROUND: If women tend to forget and underreport their past oral contraceptive (OC) use, but the recall among cases is enhanced by the presence of disease, recall bias may explain some reported health effects of OC use. METHODS: Two different sources of information on lifetime OC use were compared for 427 (84%) of a community-based sample of 511 women aged 20-34: (i) structured interviews, using a life event calendar and picture display as memory aids, and (ii) a register of all prescriptions dispensed by pharmacies in the county since 1970. RESULTS: Interview data and pharmacy records showed high levels of agreement for any OC use, current use, time since first and last use, total duration of use, and for duration of use in different 'time windows'. But there was a tendency to under-report specific kinds of OC used in the past. CONCLUSION: Underreporting of OC use among non-cases would usually introduce little or no bias (as compared to pharmacy records) for this kind of interview and women. However, it may be preferable to use interviews for current OC use, and pharmacy records for specific kinds of OC used in the past.

PIP: In studies where women are interviewed about oral contraceptive (OC) use only after the emergence of disease (e.g., breast cancer), the experience of disease may enhance recall and reporting of OC use, resulting in overestimation of relative risks. This community-based study compared two sources of information on ever-use of OCs--structured interviews and pharmacy prescription records--in 427 women 20-34 years of age who were long-term residents of Sweden's Jamtland County where registration of prescriptions has been virtually complete since 1970. A life-events calendar and photographs of OCs in use since 1970 were used in the interviews to facilitate recall. 153 women reported current OC use; the pharmacy register failed to document a current prescription for 37 (24%). Only 4 (1.5%) of the 274 women who denied current OC use had an active prescription on file. Of the 37 women identified as never-users by interview, 2 (5%) had records of OC prescriptions (for under 2 years of use). Of the 36 women identified as never-users by pharmacy records, only 1 reported ever-use. Compared to the pharmacy registry, 13% reported a shorter and 28% a longer duration of OC use. Of women who reported OC use within 5 years of interview, 5-10 years earlier, and more than 10 years ago, 2.6% (8/312), 4.6% (14/307), and 12.8% (26/203), respectively, had no prescriptions on file for that time period. Discrepancies between the two data sources in time since first OC use were usually less than 2 years; the tendency was for women to overestimate rather than understate the actual duration of OC use. These findings suggest that interview data on OC use introduce minimal--if any--bias. Agreement between interviews and records in terms of the specific brands of OCs taken was less satisfactory. 19% of users of high-dose OCs, for example, did not recall the type of pill dispensed by the pharmacy. Thus, use of pharmacy records is recommended over interview data in studies where the specific OC formulation is of interest.

Differences in utilization of asthma drugs between two neighbouring Swedish provinces: relation to treatment in individuals with airway disease.

OBJECTIVE: To assess the extent to which drugs were used by individuals found to have asthma in a population survey. To assess the relative influence of the proportion of patients treated and doses reported on the sales of drugs. To study if observed differences in sales of asthma drugs between the county of Jämtland (with high sales) and Gävleborg (with lower sales) correlated to a difference in the control of the disease. DESIGN: A cross-sectional population study with a postal questionnaire followed by an interview and examination of symptomatic individuals. Asthma was diagnosed in subjects reporting a typical history of asthma or repeated episodes of dyspnoea and wheezing, or dry cough combined with reversibility in FEV1, PEF-variability or PC20 < or = 4 mg ml-1. SETTING: The county of Jämtland, and Gästrikland, a southern part of the county of Gävleborg in central Sweden. SUBJECTS: All 16 year olds, and 13% (randomly selected) of 30-39 and of 60-69 year olds (totalling 12732 individuals). Subjects reporting airway symptoms in the questionnaire (n = 2100) and 450 asymptomatic controls were further investigated. MAIN OUTCOME MEASURES: Drug use and symptoms reported by individuals found to have asthma or chronic obstructive pulmonary disease (COPD). RESULTS: Inhaled beta 2 agonists and inhaled steroids were used more often by individuals with asthma and COPD in Jämtland. However, regular use was more common in Gävleborg. Most of the asthmatics did not use any medication in spite of the fact that symptoms were commonly reported. The drug combinations most often used were inhaled beta 2 agonists alone or in combination with inhaled steroids. There were only minor differences in the prevalence of symptoms reported by individuals with asthma treated in different ways. CONCLUSION: Differences in the way anti-asthma drugs were used contributed to the observed difference in the sales of drugs. However, this difference was mainly caused by differences in the prevalence of asthma. The goals of asthma management plans were fulfilled only in a minority of patients despite the sales of asthma drugs being high.

Prescribing patterns for elderly community-dwelling heavy medicinal drug users in Manitoba, Canada and Jämtland, Sweden.

Patterns of drugs prescribed for elderly community-dwelling heavy medicinal drug users were determined from random samples of data bases and compared between Manitoba, Canada and Jämtland, Sweden for the year 1981. Qualitatively, there was 80% concordance between the 20 most frequently prescribed drugs in Manitoba and in Jämtland. Gender differences were rare, but there were notable quantitative differences for prescription of specific drugs between the two jurisdictions. Drugs to treat cardiovascular diseases were prominent in both groups with thiazides, triamterene and alpha-methyldopa more frequently prescribed for Manitoba patients, and furosemide, potassium supplements and digoxin more frequently prescribed for patients from Jämtland. The frequent prescribing of codeine in combination analgesics in Manitoba and phenothiazines in Jämtland appears to represent geographically disparate approaches to the use of these drugs. Overall, the concordance of prescribed drugs for elderly heavy medicinal drug users from these two jurisdictions appears to outweigh the differences. These results indicate that data from studies of heavy medicinal drug users, at least in the industrialized world, may be more widely applicable than to the geographical location from where they were obtained.

Differences in utilisation of asthma drugs between two neighbouring Swedish provinces: relation to prevalence of obstructive airway disease.

BACKGROUND: Considerable variation exists in the use of antiasthmatic drugs in different counties in Sweden. The reasons for this variation are unknown. A study was performed to determine if there is an association between sales of antiasthmatic drugs and the prevalence of obstructive airway diseases in two adjoining Swedish counties. METHOD: The prevalence of asthma-associated symptoms in the county of Jämtland where there is high drug use, and the county of Gävleborg where it is lower, was assessed in 1990 by a postal questionnaire answered by 11,300 subjects. Three age groups were included: all 16 year olds, 13% of those aged 30-39 years, and 13% of 60-69 year olds. A total of 2100 subjects reporting airway symptoms in a questionnaire and 450 asymptomatic controls were further investigated at an interview with lung function tests and, in 500 cases, with a methacholine challenge. Asthma was diagnosed in subjects reporting a typical history or repeated episodes of dyspnoea and wheezing, or dry cough combined with reversibility in FEV1, variability in peak expiratory flow, or a PC20 value of < or = 4 mg/ml. RESULTS: The prevalence of current asthma was close to 8% in all age groups in Jämtland and significantly lower (close to 6%) in all age groups in the warmer, more industrialised and more densely populated county of Gävleborg. A gender difference with a higher prevalence in women was found in Gävleborg but not in Jämtland. There was no significant difference in the use of inhaled beta 2 stimulants among subjects with asthma in the two counties. Inhaled steroids were used more often in Jämtland. However, they were used regularly by fewer than 10% of asthmatic subjects in the two younger age groups. CONCLUSION: The differences in the use of antiasthmatic drugs in these two counties reflect a difference in the prevalence of obstructive airway disease.

Sensitivity to sensitins and tuberculin in Swedish children. Part 5: A study of school children in an inland rural area.

SETTING: Since 1986 we have tested approximately 7000 non-BCG-vaccinated Swedish children with tuberculin and with Mycobacterium avium or M. scrofulaceum sensitin. In Göteborg, an urban coastal area, 25% of 8-9-year-old school children reacted to M. avium sensitin and 32% of M. scrofulaceum sensitin using a 6 mm cut-off. OBJECTIVE: To evaluate if geographical factors have an influence on the prevalence of children reacting to tuberculin and sensitins. DESIGN: 2000 schoolchildren of the same age as those in Göteborg but living in an inland rural area were Mantoux-tested in a similar way (simultaneously on separate arms with PPD RT23 and either of the two sensitins). RESULTS: 15% reacted to PPD RT23, 9.7% to M. avium and 13.9% to M. scrofulaceum sensitin. None of the children with a PPD RT23 reaction > = 6 mm showed signs of tuberculosis or had any known exposure. A reaction to PPD RT23 was usually combined with a still larger sensitin reaction. CONCLUSION: There was a considerable geographic difference in sensitin reactivity, low in an inland rural area compared to a coastal urban area. Children reacting to PPD RT23 had probably not been infected by M. tuberculosis but more likely by atypical mycobacteria. The reactions should be interpreted as cross-reactions.

Differences in utilization of asthma drugs between two neighbouring Swedish provinces: relation to symptom reporting.

Utilization of anti-asthma drugs is rapidly increasing and varies markedly between counties in Sweden. In 1989, the sales in the county of Gävleborg were less than 60% of those in neighbouring Jämtland. In order to study the possible reasons for--and effects of--this difference, an epidemiological survey was started in 1989, the first part of which is reported here. A questionnaire was sent to all 16 yr olds, and to a random sample of 30-39 and 60-69 yr olds, in the two counties. A total of 12,500 questionnaires were distributed. Overall response rate was 90%. A total of 7.2% in Jämtland and 5.8% in Gävleborg (p < 0.01) reported that they had had asthma at some time. A similar significant difference between the counties was also present in response to questions on attacks of shortness of breath, wheezing and self-reported diagnosis of asthma, as well as on use of anti-asthma drugs. There were no statistically significant differences between the counties in positive answers to questions concerning history and symptoms of chronic bronchitis; approximately 5% in the oldest age group. The findings support earlier results indicating a high asthma prevalence in northern Sweden. Contrary to reports from other countries, the prevalence was higher in the colder and less urbanised of the two provinces. We conclude that the differences in drug sales between the counties reflect a difference in prevalence of asthmatic symptoms.

Low level of antidepressant prescription for people who later commit suicide: 15 years of experience from a population-based drug database in Sweden.

The use of antidepressants has been low in Jämtland County for many years, while the suicide rate has been among the highest in Sweden. A continuous outpatient prescription recording system has been in operation in Jämtland since 1970. Through this system we traced the prescription pattern of 80 individuals who committed suicide from 1970 to 1984. Suicide patients obtained 1.5 times more prescription drugs than 80 matched controls, mainly psychotropics and vitamins. During the 3 months prior to the suicide, half of the patients had received medical attention and 73% of the women and 40% of the men had obtained prescription drugs, in one-third from the psychiatric department. While 53% and 29%, respectively, obtained psychotropic drugs, only 13% and 9% respectively were prescribed antidepressants, often in low doses. People who will commit suicide often seek medical help. The low rate of antidepressant prescription in patients committing suicide probably reflects insufficient diagnosis and treatment of depressive disorders. It is urgent--for the individual as well as for society--that diagnostic and pharmacotherapeutic routines be improved.

Regional distribution and in vivo binding of the atypical antipsychotic drug remoxipride. A biochemical and autoradiographic analysis in the rat brain.

The regional brain distribution and binding of the antipsychotic benzamide drug remoxipride was studied in the male rat. After i.v. injections of 3H-remoxipride (1 mumol.kg-1) more than 85% of the radioactivity was identified as authentic remoxipride in brain by using reversed-phase liquid chromatography. Autoradiographic and spectroscopic analysis showed that 3H-remoxipride was distributed relatively even in different brain areas, with exception of the following structures, which showed highest drug concentrations: the choroid plexus, septum, medial part of the caudate nucleus, different areas of the thalamus and hypothalamus situated close to the cerebral ventricles. A closer analysis of the autoradiograms showed a gradient of radioactivity extending from the cerebral ventricles to the deeper parts of the brain at 30 minutes after injections. After 60 minutes radioactivity was detected throughout all forebrain dopamine receptive areas. These findings suggest that remoxipride enters the cerebrospinal fluid (CSF) via the vascular bed of the choroid plexus and that it enters the brain interstitial fluid from the CSF. In the caudate nucleus, nucleus accumbens, olfactory tubercle and olfactory bulb 30-40% of the radioactivity was reduced by pretreatment with the dopamine D-2 selective drug raclopride. In addition, small, but significant, reductions (10-15%) of 3H-remoxipride derived radioactivity was found in the neocortex, hippocampus and the cerebellum, suggesting that remoxipride interacts with a D-2 receptor also in these cortical structures. Taken together, these studies show that after i.v. injections, 3H-remoxipride enters the brain primarily in unmetabolized form when given in doses that affect DA receptor mediated behaviours, that it distributes to most areas throughout the neuraxis and that it binds to D-2 receptors in different parts of the basal ganglia, neocortex, hippocampus and cerebellum.