Three decades of antidepressant, anxiolytic and hypnotic use in a national population birth cohort

Three decades of antidepressant, anxiolytic and hypnotic use in a national population birth cohort

Background Background Psychotropic medication Psychotropic medication useis common andincreasing.Use of such useis common andincreasing.Use of such drugs attheindividuallevel overlong drugs attheindividualleveloverlong periodshasnot beenreported. periodshasnot beenreported. Aims Aims To describe antidepressant, To describe antidepressant, anxiolytic andhypnoticdruguse, and anxiolytic andhypnoticdruguse, and associationsbetween suchmedicationuse associationsbetween suchmedicationuse and commonmental disorder, over a 22- and commonmentaldisorder, over a 22- year period.

year period. Method Method Questionsaboutpsychotropic Questionsaboutpsychotropic medicationuse and symptoms ofcommon medicationuse and symptoms ofcommon mentaldisorder were asked of morethan mentaldisorder were asked of morethan 3000 members ofthe1946 British birth 3000 members ofthe1946 British birth cohort atmultipletime pointsbetween cohort atmultipletime pointsbetween ages 31and 53 years. ages 31and 53 years. Results Results Prevalence of any Prevalence of any antidepressant, anxiolytic orhypnotic use antidepressant, anxiolyticorhypnotic use increasedsignificantly from1977 (30.6 per increasedsignificantly from1977 (30.6 per 1000) to1999 (59.1per1000) as the 1000) to1999 (59.1per1000) as the cohort aged.Less than 30% withmental cohort aged.Less than 30% withmental disorder used antidepressants, anxiolytics disorder used antidepressants, anxiolytics or hypnotics.Previoususe of orhypnotics.Previoususe of antidepressant, anxiolyticorhypnotic was antidepressant, anxiolyticorhypnotic was a strongpredictoroffuture use duringan a strongpredictoroffuture use duringan episode of mentaldisorder (oddsratios episode of mentaldisorder (oddsratios 3.0^8.4); this association became weaker 3.0^8.4); this association became weaker over time.

over time. Conclusions Conclusions Pharmacotherapyis Pharmacotherapyis infrequentlyused byindividualswith infrequentlyused byindividualswith commonmentaldisorderin Britain; this commonmental disorderin Britain; this hasnotchangedinthe pastthree decades. hasnotchangedinthe pastthree decades. Declaration of interest Declaration of interest None. None. Fundingdetailedin Acknowledgements. Fundingdetailedin Acknowledgements. Psychotropic medication use is common in Psychotropic medication use is common in industrialised countries. A cross-sectional industrialised countries. A cross-sectional telephone survey in France, Germany, Italy telephone survey in France, Germany, Italy and the UK found that 6.4% of the and the UK found that 6.4% of the population were using a psychotropic medi- population were using a psychotropic medi- cation (Ohayon & Lader, 2002). Further- cation (Ohayon & Lader, 2002). Further- more, use of these medications appears to more, use of these medications appears to be increasing (Middleton be increasing (Middleton et al et al, 2001; , 2001; Olfson Olfson et al et al, 2002; Helgason , 2002; Helgason et al et al, 2004).

, 2004). Longitudinal birth cohort studies can bring Longitudinal birth cohort studies can bring a unique perspective to the study of these a unique perspective to the study of these phenomena. They include not only popu- phenomena. They include not only popu- lation trends with respect to medication lation trends with respect to medication use, but also trends over time at the individ- use, but also trends over time at the individ- ual level, capturing age and period effects. ual level, capturing age and period effects. We describe use of antidepressants, anxio- We describe use of antidepressants, anxio- lytics and hypnotics, and the associations lytics and hypnotics, and the associations between use of these medications and com- between use of these medications and com- mon mental disorder up to age 53 years in a mon mental disorder up to age 53 years in a general population birth cohort spanning general population birth cohort spanning the second half of the 20th century, the the second half of the 20th century, the era of modern psychotropic drug treat- era of modern psychotropic drug treat- ments. We predicted that use of psychotro- ments. We predicted that use of psychotro- pic medication would increase as the cohort pic medication would increase as the cohort aged, but that a substantial proportion of aged, but that a substantial proportion of participants with evidence of depression participants with evidence of depression and anxiety would remain untreated. and anxiety would remain untreated. METHOD METHOD Participants Participants The sample consisted of participants in the The sample consisted of participants in the Medical Research Council National Survey Medical Research Council National Survey of Health and Development (NSHD). This of Health and Development (NSHD). This survey was originally conceived as a study survey was originally conceived as a study of maternity, and included every child born of maternity, and included every child born in England, Scotland or Wales during the in England, Scotland or Wales during the week of 3–9 March 1946 (Wadsworth, week of 3–9 March 1946 (Wadsworth, 1991). From all the singleton births to 1991). From all the singleton births to married women a stratified sample of 5362 married women a stratified sample of 5362 individuals was selected by taking a random individuals was selected by taking a random 1 in 4 of all births to women married to 1 in 4 of all births to women married to manual workers, and all births to women manual workers, and all births to women married to non-manual and agricultural married to non-manual and agricultural workers. That sample has been prospectively workers. That sample has been prospectively studied on 22 occasions up to age 53 years. studied on 22 occasions up to age 53 years. Data included information on development, Data included information on development, education, physical and mental health, education, physical and mental health, employment and many other features employment and many other features (Wadsworth, 1991; Wadsworth (Wadsworth, 1991; Wadsworth et al et al, 2003).

, 2003). Follow-up of those alive and still resi- Follow-up of those alive and still resi- dent in England, Scotland or Wales has dent in England, Scotland or Wales has been very successful; more than 80% have been very successful; more than 80% have been followed throughout the cohort’s been followed throughout the cohort’s adult years, excluding those who died, emi- adult years, excluding those who died, emi- grated or have permanently withdrawn grated or have permanently withdrawn from the study (Wadsworth from the study (Wadsworth et al et al, 2003).

, 2003). Analyses show few significant biases be- Analyses show few significant biases be- tween those who remained in the study tween those who remained in the study and those who did not (Wadsworth and those who did not (Wadsworth et al et al, , 1992), and comparisons with census data 1992), and comparisons with census data suggest that the remaining cohort suggest that the remaining cohort ( (n n¼3673 at age 53 years) is broadly repre- 3673 at age 53 years) is broadly repre- sentative of all native-born adults of a simi- sentative of all native-born adults of a simi- lar age and currently resident in England, lar age and currently resident in England, Scotland or Wales (Wadsworth Scotland or Wales (Wadsworth et al et al, 2003).

, 2003). Psychiatric treatment Psychiatric treatment Survey members reported all prescription Survey members reported all prescription medication use in a postal questionnaire medication use in a postal questionnaire at age 31 years, and in person to a nurse at age 31 years, and in person to a nurse interviewer at ages 36, 43 and 53 years. interviewer at ages 36, 43 and 53 years. Medications recorded were then matched Medications recorded were then matched to a to a British National Formulary British National Formulary ( (BNF BNF) ) code (British Medical Association & Royal code (British Medical Association & Royal Pharmaceutical Society of Great Britain, Pharmaceutical Society of Great Britain, 2002) by a trained research nurse. Medica- 2002) by a trained research nurse. Medica- tions described in this report are those used tions described in this report are those used for treatment of common psychiatric for treatment of common psychiatric symptoms: hypnotics ( symptoms: hypnotics (BNF BNF section 4.1.1), section 4.1.1), anxiolytics ( anxiolytics (BNF BNF section 4.1.2) and anti- section 4.1.2) and anti- depressants ( depressants (BNF BNF section 4.3). In addition, section 4.3). In addition, survey members were asked at age 36 years survey members were asked at age 36 years and age 43 years if they had visited a and age 43 years if they had visited a physician in the previous year for ‘nerves’. physician in the previous year for ‘nerves’. Definitions Definitions Throughout this paper we use the term Throughout this paper we use the term ‘common mental disorder’ to describe cases ‘common mental disorder’ to describe cases of mental disorder characterised by of mental disorder characterised by symptoms of depression and/or anxiety symptoms of depression and/or anxiety (Goldberg, 1991).

(Goldberg, 1991). Common mental disorder Common mental disorder Presence of adult common mental disorder Presence of adult common mental disorder was measured by the Present State Examin- was measured by the Present State Examin- ation (PSE; Wing ation (PSE; Wing et al et al, 1974) at age 36 , 1974) at age 36 years, by the Psychiatric Symptom Fre- years, by the Psychiatric Symptom Fre- quency scale (PSF; Lindelow quency scale (PSF; Lindelow et al et al, 1997) , 1997) at age 43 years and by the 28-item General at age 43 years and by the 28-item General Health Questionnaire (GHQ; Goldberg & Health Questionnaire (GHQ; Goldberg & Hillier, 1979) at age 53 years. Survey mem- Hillier, 1979) at age 53 years. Survey mem- bers were categorised as cases at age 36 bers were categorised as cases at age 36 years if they scored 5 or higher on the Index years if they scored 5 or higher on the Index of Definition on the PSE (Wing of Definition on the PSE (Wing et al et al, 1978), , 1978), yielding a prevalence of 6%. Survey yielding a prevalence of 6%. Survey members were categorised as cases if they members were categorised as cases if they 15 6 15 6 B R I T IS H J O UR N AL O F P SYC HI AT RY BR I T IS H J O URNA L O F P SYC HIAT RY ( 2 0 0 6 ) , 1 8 9, 1 5 6 ^ 1 6 0 . d o i : 1 0 .11 9 2 / b j p . b p .1 0 5 . 0 1 7 4 3 4 ( 2 0 0 6 ) , 1 8 9, 1 5 6 ^ 1 6 0 . d o i : 1 0 .11 9 2 / b j p . b p .1 0 5 . 0 17 4 3 4 Three decades of antidepressant, anxiolytic and Three decades of antidepressant, anxiolytic and hypnotic use in a national population birth cohort hypnotic use in a national population birth cohort IAN COLMAN, MICHAEL E. J. WADSWORTH, TIM J. CROUDACE IAN COLMAN, MICHAEL E. J. WADSWORTH, TIM J. CROUDACE and PETER B. JONES and PETER B. JONES

P S YCHOT ROP IC ME DIC AT ION US E 1 9 7 7 ^ 1 9 9 9 P S YCHOT ROP IC ME DIC AT ION US E 1 9 7 7 ^ 1 9 9 9 scored in the most severely affected 6% on scored in the most severely affected 6% on the PSF and GHQ at ages 43 and 53 years the PSF and GHQ at ages 43 and 53 years respectively. respectively. Statistical method Statistical method Prevalence of reported use of antidepres- Prevalence of reported use of antidepres- sants, anxiolytics and hypnotics at ages sants, anxiolytics and hypnotics at ages 31, 36, 43 and 53 years is presented as 31, 36, 43 and 53 years is presented as crude data and as number of individuals crude data and as number of individuals per 1000 persons in the survey population. per 1000 persons in the survey population. The trend in prevalence over these four ages The trend in prevalence over these four ages was analysed using a chi-squared test for was analysed using a chi-squared test for trend. Prevalence of antidepressant, anxio- trend. Prevalence of antidepressant, anxio- lytic or hypnotic use among those with lytic or hypnotic use among those with common mental disorder is presented as a common mental disorder is presented as a proportion, and associations between medi- proportion, and associations between medi- cation use and common mental disorder are cation use and common mental disorder are presented using odds ratios and 95% confi- presented using odds ratios and 95% confi- dence intervals. The association between dence intervals. The association between severity of symptoms of common mental severity of symptoms of common mental disorder and prevalence of antidepressant, disorder and prevalence of antidepressant, anxiolytic or hypnotic use was analysed anxiolytic or hypnotic use was analysed using a chi-squared test for trend. Preva- using a chi-squared test for trend. Preva- lence of antidepressant, anxiolytic or hyp- lence of antidepressant, anxiolytic or hyp- notic use and associations between notic use and associations between medication use and common mental disor- medication use and common mental disor- der over time are presented with propor- der over time are presented with propor- tions, ORs and 95% CIs. The focus of tions, ORs and 95% CIs. The focus of our analysis was common mental disorders, our analysis was common mental disorders, so we eliminated individuals who reported so we eliminated individuals who reported use of antipsychotics ( use of antipsychotics (BNF BNF sections 4.2.1 sections 4.2.1 and 4.2.2) or mood stabilisers (antimanic and 4.2.2) or mood stabilisers (antimanic drugs; drugs; BNF BNF section 4.2.3) at any time dur- section 4.2.3) at any time dur- ing the follow-up period ( ing the follow-up period (n n¼55). All ana- 55). All ana- lyses were performed using Stata version lyses were performed using Stata version 8.0 for Windows.

8.0 for Windows. RESULTS RESULTS Prevalence of antidepressant, Prevalence of antidepressant, anxiolytic and hypnotic use anxiolytic and hypnotic use Prevalence of any antidepressant, anxiolytic Prevalence of any antidepressant, anxiolytic or hypnotic use increased significantly from or hypnotic use increased significantly from 1977 (30.6 per 1000) through 1982 (44.6 1977 (30.6 per 1000) through 1982 (44.6 per 1000) and 1989 (45.2 per 1000) to 1999 per 1000) and 1989 (45.2 per 1000) to 1999 (59.1 per 1000) ( (59.1 per 1000) (w w2 2 test for trend, test for trend, P P5 5 0.001), as the cohort aged (Table 1). Preva- 0.001), as the cohort aged (Table 1). Preva- lence of individuals using more than one class lence of individuals using more than one class of psychotropic medication was low: 5.4 per of psychotropic medication was low: 5.4 per 1000 in 1977, 4.3 per 1000 in 1982, 4.7 per 1000 in 1977, 4.3 per 1000 in 1982, 4.7 per 1000 in 1989, to 7.1 per 1000 in 1999. 1000 in 1989, to 7.1 per 1000 in 1999. Use of specific classes of medications in Use of specific classes of medications in 1977 (age 31), 1982 (age 36), 1989 (age 43) 1977 (age 31), 1982 (age 36), 1989 (age 43) and 1999 (age 53) is shown in Table 1. Use and 1999 (age 53) is shown in Table 1. Use of anxiolytic medications dropped from of anxiolytic medications dropped from 1977 to 1999, whereas antidepressant use, 1977 to 1999, whereas antidepressant use, in contrast, increased. With regard to in contrast, increased. With regard to specific medications, the most common specific medications, the most common drug in 1977, 1982 and 1989 was drug in 1977, 1982 and 1989 was diazepam (13.9, 16.5 and 12.8 per 1000 diazepam (13.9, 16.5 and 12.8 per 1000 respectively). In 1999 the most common respectively). In 1999 the most common medication was the tricyclic antidepressant medication was the tricyclic antidepressant amitriptyline (10.9 per 1000), followed by amitriptyline (10.9 per 1000), followed by the selective serotonin reuptake inhibitor the selective serotonin reuptake inhibitor fluoxetine (9.2 per 1000).

fluoxetine (9.2 per 1000). Associations between Associations between antidepressant, anxiolytic antidepressant, anxiolytic or hypnotic use and common or hypnotic use and common mental disorder mental disorder Table 2 shows the prevalence of antidepres- Table 2 shows the prevalence of antidepres- sant, anxiolytic or hypnotic use among sant, anxiolytic or hypnotic use among individuals with and without common individuals with and without common mental disorder at ages 36, 43 and 53 mental disorder at ages 36, 43 and 53 years. Prevalence of medication use among years. Prevalence of medication use among those with such disorder was relatively con- those with such disorder was relatively con- stant: 23.3% at age 36, 27.0% at age 43 stant: 23.3% at age 36, 27.0% at age 43 and 27.0% at age 53. Those identified as and 27.0% at age 53. Those identified as having a common mental disorder were sig- having a common mental disorder were sig- nificantly more likely to be using these psy- nificantly more likely to be using these psy- chotropic medications than those below the chotropic medications than those below the cut-off for such disorder, with OR in the cut-off for such disorder, with OR in the range 7.7–11.9 (Table 2). range 7.7–11.9 (Table 2). Among those using an antidepressant, Among those using an antidepressant, anxiolytic or hypnotic, only 30.6% were anxiolytic or hypnotic, only 30.6% were identified as having a common mental identified as having a common mental disorder at age 36, 37.5% at age 43 and disorder at age 36, 37.5% at age 43 and 27.2% at age 53 years. Figure 1 shows that 27.2% at age 53 years. Figure 1 shows that those using an antidepressant, anxiolytic or those using an antidepressant, anxiolytic or hypnotic who did not reach the threshold hypnotic who did not reach the threshold for common mental disorder for common mental disorder might have might have been experiencing sub-threshold been experiencing sub-threshold or partially or partially treated symptoms. A significant trend can treated symptoms. A significant trend can be seen between severity of symptoms and be seen between severity of symptoms and prevalence of medication use at ages 36, prevalence of medication use at ages 36, 43 and 53 years ( 43 and 53 years (w w2 2 test for trend; test for trend; P P5 50.001 for all three ages). 0.001 for all three ages). Physician visits for ‘nerves’ Physician visits for ‘nerves’ At age 36 years, 10.6% of survey members At age 36 years, 10.6% of survey members reported seeing a physician for treatment of reported seeing a physician for treatment of ‘nerves’ in the past year, and 5.3% reported ‘nerves’ in the past year, and 5.3% reported seeing a physician for the same reason at seeing a physician for the same reason at age 43. Less than half of those with com- age 43. Less than half of those with com- mon mental disorder reported visiting a mon mental disorder reported visiting a physician for treatment of nerves in the pre- physician for treatment of nerves in the pre- vious year (43.3% and 38.2% at age 36 vious year (43.3% and 38.2% at age 36 and age 43 respectively). Among those and age 43 respectively). Among those who had a common mental disorder at who had a common mental disorder at age 36 and had seen a physician for treat- age 36 and had seen a physician for treat- ment of nerves in the previous year, ment of nerves in the previous year, 47.9% were using an antidepressant, 47.9% were using an antidepressant, anxiolytic or hypnotic, whereas the corre- anxiolytic or hypnotic, whereas the corre- sponding figure at age 43 was 57.4%. sponding figure at age 43 was 57.4%. Finally, among those who were currently Finally, among those who were currently using an antidepressant, anxiolytic or using an antidepressant, anxiolytic or hypnotic, 37.0% and 43.7%, at age 36 hypnotic, 37.0% and 43.7%, at age 36 and 43 respectively, did not report having and 43 respectively, did not report having 157 157 Table1 Table1 Prevalence of antidepressant, anxiolytic and hypnotic use in the National Survey of Health and Prevalence of antidepressant, anxiolytic and hypnotic use in the National Survey of Health and Development in1977,1982,1989 and1999 Development in1977,1982,1989 and1999 Year Year 1977 1977 1982 1982 1989 1989 1999 1999 Age of cohort, years Age of cohort, years 31 31 36 36 43 43 53 53 Size of sample reporting, Size of sample reporting, n n 3299 3299 3272 3272 3211 3211 2945 2945 Medication use, Medication use, n n Any antidepressant, anxiolytic or hypnotic Any antidepressant, anxiolytic or hypnotic 101 101 146 146 145 145 174 174 More than one class More than one class 18 18 14 14 15 15 21 21 Hypnotics Hypnotics 19 19 30 30 46 46 28 28 Anxiolytics Anxiolytics 71 71 97 97 61 61 25 25 Antidepressants Antidepressants 33 33 35 35 58 58 144 144 Tricyclic antidepressants Tricyclic antidepressants 31 31 30 30 56 56 77 77 MAO inhibitors MAO inhibitors 1 1 2 2 0 0 0 Compound antidepressants Compound antidepressants 0 0 1 1 0 0 2 2 SSRIs SSRIs 0 0 0 0 1 1 61 61 Other antidepressants Other antidepressants 1 1 4 4 3 3 10 10 MAO, monoamine oxidase; SSRIs, selective serotonin reuptake inhibitors. MAO, monoamine oxidase; SSRIs, selective serotonin reuptake inhibitors. Table 2 Table 2 Association between antidepressant, Association between antidepressant, anxiolytic or hypnotic use and common mental anxiolytic or hypnotic use and common mental disorder at ages 36, 43, and 53 years disorder at ages 36, 43, and 53 years Age, Age, years years Prevalence of Prevalence of medication use, % medication use, % Odds ratio Odds ratio (95% CI) (95% CI) CMD CMD1 1 No CMD No CMD2 2 36 36 23.3 23.3 3.3 3.3 9.0 (6.1^13.3) 9.0 (6.1^13.3) 43 43 27.0 27.0 3.0 3.0 11.9 (8.2^17.4) 11.9 (8.2^17.4) 53 53 27.0 27.0 4.6 4.6 7.7 (5.3^11.3) 7.7 (5.3^11.3) CMD, common mental disorder. CMD, common mental disorder. 1. Sample 1. Sample n n¼189 at age 36, 189 at age 36, n n¼200 at age 43, 200 at age 43, n n¼174 at 174 at age 53 years. age 53 years. 2. Sample 2. Sample n n¼3057 at age 36, 3057 at age 36, n n¼2994 at age 43, 2994 at age 43, n n¼2925 2925 at age 53 years. at age 53 years.

COLMAN E T AL COL MAN E T AL seen a physician for treatment of nerves in seen a physician for treatment of nerves in the past year. the past year. Antidepressant, anxiolytic and Antidepressant, anxiolytic and hypnotic use over time hypnotic use over time Investigation of medication use over time Investigation of medication use over time revealed that previous use of antidepres- revealed that previous use of antidepres- sants, anxiolytics or hypnotics was a strong sants, anxiolytics or hypnotics was a strong predictor of future use (Table 3). Individ- predictor of future use (Table 3). Individ- uals who used such medications at age 31 uals who used such medications at age 31 were 14.5 times more likely to use them were 14.5 times more likely to use them at age 36 than those not using these drugs at age 36 than those not using these drugs at age 31. Similar associations could be at age 31. Similar associations could be seen from age 36 to age 43, and from age seen from age 36 to age 43, and from age 43 to age 53. Longer-term associations 43 to age 53. Longer-term associations were also evident – individuals who used were also evident – individuals who used antidepressants, anxiolytics or hypnotics antidepressants, anxiolytics or hypnotics at age 31 were 9.8 times more likely to at age 31 were 9.8 times more likely to use these medications at age 53 than those use these medications at age 53 than those not using them at age 31.

not using them at age 31. During an episode of common mental During an episode of common mental disorder, individuals were more likely to disorder, individuals were more likely to use antidepressants, anxiolytics or hypno- use antidepressants, anxiolytics or hypno- tics if they had used such medications in tics if they had used such medications in the past (Table 4). Individuals at age 36, the past (Table 4). Individuals at age 36, for example, were 8.6 times more likely to for example, were 8.6 times more likely to use antidepressants, anxiolytics or hypno- use antidepressants, anxiolytics or hypno- tics during an episode of common mental tics during an episode of common mental disorder if they had used these drugs at disorder if they had used these drugs at age 31. Similar results were observed for age 31. Similar results were observed for those with common mental disorder at ages those with common mental disorder at ages 43 and 53, although the effect was less 43 and 53, although the effect was less pronounced at each subsequent age. It is pronounced at each subsequent age. It is notable that the proportion of individuals notable that the proportion of individuals who had used antidepressants, anxiolytics who had used antidepressants, anxiolytics or hypnotics in the past and continued to or hypnotics in the past and continued to use them in a subsequent episode of com- use them in a subsequent episode of com- mon mental disorder dropped as the cohort mon mental disorder dropped as the cohort aged. For example, only 40.0% of individ- aged. For example, only 40.0% of individ- uals who had previously used an antide- uals who had previously used an antide- pressant, anxiolytic or hypnotic chose this pressant, anxiolytic or hypnotic chose this treatment during an episode of common treatment during an episode of common mental disorder at age 53. mental disorder at age 53. DISCUSSION DISCUSSION Population trends in use Population trends in use of psychotropic medications of psychotropic medications Since their birth in 1946, members of the Since their birth in 1946, members of the Medical Research Council National Survey Medical Research Council National Survey of Health and Development have lived of Health and Development have lived through an age of tremendous change in through an age of tremendous change in the treatment of mental disorders. The use the treatment of mental disorders. The use of antidepressants, anxiolytics and hypno- of antidepressants, anxiolytics and hypno- tics by cohort members over the past 30 tics by cohort members over the past 30 years reflects general population trends as years reflects general population trends as provided by prescription data in other stu- provided by prescription data in other stu- dies. With regard to antidepressant use by dies. With regard to antidepressant use by members of the survey, for example, there members of the survey, for example, there was a significant increase from 1977 to was a significant increase from 1977 to 1999, as has been reported elsewhere 1999, as has been reported elsewhere (Middleton (Middleton et al et al, 2001; Olfson , 2001; Olfson et al et al, , 2002; Helgason 2002; Helgason et al et al, 2004). This period , 2004). This period also saw the initiation of the Defeat Depres- also saw the initiation of the Defeat Depres- sion Campaign in Britain, during which sion Campaign in Britain, during which there was increasing awareness of depres- there was increasing awareness of depres- sion and treatment with antidepressants sion and treatment with antidepressants among the British population (Paykel among the British population (Paykel et et al al, 1998). Although the dramatic increase , 1998). Although the dramatic increase in antidepressant use can be attributed to in antidepressant use can be attributed to the introduction of selective serotonin re- the introduction of selective serotonin re- uptake inhibitors, this has not resulted in uptake inhibitors, this has not resulted in a corresponding drop in the use of tricyclic a corresponding drop in the use of tricyclic antidepressants (Middleton antidepressants (Middleton et al et al, 2001; , 2001; Helgason Helgason et al et al, 2004). At the same time, , 2004). At the same time, however, the cohort has been ageing. The however, the cohort has been ageing. The use of psychotropic medications increases use of psychotropic medications increases with age, as has been demonstrated in with age, as has been demonstrated in several countries (Middleton several countries (Middleton et al et al, 2001; , 2001; Ohayon & Lader, 2002; Bebbington Ohayon & Lader, 2002; Bebbington et al et al, , 2003). Consequently, the increase observed 2003). Consequently, the increase observed in our study probably reflects both an age- in our study probably reflects both an age- ing effect and a time-period effect. ing effect and a time-period effect. Mental disorder and use Mental disorder and use of antidepressants, anxiolytics of antidepressants, anxiolytics and hypnotics and hypnotics The associations between mental disorder The associations between mental disorder among members of the NSHD and among members of the NSHD and 15 8 15 8 Fig.1 Fig.1 Association between previous antidepressant, anxiolytic or hypnotic use and severity of common Association between previous antidepressant, anxiolytic or hypnotic use and severity of common mental symptoms at ages 36, 43, and 53 years.GHQ,General Health Questionnaire; PSE, Present State mental symptoms at ages 36, 43, and 53 years.GHQ,General Health Questionnaire; PSE, Present State Examination; PSF, Psychiatric Symptom Frequency.

Examination; PSF, Psychiatric Symptom Frequency.

P S YCHOT ROP IC ME DIC AT ION US E 1 9 7 7 ^ 1 9 9 9 P S YCHOT ROP IC ME DIC AT ION US E 1 9 7 7 ^ 1 9 9 9 psychiatric treatment are notable. At ages psychiatric treatment are notable. At ages 36 and 43, less than half of those with 36 and 43, less than half of those with common mental disorder had visited a common mental disorder had visited a physician for treatment for nerves in the physician for treatment for nerves in the previous year. Less than a third of individ- previous year. Less than a third of individ- uals with common mental disorder were uals with common mental disorder were using a psychotropic medication at ages using a psychotropic medication at ages 36, 43 and 53. These results mirror studies 36, 43 and 53. These results mirror studies from numerous countries that show that from numerous countries that show that less than half of individuals with common less than half of individuals with common mental disorder seek physician treatment mental disorder seek physician treatment (Howard (Howard et al et al, 1996; Lefebvre , 1996; Lefebvre et al et al, 1998; , 1998; Andrews Andrews et al et al, 2001; Spijker , 2001; Spijker et al et al, 2001; , 2001; Bebbington Bebbington et al et al, 2003; Burns , 2003; Burns et al et al, , 2003), and less than 40% use psychotropic 2003), and less than 40% use psychotropic medications (Spijker medications (Spijker et al et al, 2001; Bebbing- , 2001; Bebbing- ton ton et al et al, 2003; Simon , 2003; Simon et al et al, 2004; Patten , 2004; Patten et al et al, 2005). , 2005).

It is less clear why the majority of indi- It is less clear why the majority of indi- viduals with evidence of common mental viduals with evidence of common mental disorder are not treated for it. There is a disorder are not treated for it. There is a strong body of evidence suggesting that an strong body of evidence suggesting that an important factor is patient perception of important factor is patient perception of the need for help. In the National Comor- the need for help. In the National Comor- bidity Survey in the USA, only 34% of bidity Survey in the USA, only 34% of 1792 individuals with mood and/or anxiety 1792 individuals with mood and/or anxiety disorders perceived a need for professional disorders perceived a need for professional help (Mojtabai help (Mojtabai et al et al, 2002). Regardless of , 2002). Regardless of reasons that influence the decision to seek reasons that influence the decision to seek care, it appears that Goldberg & Huxley’s care, it appears that Goldberg & Huxley’s seminal model of the pathway to psychi- seminal model of the pathway to psychi- atric care (Goldberg & Huxley, 1980) atric care (Goldberg & Huxley, 1980) remains pertinent: it is only a fraction of remains pertinent: it is only a fraction of individuals with common mental disorders individuals with common mental disorders who seek help, a smaller fraction have their who seek help, a smaller fraction have their disorder recognised by their physician, and disorder recognised by their physician, and a yet smaller fraction receive appropriate a yet smaller fraction receive appropriate care.

care. It is notable that the majority of indi- It is notable that the majority of indi- viduals using a psychotropic medication viduals using a psychotropic medication do not reach the threshold for common do not reach the threshold for common mental disorder. Similar results have re- mental disorder. Similar results have re- cently been reported in a Canadian study cently been reported in a Canadian study (Patten (Patten et al et al, 2005). Without data describ- , 2005). Without data describ- ing the course of their illness, it is unclear ing the course of their illness, it is unclear whether these are patients whose symptoms whether these are patients whose symptoms have recently subsided, patients who are on have recently subsided, patients who are on successful maintenance therapy, or patients successful maintenance therapy, or patients who are being treated more aggressively who are being treated more aggressively than may be necessary. Our results, how- than may be necessary. Our results, how- ever, showing a strong association between ever, showing a strong association between severity of symptoms and likelihood of severity of symptoms and likelihood of treatment with psychotropic medication treatment with psychotropic medication suggest that individuals who do not meet suggest that individuals who do not meet the threshold for common mental disorder the threshold for common mental disorder but are using psychotropic medications but are using psychotropic medications are probably experiencing sub-threshold are probably experiencing sub-threshold symptoms and their treatment may be symptoms and their treatment may be appropriate.

appropriate. Individual use of antidepressants, Individual use of antidepressants, anxiolytics and hypnotics over time anxiolytics and hypnotics over time Presenting data from 1977 to 1999 gives a Presenting data from 1977 to 1999 gives a unique perspective on individuals’ use of unique perspective on individuals’ use of psychotropic medications over time. Psy- psychotropic medications over time. Psy- chotropic medication use at any time was chotropic medication use at any time was strongly predictive of future use, even 22 strongly predictive of future use, even 22 years later. In addition, as retrospective stu- years later. In addition, as retrospective stu- dies have suggested (Blumenthal & Endi- dies have suggested (Blumenthal & Endi- cott, 1996; Burns cott, 1996; Burns et al et al, 2003), previous , 2003), previous use of psychotropic medication is a strong use of psychotropic medication is a strong predictor of whether individuals would predictor of whether individuals would seek pharmaceutical treatment during a seek pharmaceutical treatment during a future episode of mental disorder. It was future episode of mental disorder. It was notable, however, that this association notable, however, that this association became weaker as the cohort aged. Not became weaker as the cohort aged. Not using a treatment during an episode of using a treatment during an episode of mental disorder that had been previously mental disorder that had been previously employed may indicate a treatment failure employed may indicate a treatment failure in the past. Individuals may be requesting in the past. Individuals may be requesting non-pharmaceutical treatments such as non-pharmaceutical treatments such as cognitive–behavioural therapy, or simply cognitive–behavioural therapy, or simply not seeking treatment at all.

not seeking treatment at all. Limitations and strengths Limitations and strengths of the study of the study One limitation of our study is that we do One limitation of our study is that we do not have information on non-pharmaceuti- not have information on non-pharmaceuti- cal treatment of mental disorder among the cal treatment of mental disorder among the survey members. The fact that approxi- survey members. The fact that approxi- mately 40–50% of individuals in our inves- mately 40–50% of individuals in our inves- tigation who had a common mental tigation who had a common mental disorder and saw a physician for ‘nerves’ disorder and saw a physician for ‘nerves’ in the past year were not taking psycho- in the past year were not taking psycho- tropic medication suggests that some might tropic medication suggests that some might have been treated with psychotherapy or have been treated with psychotherapy or other non-pharmacological approaches. other non-pharmacological approaches. Results from a British study show that Results from a British study show that psychotherapeutic treatment is almost as psychotherapeutic treatment is almost as common as treatment with psychotropic common as treatment with psychotropic medication among individuals with a medication among individuals with a neurotic mental disorder who consulted a neurotic mental disorder who consulted a primary care physician in the previous year primary care physician in the previous year (Bebbington (Bebbington et al et al, 2003), and similar results , 2003), and similar results have been reported in the USA (Olfson have been reported in the USA (Olfson et et al al, 2002). There is evidence to support , 2002). There is evidence to support some psychotherapeutic approaches, such some psychotherapeutic approaches, such as cognitive–behavioural therapy, as an as cognitive–behavioural therapy, as an alternative or adjunct to pharmacotherapy alternative or adjunct to pharmacotherapy for depression (DeRubeis for depression (DeRubeis et al et al, 1999, , 1999, 2005), so it is possible that the proportion 2005), so it is possible that the proportion of individuals who are receiving appropriate of individuals who are receiving appropriate treatment for their mental disorder is higher treatment for their mental disorder is higher than the proportions using psychotropic than the proportions using psychotropic medication reported here. In addition, it is medication reported here. In addition, it is worth noting that the majority of cases of worth noting that the majority of cases of depression remit without any form of depression remit without any form of psychiatric treatment (Wells psychiatric treatment (Wells et al et al, 1992).

, 1992). Another limitation of this study is that Another limitation of this study is that we do not measure distinct DSM disorders we do not measure distinct DSM disorders separately. Given the comorbidity between separately. Given the comorbidity between many DSM mental disorders (Kessler many DSM mental disorders (Kessler et et al al, 1994), we do not expect this to affect , 1994), we do not expect this to affect our results significantly. Evidence suggests, our results significantly. Evidence suggests, for example, that mixed and/or comorbid for example, that mixed and/or comorbid anxiety and depression are more common anxiety and depression are more common 15 9 15 9 Table 3 Table 3 Association between previous antidepressant, anxiolytic or hypnotic use and current use at ages 36, Association between previous antidepressant, anxiolytic or hypnotic use and current use at ages 36, 43 and 53 years 43 and 53 years Odds ratios for medication use Odds ratios for medication use Age 36 years Age 36 years OR (95% CI) OR (95% CI) Age 43 years Age 43 years OR (95% CI) OR (95% CI) Age 53 years Age 53 years OR (95% CI) OR (95% CI) Previous antidepressant, Previous antidepressant, anxiolytic or hypnotic use at age anxiolytic or hypnotic use at age 31 years 31 years 14.5 (9.0^23.4) 14.5 (9.0^23.4) 8.5 (5.0^14.4) 8.5 (5.0^14.4) 9.8 (5.8^16.5) 9.8 (5.8^16.5) 36 years 36 years 10.0 (6.4^15.6) 10.0 (6.4^15.6) 8.6 (5.5^13.3) 8.6 (5.5^13.3) 43 years 43 years 8.8 (5.7^13.6) 8.8 (5.7^13.6) Table 4 T able 4 Association between previous antide- Association between previous antide- pressant, anxiolytic or hypnotic use and current use pressant, anxiolytic or hypnotic use and current use among those with common mental disorder at ages among those with common mental disorder at ages 36, 43 and 53 years 36, 43 and 53 years Age, Age, years years Prevalence of medication Prevalence of medication use during episode use during episode of CMD, % of CMD, % Odds ratio Odds ratio (95% CI) (95% CI) Previous Previous use use1 1 No No previous previous use use2 2 36 36 62.5 62.5 16.2 16.2 8.6 (3.4^22.2) 8.6 (3.4^22.2) 43 43 51.6 51.6 20.5 20.5 4.1 (1.8^9.5) 4.1 (1.8^9.5) 53 53 40.0 40.0 19.3 19.3 2.8 (1.3^6.2) 2.8 (1.3^6.2) CMD, common mental disorder. CMD, common mental disorder. 1. Sample 1. Sample n n¼24 at age 36, 24 at age 36, n n¼31at age 43, 31at age 43, n n¼40 at age 53 40 at age 53 years.

years. 2. Sample 2. Sample n n¼136 at age 36, 136 at age 36, n n¼127 at age 43, 127 at age 43, n n¼109 at 109 at age 53 years. age 53 years.

COLMAN E T AL COL MAN E T AL than either disorder alone (Singleton than either disorder alone (Singleton et al et al, , 2003), symptoms of anxiety are frequently 2003), symptoms of anxiety are frequently successfully treated with selective serotonin successfully treated with selective serotonin reuptake inhibitor antidepressants (Kapc- reuptake inhibitor antidepressants (Kapc- zinski zinski et al et al, 2003) and individuals with nu- , 2003) and individuals with nu- merous anxiety and depressive disorders merous anxiety and depressive disorders have increased use of antidepressants, an- have increased use of antidepressants, an- xiolytics and hypnotics (Bebbington xiolytics and hypnotics (Bebbington et al et al, , 2003; Ohayon & Lader, 2002). Further- 2003; Ohayon & Lader, 2002). Further- more, all classes of psychotropic medica- more, all classes of psychotropic medica- tions (antidepressants, anxiolytics and tions (antidepressants, anxiolytics and hypnotics) in our study were significantly hypnotics) in our study were significantly associated with our measure of common associated with our measure of common mental disorder (further information avail- mental disorder (further information avail- able from the authors upon request). able from the authors upon request). A final limitation is that we did not A final limitation is that we did not know the stage of illness of the participants know the stage of illness of the participants with mental disorder. It is possible that with mental disorder. It is possible that individuals who had not sought treatment individuals who had not sought treatment were at an early phase of their mental ill- were at an early phase of their mental ill- ness and would have sought treatment as ness and would have sought treatment as the illness continued. All comparable stu- the illness continued. All comparable stu- dies in this area face this limitation, the dies in this area face this limitation, the only solution being an intensive prospective only solution being an intensive prospective study of the onset of illness and whether study of the onset of illness and whether individuals subsequently seek treatment. individuals subsequently seek treatment. The study design of the NSHD also The study design of the NSHD also offers some notable methodological offers some notable methodological strengths. This survey has a large sample strengths. This survey has a large sample that is population-based, with all data that is population-based, with all data being prospectively collected over a 53-year being prospectively collected over a 53-year period. This has allowed us to present data period. This has allowed us to present data on population trends of antidepressant, on population trends of antidepressant, anxiolytic and hypnotic use, associations anxiolytic and hypnotic use, associations between antidepressant, anxiolytic and between antidepressant, anxiolytic and hypnotic use and common mental disorder, hypnotic use and common mental disorder, and trends in individual use of these medi- and trends in individual use of these medi- cations over time. These results confirm cations over time. These results confirm that although psychotropic medication use that although psychotropic medication use is rising, the majority of individuals with is rising, the majority of individuals with an identifiable common mental disorder an identifiable common mental disorder are not being treated with drugs. are not being treated with drugs. ACKNOWLEDGEMENTS ACKNOWLEDGEMENTS The authors are grateful for funding from the Insti- The authors are grateful for funding from the Insti- tute for Social Studies in Medical Care (I.C.), the tute for Social Studies in Medical Care (I.C.), the UK Medical Research Council (M.E.J.

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10.1192/bjp.bp.105.017434 Access the most recent version at DOI: 2006, 189:156-160. BJP Ian Colman, Michael E. J. Wadsworth, Tim J. Croudace and Peter B. Jones a national population birth cohort Three decades of antidepressant, anxiolytic and hypnotic use in References http://bjp.rcpsych.org/content/189/2/156#BIBL This article cites 25 articles, 6 of which you can access for free at: permissions Reprints/ permissions@rcpsych.ac.uk write to To obtain reprints or permission to reproduce material from this paper, please to this article at You can respond http://bjp.rcpsych.org/letters/submit/bjprcpsych;189/2/156 from Downloaded The Royal College of Psychiatrists Published by on February 4, 2015 http://bjp.rcpsych.org/ http://bjp.rcpsych.org/site/subscriptions/ go to: The British Journal of Psychiatry To subscribe to

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