Influence of psychotherapist density and antidepressant sales on suicide rates

Acta Psychiatr Scand 2009: 119: 236–242 Journal Compilation Ó 2008 Blackwell Munksgaard Influence of psychotherapist density andantidepressant sales on suicide rates Kapusta ND, Niederkrotenthaler T, Etzersdorfer E, Voracek M, Dervic K, Jandl-Jager E, Sonneck G. Influence of psychotherapist density and antidepressant sales on suicide rates.
E. Etzersdorfer3, M. Voracek4,K. Dervic5, E. Jandl-Jager1, Objective: Antidepressant sales and suicide rates have been shown to be correlated in industrialized countries. The aim was to study the 1Department of Psychoanalysis and Psychotherapy, possible effects of psychotherapy utilization on suicide rates.
Medical University of Vienna, Vienna, Austria, 2Center Method: We assessed the impact of antidepressant sales and of Public Health, Institute for Medical Psychology, psychotherapist density on suicide rates between 1991 and 2005. To Medical University of Vienna, Vienna, Austria, 3Furtbach adjust for serial correlation in time series, three first-order Hospital for Psychiatry and Psychotherapy, Stuttgart, autoregressive models adjusted for per capita alcohol consumption and Germany, 4Department of Basic Psychological Research, School of Psychology, University of Vienna, Vienna, Results: Antidepressant sales and the density of psychotherapists in Austria, 5Department of Child and Adolescent the population were negatively associated with suicide rates.
Psychiatry ⁄ University Hospital, Medical University of Conclusion: This study provides evidence that decreasing suicide rates Vienna, Vienna, Austria and 6Ludwig Boltzmann were associated with both increasing antidepressant sales and an Institute for Social Psychiatry, Vienna, Austria increasing density of psychotherapists. The decrease of suicide ratescould reflect a general improvement in mental health care rather than Key words: suicide; antidepressives; psychotherapy being caused by antidepressant sales or psychotherapist density alone.
Nestor D Kapusta, MD, Department of Psychoanalysisand Psychotherapy, Medical University of Vienna,Waehringer Guertel 18-20, A-1090 Vienna, Austria.
E-mail: [email protected] Accepted for publication October 22, 2008 This study implies that antidepressant sales were associated with suicide rates.
The decrease in suicide rates can alternatively be explained by increased psychotherapist density in amodel adjusted for unemployment and per capita alcohol consumption.
The high correlation of antidepressant sales and psychotherapist density suggests a commonunderlying factor which could be responsible for the decrease in suicide rates.
Ecological studies can only find associations.
The interpretation of the results has to consider multicollinearity between antidepressant sales andpsychotherapist density.
The results challenge the hypothesis that antidepressants are solely responsible for the decrease insuicide rates, but further examination of the influence of psychotherapy on suicide rates is needed aspsychotherapist density may not properly reflect psychotherapy utilization.
rates (1–3) and per capita alcohol consumption (4, 5). In addition, a number of studies suggest an Suicide is the result of a complex interplay of impact of increasing antidepressant sales on decreasing suicide rates (6–12); although several factors. At the aggregate level, suicide rates have studies support this hypothesis only partially been shown to be influenced by unemployment (13–15), others do not (16, 17). The Food and Psychotherapist density and suicide rates Drug Administration (FDA) black box warning on did not consult a physician in the 10 days prior to antidepressant use initiated a scientific controversy death by a physician authorized by the local health about the safety of antidepressants (18). Associa- authority (30). Given the fact that low autopsy tions of antidepressant sales and suicide rates rates may negatively affect suicide rates (31), it has gained increased interest because of the contro- to be mentioned that the rate of autopsies in versy and support the evidence for the suicide- Austria is relatively high compared with the preventive effects of antidepressant intake. Such international average (32). A recent study reported associations, however, are prone to misinterpreta- an average autopsy rate of 29% in Austria between tion, when derived from unadjusted models (19).
1991 and 2000 (30). Figures on the unemployment The evidence drawn from the seminal Gotland rates were obtained from the Organization for study (20) and their replications (21, 22) supports the fact that education of general practitioners in (OECD). Statistics on alcohol consumption per the diagnosis and treatment of depression increases capita were obtained from the Austrian Alcohol antidepressant use and decreases suicide rates.
Coordination and Information Center (33). The Moreover, the general availability of healthcare Austrian Institute of Health provided figures on services seems to influence the diagnosis and the official numbers of psychotherapists registered treatment of depression (23) and it has been by the Austrian Ministry of Health and Women reported that suicide rates correlate with access to (34). In Austria, after the enactment of a psycho- healthcare facilities, including psychiatrists and therapy law in 1991 that regulated the training and other physicians (24). However, there is evidence qualification criteria for the profession of psycho- that, besides antidepressants, psychotherapy is therapists for the first time nationwide (35), the effective in the treatment of depression (25, 26) number of psychotherapists grew steadily. The and in suicide prevention (27). In the USA, a initial registration process of active psychothera- national trend of increased psychotherapeutic pists lasted 2 years. A prelegislation survey on the treatment has been discussed as a possible moder- number of persons providing psychotherapy esti- ating variable of suicide rates (11); an increase in mated that approximately 3000 (39.6 per 100 000) the visits to psychotherapists for mood disorders persons would qualify for the registration process correlated with a decrease in suicide rates (28).
(36). Therefore, the psychotherapist density in 1991 A recent study of prepaid health plan register and 1992 from Table 1 has been adjusted to the data showed that the number of suicide attempts calculated growth of the psychotherapist density decreases among persons either starting anti- between 1993 and 2005 (y = 0.264x + 2.082) to depressant medication or psychotherapy (29).
reduce the registration bias. Statistics on antide- As psychotherapy has become an integral part of pressant sales were obtained from IMS Health the treatment of mental disorders and mood Austria (Vienna), an independent international disorders, and is often seen as an alternative or agency that monitors the pharmaceutical market.
adjunct to medication, it would be interesting to All antidepressants, regardless of class, were shed light on the possible influence of psychother- included in the analysis. Data on over-the-counter package sales were converted to defined daily doses(DDD ⁄ 1000 inhabitants per day) as suggested bythe World Health Organization (37). In Austria, antidepressants are available only on prescription.
The aim of the study was to evaluate three multi- Only 20% of psychotherapists are physicians and variate statistical models with respect to decrease therefore entitled to prescribe antidepressants. All in suicide rates in Austria, with antidepressant other psychotherapists are mostly psychologists use, psychotherapist density, alcohol consumption (45%), teachers (13%), social workers (8%) and and unemployment as predictor variables.
pedagogues (8%) as well as other professionals(36). Suicide rates were defined as the number ofsuicides per 100 000 inhabitants per year. The density of psychotherapists per year was calculatedas the number of psychotherapists per 100 000 of Data on the number of suicides per year as well ason the size of the general population were obtained from Statistics Austria. In Austria, a death certif-icate must be issued for every deceased person. An We applied a variable selection method, as autopsy has to be performed on all persons who described by Neter et al. (38). In the first step, we Table 1. Suicide rates, psychotherapist density, antidepressant sales and socioeconomic factors in Austria (1991–2005) tested all variables for their inter-relations. A antidepressant use, there was a twofold increase in strong correlation between antidepressant use and psychotherapist density was observed (PearsonÕsr = 0.96, P < 0.001). In the second step, we calculated first-order autoregressive (AR1) modelsof aggregate time-series data to adjust for serial In the crude AR1 models, psychotherapist density correlation in time series for each predictor (anti- and antidepressant use significantly negatively depressant sales, psychotherapist density, unem- correlated with the total suicide rate, while per capita alcohol consumption and unemployment Finally, the effect parameters were analyzed in did not correlate with the total suicide rate.
three first-order autoregressive models adjusted for The adjusted AR1 model estimates are shown in unemployment and alcohol consumption, with Table 2. The results indicate that model 1, with suicide rate as the outcome variable and (1) antidepressant use being the significant predictor antidepressant use, (2) psychotherapist density variable, fits the data as well as model 2 with and (3) both simultaneously as predictor variables.
psychotherapist density as the significant variable Regression model diagnostics included examina- (r2). In model 3, with all explanatory variables in tion of autocorrelation and partial autocorrelation one common model, both the effect of antidepres- plots as well as the inspection of heteroscedasticity sant use and that of psychotherapist density are plots. All statistics were calculated using spss (version 14.0; SPSS Inc., Chicago, IL, USA).
Significance was set at P < 0.05 (two tailed).
This study found that both antidepressant use and psychotherapist density increased rapidly in Austria During the 15-year period (1991–2005), the overall during 1991–2005, whereas the total suicide rate suicide rate in Austria decreased from 22.6 (per decreased. After controlling for alcohol consump- 100 000 inhabitants per year) to 17.0. This decreas- tion per capita and unemployment rates, antidepres- ing trend can be observed since 1987. The suicide sant sales were found to be inversely associated with rates in terms of age categories (0–19, 20–64, and the overall suicide rate. The inverse relationship 65+ years) are shown in Fig. 1. Tests for trends in between antidepressant sales and suicide rates suicide rates during 1991–2005 were applied and between 1991 and 2005, as shown in our study, conforms with previous studies with comparable During the time period, per capita alcohol timeframes: Japan, 1999–2003 (6); England, 1993– consumption decreased by 15%, the overall unem- 2002 (10); USA, 1985–1999 (11); Northern Ireland, ployment rate ranged from 3.5% to 5.2% (mean 1989–1999 (14); Italy, 1983–2000 (16); Iceland, 4.0%; SD 0.52%). Raw data are presented in 1989–2000 (17); Sweden, 1995–2002 (21) and Table 1. Besides a more than fivefold increase in Finland, 1994–2001 (23). Reseland et al. (31) Psychotherapist density and suicide rates Fig. 1. The course of antidepressant sales, psychotherapist density and the suicide rate in Austria (1970–2005).
Table 2. Model estimates of first-order autoregressive analyses with total suicide antidepressant prescriptions on suicide, whereas this hypothesis has been supported by all multivariatestudies. The problem of unstable results of unad- justed studies can also be derived from five morerecent studies from Japan (6), Italy (16) and the Nordic countries (7, 13, 23). When HillÕs (41) nine epidemiologic criteria for causality (strength of association, consistency, specificity, temporality, biological gradient, plausibility, coherence, experi- ment and analogy) are applied to the model of the preventive effects of antidepressants on suicide, it is obvious that many of them remain unmet. Ecologic studies can contribute to the criteria of plausibility, consistency, temporality and analogy. Other study designs are needed to meet the other criteria.
The second result of this study – the negative association between the density of psychotherapists and suicide rates – is an alternative hypothetical explanation of the decrease in suicide rates. Thisplausible correlation is partially supported by a *Significant predictors (P < 0.05).
recent report indicating an increase in psychother-apist density in urban areas during 1991–2005 in examined even longer periods including all types Austria (34), which coincides with decreasing of antidepressants for the Nordic countries: suicide rates in urban areas of Austria (42). In Norway, 1974–2003; Sweden, 1977–2003; Den- the USA, visits to psychotherapists for mood mark, 1985–2003 and Finland, 1985–2003. Rising disorders were found to have increased between antidepressant use has previously been discussed in 1987 and 1997 (28). This finding has been discussed Austria as a possible factor influencing the decline in as a possible influence on suicide rates (11).
the general suicide rate (39). Of 13 ecologic studies However, as the increased density of psycho- on antidepressant sales and suicide published therapists in Austria does not necessarily reflect the between 1998 and 2005, only five were controlled utilization of psychotherapeutic care, this question for socioeconomic variables (40). Interestingly, it requires further examination. Because data on were the models that did not adjust for socioeco- psychotherapy use in Austria (e.g. numbers of nomic changes which produced controversial results visits) are not available, because of a lack of in terms of the hypothesis of preventive effects of assessment by the authorities, another indirect measure of psychotherapy use is the total cost other physicians increased from 302 to 442 per incurred to the social insurance system for refund- 100 000 inhabitants (+46%) (45). As shown in our ing psychotherapeutic visits. The official costs study, the density of psychotherapists in Austria increased by 68% from €22m in 1997 to €37m in increased from 40 to 74 per 100 000 (+86%), 2002 (43), which is well above the inflation rate therefore stronger than the density of general (about 3% per year) (44). This rise in costs practitioners. These numbers suggest that the corresponds to a similar 85% increase in psycho- density of psychotherapists is high, with nearly a therapist density during the same period. It has to half psychotherapist per every general practitioner.
be noted that psychotherapists in private practice Finally, as it is beyond the scope of this study to are only partly reimbursed by health insurances explore if the increasing psychotherapist density and that there are no reliable estimates of privately and the increasing number of antidepressants sold financed psychotherapy visits in Austria.
may reflect improvements in mental health care Nevertheless, as for antidepressant sales, we and its utilization in Austria, further studies are found an association between psychotherapist needed. In this context, a cross-sectional study density and suicide rates. This alternative expla- from the USA showed that suicide rates correlate nation challenges the hypothesis that the decrease with access to health care, including density of in suicide rates is solely because of increased psychiatrists and other physicians (24). Recently, it antidepressant use. The complex phenomenon of has been suggested that the availability of health- decreasing suicide rates cannot be attributed to a care services may help to increase the diagnosis of single factor. As antidepressant sales and psycho- depression (23). Therefore, it seems reasonable to therapist density strongly correlated in our study, assume that improved societal awareness of mental it is unsurprising that both models revealed a disorders would consequently lead to better diag- similar result. This exemplifies the problem of nosis and management of persons with mental multicollinearity in ecologic studies: a common disorders, and this has been previously discussed in underlying factor may be misleadingly masked by model selection. Model 3 with both antidepressantsales and psychotherapist density as explaining variables demonstrates the effect of multicollin-earity. The effect size of both variables was not Besides the limitations of the data on psychother- significant, without a major alteration in the apy use described above, this study has several model fit r2. From a statistical point of view, other limitations. Data on antidepressant use in one should decide which of the two variables to terms of age groups were not available and the exclude. As described before, there is more multivariate models were hence not stratified by evidence for the association of antidepressant age. Furthermore, only antidepressants were taken sales and suicide rates, than for the association into account, other compounds such as anti- of psychotherapist density and suicide rates.
psychotics or anxiolytics were not included in the study, and data on different categories of anti- independent of psychiatric care. Although only 20% of psychotherapists are also physicians (36) Psychotherapist density and the amount of and therefore entitled to prescribe drugs, psycho- antidepressant use are only proxies, i.e. antide- therapy is not only seen as an alternative but often pressant sales figures may not equal antidepres- used as an adjunct to medical treatment, which sant intake (we do not know the fate of sold partially explains the association between anti- drugs, i.e. whether they are actually taken or not), depressant sales and psychotherapist density. The and density figures of psychotherapists may not enactment of the psychotherapy law in 1991 equal the number of clients treated and psycho- coincided with the introduction of SSRIs in Aus- therapy hours consumed. We also do not know tria in late 1989. It is possible, that with a growing whether proportionally more depressive patients awareness of depressive disorders and the need for are utilizing psychotherapy now, with increasing pharmacological treatment, the awareness and number of psychotherapists, than previously when there were fewer psychotherapists. Furthermore, In the Gotland study, it has been shown that statistics on psychotherapists and antidepressants general practitioners were the personnel to influ- have been recorded only since 1991, while the ence suicide rates the most (20). In Austria, the decline in suicide rates in Austria began after density of general practitioners increased between 1990 and 2005 from 109 to 147 per 100 000 To conclude, the decline in suicide rates in inhabitants (+35%) and the proportion of all Austria during 1991–2005 was associated with an Psychotherapist density and suicide rates increase in antidepressant sales and in psychother- 15. Barbui C, Campomori A, DÕAvanzo B, Negri E, Garattini S.
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