BRITISH JOURNAL OF PSYCHIATRY (2006), 188, 354^358
Relationship between antidepressant sales the data for Denmark were available up to 2000 and the data for Finland were and secular trends in suicide rates available up to 2003. We were also able to obtain age-specific suicide trend data for Sweden and Norway. Antidepressant in the Nordic countries sales data, expressed in terms of defined daily doses (DDDs) for SSRIs and other SVEIN RESELAND, ISABELLE BRAYandBRAY andDAVID GUNNELL antidepressants, were available up to 2003 for all four countries. Data on total anti- depressant and SSRI prescribing were available from 1974 and 1990 respectively for Norway, from 1977 and 1991 Background The effectof recent There are concerns that selective serotonin respectively for Sweden, from 1990 for increasesincreasesin in antidepressant prescribing on reuptake inhibitors (SSRIs) may precipitate both for Denmark and from 1985 and suicidal behaviour in some individuals 1989 respectively for Finland. population suicide rates is uncertain. (Healy, 2003). In the UK, the Medicines We plotted separate graphs for each of Aims ToinvestigateTo investigate the relationship and Healthcare products Regulatory the four countries to enable us to compare Agency (MHRA) recently concluded that the time trends in levels of antidepressant between antidepressant sales and trends a modest increase in the risk of self-harm prescribing with the trends in overall and in suicide rates. in SSRI users could not be ruled out, but gender-specific suicide rates. For Norway that there was too little evidence available and Sweden we also plotted age- and MethodMethod Graphical and quantitative to assess the suicide risk (Medicines and gender-specific suicide rates for three age assessment of trends in suicide and Healthcare products Regulatory Agency, groups (15–24, 25–44 and 4445 years), as antidepressant salesin Norway,Sweden, 2004). In contrast, an analysis of secular data from other countries suggest that time Denmark and Finland. trends in antidepressant prescribing and trends in suicide rates vary with age suicide in the Nordic countries, based (Cantor, 2000). ResultsResults Suiciderates declinedin allfour mainly on data for the period 1990–1996, To estimate the years (with 95% CI) in countries during the1990s, whereas suggests that reductions in the suicide rate which changes in trends in suicide rates coincided with increased antidepressant occurred we used Joinpoint software antidepressant salesincreased by 3- to 4- prescribing (Isacsson, 2000). However, version 2.7 (available from http://srab.cancer. fold.Decreasingsuicide ratesinrates in Sweden time trends in antidepressant prescribing gov/joinpoint). Join-point regression is a and Denmark preceded the rise in anti- and suicide in other countries provide con- form of analysis in which trend data are depressant salesbyover10 years, although flicting evidence for this hypothesis described by a number of contiguous linear the reductions accelerated between1988 (Gunnell & Ashby, 2004). In this paper segments and ‘join points’ where trends we update Isacsson’s analysis with more change (Kim et aletal, 2000). Permutation tests and1990.In Norway,Norway,a a modest but short- recent data on antidepressant sales and are used to determine the minimum number lived declinedeclinein in suicidesuiciderates rates began around suicide rates in the Nordic countries. In of join points required to provide an the time ofthe increase in antidepressant addition, we extend his time series further adequate fit to the data. sales.sales.In In Finland, decreasesdecreasesin in male suicide back in time to investigate whether the reductions in suicide in these countries rates and to a lesser extentin female RESULTSRESULTS coincided with or pre-dated the increases suicide rates began around the time of in antidepressant sales. In all four countries, SSRI sales rose rapidly increased antidepressant sales.In allfour from around 1991–1993 onwards (Fig. 1). countries decreasesdecreasesin in suicide rates In Sweden and Norway there was some appeared to precede the widespread use METHOD evidence of a brief compensatory decline of SSRIs. in the sales of other antidepressants, but Data on suicide rates from the year 1961 this effect was short-lived. The net effect Conclusions We found mixed evidence and levels of antidepressant prescribing on overall antidepressant sales of the for as long a time period as was available thatthatincreasesin increasesin antidepressant sales have increase in the use of SSRIs in the 1990s (in all cases before 1990) were obtained was that by 2000 overall levels of anti- coincided with a reduction inthe number from Statistics Norway, the Norwegian depressant sales in all four countries were of suicidessuicidesin in Nordic countries. Institute of Public Health, Statistics 3- to 4-fold greater than in 1990. Sweden, the National Board of Health Declaration of interest D.G. wa s aaD.G. and Welfare (Sweden), the National Board member ofthe Medicines and Healthcare of Health (Denmark), the Danish Associa- NorwayNorway products Regulatory Agency Expert tion of the Pharmaceutical Industry (Lif), The Norwegian statistics show that after a Statistics Finland and the National Agency steady rise in suicide rates throughout the WorkingGroupontheSafetyofSSRIs.HeWorking Group on the Safety of SSRIs.He for Medicines (Finland). 1970s and 1980s, the rates began to decline was an independent advisor, receiving The data on suicide rates for Norway around 1990, which partly coincided with expenses and an attendance fee. and Sweden were available up to 2002, the period when SSRIs were introduced
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Fig. 11Fig. Number of suicides v. SSRI and other antidepressant sales in (a) Norway (1961^2002), (b) Sweden (1961^2002), (c) Denmark (1961^2000) and (d) Finland (1961^2003). SSRI, selective serotonin reuptake inhibitor; DDD, defined daily dose.,total; , total; ,male;,male;...... ,female; &&