Drop in SSRI Prescribing in the United Kingdom Did Not Lead to Youth Suicide Spike

Marlene Busko

February 21, 2008

February 21, 2008 — Reduced prescribing of selective serotonin reuptake inhibitor (SSRI) antidepressants for young people in the United Kingdom following regulatory action in 2003 did not lead to an increase in suicidal behavior, according to an ecological time series study.

The study, led by Benedict W. Wheeler, PhD, from the University of Bristol, in the United Kingdom, was published online February 14 in BMJ.

"The findings are important, in that reduced access to antidepressants in young people in the United Kingdom following regulatory intervention appears not to have had an adverse impact on suicide deaths or hospital admissions for deliberate self-harm," Dr. Wheeler told Medscape Psychiatry.

Continuing adherence to regulatory guidance on prescribing antidepressants to young people is supported by this evidence, he added.

In June 2003, based on a review of trial data, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) contraindicated the SSRI paroxetine in individuals younger than 18 years. In December 2003, the MHRA warned that the balance of risk vs benefits for most SSRIs except fluoxetine was unfavorable for young people.

Studies from the United States and the Netherlands suggested that following similar regulatory action in those countries, there was an increase in pediatric suicides.

The research team aimed to evaluate the impact of changing patterns of antidepressant use on suicide or self-harm in young people in the United Kingdom following the 2003 regulatory action.

They analyzed 3 sets of data from 1993 to 2006: antidepressant prescriptions for 12- to 19-year-olds in the United Kingdom, annual deaths from suicide in 12- to 17-year-olds in England and Wales, and hospital admissions for self-harm in 12- to 17-year-olds in England.

They found that among young people, antidepressant prescribing doubled from 1999 to 2003 and then dropped back to the 1999 level by 2005. Deaths from suicides, however, declined annually from 1993 to 2005, and the rate of hospital admission for self-harm remained relatively stable.

"These data for England do not indicate that reductions in antidepressant use have led to an increase in suicidal behavior," the group writes.

The findings differ from those of Gibbons and colleagues, who reported that mortality rates for suicides in 5- to 19-year-olds in the United States increased in 2004, the year following regulatory action (Gibbons RD et al. Am J Psychiatry 2007;164:1356-1363), said Dr. Wheeler. More recent critiques of that study, however, suggest that the US situation may not actually differ that much from the United Kingdom's, he noted (Letters to the editor. Am J Psychiatry 2007;164:1907-1910).

Steady Decline in Suicide

In a related time trend study also published online February 14 in BMJ, Lucy Biddle, PhD, and colleagues at the University of Bristol report that the rate of death by suicide in young men in England and Wales is the lowest that it has been in the past 30 years. They speculate that unemployment reduction and laws that limit car exhaust might be key reasons for this.

From 1950 to 1998, rates of suicide in young men in England and Wales doubled, while rates in women and older men declined, they write. To investigate recent trends in overall suicide, they examined data from 1968 to 2005 for men and women aged 15 to 34 years.

They found that suicide rates in young men aged 15 to 24 years and aged 25 to 34 years peaked in 1990 and 1998, respectively, and have since shown a steady decline. Rates in 2005 were the lowest that they have been since the mid-1970s.

Suicide rates in young women have shown more stability over time, but are at the lowest level that they have been in many years.

They did not find any temporal correlation between changes in suicide rates and changes in rates of antidepressant prescribing.

Regular Follow-up is Critical

Observational data clearly show that warnings in the United Kingdom and the United States reduced rates of antidepressant prescribing, Gregory Simon, MD, from the Center for Health Studies, Group Health Cooperative, in Seattle, Washington, writes in an accompanying editorial.

The most recent US data suggest that youth suicide rates have begun to decline again, so the earlier finding of an increase may just be coincidence, he told Medscape Psychiatry.

"The Food and Drug Administration [FDA] most definitely did not advise against using antidepressants when they are indicated," he added. "But the FDA did recommend regular follow-up after starting treatment. That's exactly what psychiatrists should be doing — prescribing antidepressants when they are indicated and making sure to follow up regularly."

Drs. Wheeler and Biddle report having no financial disclosures. Dr. Simon has received compensation as a consultant for Bristol-Myers Squibb and Wyeth Pharmaceuticals.

BMJ. Published online before print February 14, 2008. Abstract Abstract Abstract


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