C International Psychogeriatric Association 2015 International Psychogeriatrics (2015), 27:11, 1795–1803 doi:10.1017/S1041610215000216
Beliefs about antidepressants among persons aged 70 years and older in treatment after a suicide attempt ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Eva Lesén,1 Stefan Wiktorsson,2 Anders Carlsten,3 Margda Waern2 and Tove Hedenrud4 1
Nordic Health Economics AB, Gothenburg, Sweden Section of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 3 Medical Products Agency, Uppsala, Sweden 4 Dept. of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 2
ABSTRACT
Background: The use of antidepressants is associated with decreased suicide risk in late life, and these drugs are often prescribed after a suicide attempt. Yet little is known about attitudes to antidepressants in older persons with suicidal behavior. The aim of this study was to assess beliefs about antidepressant medicines in older persons in treatment one year after a suicide attempt. Methods: Forty-four individuals aged 70 years and older, who were treated in emergency wards at five hospitals in western Sweden in connection with a suicide attempt, were interviewed at index attempt and one year later. Beliefs about medicines questionnaire (BMQ) specific for antidepressants were analyzed one year after index attempt, in relation to sociodemographic variables, medication use, psychiatric evaluation, and personality traits. Results: The majority of participants perceived the necessity of their antidepressant medicine to outweigh their concerns. Lower perceived necessity of antidepressants was observed in those who were not on antidepressants at the time of the attempt as well as those with no prior history of suicide attempt before the index attempt. Individuals reporting hopelessness at follow-up had a higher perceived concern about using medication. Conclusions: Beliefs about antidepressants tended to be more positive than negative in older persons taking these drugs in the aftermath of a suicide attempt. Further studies are called for, and should include objective measures of medication adherence. Key words: beliefs about antidepressants, suicide attempt, older persons
Introduction Older persons have particularly high suicide rates compared to younger age groups (Conwell et al., 2002; Hawton and Van Heeringen, 2009). Mental health problems, such as mood disorders, substance misuse, and a history of suicide attempt have been identified as risk factors for suicidal behavior among older people (Conwell et al., 2002). Up to three quarters of those who commit suicide in late life suffer from a current depression, and the recognition and treatment of depression is thus an important target for the prevention of suicide in this age group (Conwell et al., 2002; Lapierre et al., 2011).
Correspondence should be addressed to: Tove Hedenrud, Dept. of Public Health and Community Medicine, P.O. Box 453, 405 30 Gothenburg, Sweden. Phone: +46-31-786 6855. Email: [email protected]. Received 1 Aug 2014; revision requested 17 Oct 2014; revised version received 22 Jan 2015; accepted 27 Jan 2015. First published online 2 March 2015.
There are several studies indicating that the use of antidepressants is associated with decreased suicide risk in older people (Gibbons et al., 2007; Barbui et al., 2009). In the light of this, it is remarkable that we know so little about attitudes to antidepressant medication among older adults at high risk of suicide. Among older persons who are prescribed antidepressants, adherence to treatment may be suboptimal, which is likely to influence treatment results (Maidment et al., 2002; Fawzi et al., 2012; Pompili et al., 2013), and could indeed increase the risk of suicide. Factors associated with poor adherence to medication in general are e.g. depression, side effects, and a lack of belief in the effect of the medicine (Osterberg and Blaschke, 2005). In a qualitative study, older persons with depression, expressing reluctance toward antidepressants, expressed a fear of dependence and prior negative experiences with antidepressants (Givens et al., 2006). Concerning beliefs about
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
1796
E. Lesén et al.
antidepressants, older age and an increased severity of depression have been associated with a perceived necessity of antidepressant medicine, among 18– 75 year-olds with depression (Aikens et al., 2008). Clinical intervention studies for older depressed persons show that those who are suicidal are slower to respond to antidepressant treatment than those who are not. Further, they may require augmentation treatment (Szanto et al., 2001; 2003). Yet knowledge about correlates of beliefs about antidepressant medicines among the suicidal older persons is poor. Recently, we carried out a prospective study on a clinical cohort of persons aged 70 years and above who were treated in hospital in connection with a suicide attempt (Wiktorsson et al., 2010). Almost all were prescribed antidepressants at discharge. The aim of this study was to assess beliefs about antidepressant medicines in this cohort, one year after the index attempt. Another aim was to analyze the association between beliefs about antidepressant medicines and sociodemographic and clinical variables.
Methods Study population The cohort has previously been described in detail (Wiktorsson et al., 2010). Briefly, individuals aged 70 years and older who were treated in hospital in connection with a suicide attempt were eligible for inclusion. Persons with dementia (n = 2), terminal illness (n = 2) and language difficulties (n = 1) were excluded. The participants were identified in emergency wards at five hospitals in western Sweden during 2003–2006. Of the 133 who were invited to participate, 103 accepted (77%) (Figure 1). As previously described (Wiktorsson et al., 2011), 16 died before the one-year followup and two were not possible to trace. Among the remaining 85 individuals, 60 accepted reassessment and gave informed consent for the one-year followup (response rate 71%). The study includes no control group, since virtually all depressed older persons in Sweden who attempt suicide are prescribed antidepressant medication. A psychologist (SW) performed both the baseline and the follow-up interviews. The median duration from the suicide attempt to the baseline interview was 11 days, and 391 days (median) passed from the suicide attempt to the follow-up interview. Participants who reported having a prescription for antidepressant medicine at the 12 month followup interview were eligible for this study (n = 47). Participants’ beliefs about their antidepressant medicine were assessed with the BMQ specific
for antidepressants (Horne and Weinman, 1999). Three persons lacked cognitive ability to respond to the BMQ as determined by the interviewer hence, the study includes 44 individuals. Selfreported antidepressant use was later confirmed in a medical record review. All participants gave written informed consent. All procedures were in accordance with ethical standards and the Helsinki Declaration. The study was approved by the Regional Ethical Review Board in Gothenburg. Beliefs about antidepressant medicines The BMQ specific for antidepressants includes 10 items; 5 items on beliefs about the necessity of using antidepressant medicines (the necessity subscale), and 5 items assessing concerns about using antidepressant medicines (the concerns subscale). Due to the frailty of the participants, the BMQ items were read out loud by the interviewer, and the participants responded orally. Each BMQ item is scored on a 5-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. Separate subscale scores were calculated for the necessity subscale and for the concerns subscale. The scores on each subscale could thus range from 5 to 25 points. A necessity-concerns differential was calculated by subtracting the concerns subscale score from the necessity subscale score. A positive differential indicates that the perceived benefits outweigh the perceived concerns for that patient. The English BMQ specific for antidepressants was translated to Swedish by MW and translated back to English by Language Services in Cambridge, UK. The English back translation was approved by the original author Professor Robert Horne at the UCL School of Pharmacy, London, UK (personal communication). Covariates SOCIODEMOGRAPHIC VARIABLES
Information about age, sex, marital status, cohabitation, and educational level was selfreported by the participants. CLINICAL VARIABLES Medication: Data on prescribed
antidepressant medicines prior to the index attempt was collected by self-report and via medical records. Information on prescriptions at discharge following the index attempt was collected from medical records. The number of prescribed medicines at follow-up was assessed by self-report and included medicines used regularly and as needed. The respondents were also asked if they took the antidepressant as prescribed (yes/no). Ongoing prescriptions were classified according to the Anatomical Therapeutic
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
Beliefs about antidepressants among suicide attempters
1797
Participants in the baseline study (N=103) Died before follow-up (N=16)
Untraceable (N=2) Eligible for the one-year follow-up study (N =85) Declined participation (N=25)
Participants in the follow-up study (N=60) Participants reporting not using antidepressants (N=13)
Participants reporting ongoing prescription of antidepressants (N=47)
Excluded due to cognitive impairment (N=3)
Participants in the current BMQ study (N=44)
Figure 1. (Colour online) Participant flow.
Chemical classification system (Who Collaborating Centre for Drug Statistics Methodology, 2012). Psychiatric examination: Major depression was diagnosed according to the Diagnostic and Statistical Manual of Mental disorders, fourth edition (DSMIV) and minor depression was based on DSM-IV research criteria (Frances and American Psychiatric Association, 1994). The symptom algorithms employed have been shown in detail (Wiktorsson et al., 2010). Information about lifetime history of alcohol or tablet misuse/dependence was assessed by self-report, medical record review and hospital discharge register (Morin et al., 2012). Past month anxiety symptom burden was rated using a slightly modified version of the Brief Scale for Anxiety (BSA) (Tyrer et al., 1984), a subscale of the Comprehensive Psychopathological Rating scale (CPRS) (Asberg et al., 1978). The phobia
question was not included in this version and there were thus 9 items; each scored from 0–6, with higher scores indicating more severe symptoms. History of psychiatric treatment was assessed based on interview data and medical records from primary care, psychiatric clinics, hospital emergency departments and geriatric departments. The item “Do you think your situation is hopeless?” from the Geriatric Depression Scale (Yesavage et al., 1982) was used to assess hopelessness at both interviews. Information about number of suicide attempts prior to index attempt was based on self-report at index attempt and medical record review. The presence of suicidal feelings between index attempt and follow-up were examined using Paykel’s five questions concerning life weariness, death wishes, suicidal thoughts, suicidal plans, and suicide attempts (Paykel et al., 1974).
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
1798
E. Lesén et al.
Table 1. Clinical characteristics of older suicide attempters at baseline and at one-year follow-up (N = 44) BASELINE
n (%)
FOLLOW-UP
n (%)
............................................................................................................................................................................................................................................................................................................................
Medication Antidepressant prescriptiona Concurrent medicinesb ; median (IQR) Psychiatric examination Major depression Minor depression Anxiety symptom burdenc ; median BSAd score (IQR) History of previous psychiatric treatment Perceived hopelessness One or more attempts prior to index attempt Alcohol/tablet misuse or dependence, lifetime Personality traits Eysenck Personality Inventory; median score (IQR) Neuroticism score Extroversion score a Prior to the index attempt. b At baseline interview. c The month prior to the index d Brief
32 (73) 10 (8–11)
44 (100) 10 (7–13)
30 (68) 10 (23) 10 (5–12) 27 (61) 22 (50) 16 (36) 15 (34)
12 (27) 9 (20) 4 (2–6) 9 (20)
10 (6–14) 11 (9–14)
attempt and the month prior to the follow-up.
Scale for Anxiety.
Personality traits: The Eysenck Personality Inventory (EPI) measured two personality dimensions: neuroticism-emotional stability and extroversion– introversion (Eysenck and Eysenck, 1964). Each of the two dimensions comprises 24 dichotomous (yes/no) items. High scores on the neuroticism scale imply emotional reactivity, anxiety and psychosomatic concerns. Impulsive, outgoing persons score high on extroversion.
Statistical analyses The median and interquartile ranges (IQR) were calculated for the necessity and concerns subscale scores. Non-parametric tests were used since data was not normally distributed. Median values were compared between groups with two-tailed Mann–Whitney test with correction for ties. For continuous variables, the median and IQR were calculated, and Spearman’s rank correlation was used to assess the correlation with the necessity and concerns subscale scores, respectively. The statistical significance level was 0.05. Stata 10.1 statistical software (StataCorp, Texas, USA) was used for statistical analyses.
Results Half of the participants were older than 80 years, and the majority (57%) was women. Fifty-five percent had only mandatory education (7 years or less). One-fifth was married or cohabiting. Twentyseven (61%) participants had a history of psychiatric
treatment. Further clinical characteristics are presented in Table 1. Thirty-two participants had an ongoing prescription for antidepressants prior to the index attempt. Among these, 28 participants reported that they took their antidepressants as prescribed. Six persons (21%) used more than one antidepressant at baseline. All participants had a prescription for antidepressant medicine at followup as this was an inclusion criterion for the study; 14 of these (32%) used more than one antidepressant. Two reported that they did not take the prescribed antidepressant. The median number of medicines was 10 at both baseline examination and at followup. The most common type of antidepressant at follow-up was mirtazapine (n = 27, 61%) followed by escitalopram (n = 10, 23%). Other antidepressants were venlafaxine (n = 6), sertraline (n = 5), citalopram (n = 5), duloxetine (n = 2), reboxetine (n = 1), amitriptyline (n = 1), clomipramine (n = 1) and paroxetine (n = 1). Thirty-three (75%) participants had a prescription of hypnotics. The most common was zopiclone (n = 22, 50%) followed by oxazepam (n = 18, 41%). Further, 9 persons were prescribed propiomazine and 7 persons zolpidem. Sedatives were prescribed to 9 persons (21%) as follows; diazepam (n = 3), alprazolam (n = 3), hydroxyzine (n = 2) and promethazine (n = 2). Ten persons had a prescription for antipsychotics. The most common was risperidone (n = 5), followed by olanzapine (n = 3), aripiprazole (n = 2), perphenazine (n = 1), zuclopenthixol (n = 1) and quetiapine (n = 1).
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
Beliefs about antidepressants among suicide attempters
Finally, three persons (7%) had a prescription of mood stabilizers, lamotrigine (n = 3) and lithium (n = 1). The percentage with major depression was lower at follow-up than at index attempt (27% at followup vs. 68% at index attempt; p < 0.001), as was the percentage experiencing hopelessness (20% vs. 50%; p = 0.002). Further, 18 participants (42%) acknowledged having experienced some level of suicidal feelings during the follow-up period (life weariness, n = 13 (30%), death wishes, n = 16 (37%), suicidal thoughts, n = 9 (21%), suicidal plans, n = 4 (9%), and suicide attempts, n = 2 (5%)). As presented in Table 2, the median score was 18 on the necessity subscale of BMQ and 12 on the concerns subscale. A positive necessity-concerns differential was observed among more than half of the participants (median = 2, range −12 to 18), i.e. the perceived necessity outweighed the perceived concerns they had. About half of the participants (48%; n = 21) acknowledged that they were worried about becoming too dependent on their antidepressant. Table 2 shows further that low education, use of antidepressant medicine at index attempt, major depression at index attempt, a history of psychiatric treatment, and previous suicide attempt were associated with a higher perceived necessity of antidepressant medicines. Hopelessness at follow-up was associated with higher perceived concerns. Among the continuous variables (Table 3), higher severity of anxiety symptoms at index attempt was associated with a higher perceived necessity of antidepressant medicines, and a higher score on the extroversion scale was associated with a lower score on the necessity scale.
Discussion This is the first study assessing beliefs about antidepressant medicines in a clinical cohort of older persons at high risk of suicide. The majority of participants perceived the necessity of their antidepressant medicine to outweigh their concerns. Lower perceived necessity of antidepressants was observed in those who were not on antidepressants at the time of the attempt as well as those with no prior history of suicide attempt before the index attempt. Individuals reporting hopelessness at follow-up had a higher perceived concern about using medication. Since a history of suicide attempt is a particularly strong risk factor for completed suicide in late life (Conwell et al., 2002), and the identification and treatment of depression is a priority for suicide
1799
prevention in this age group, it is encouraging that the majority of the participants perceived that the necessity of antidepressants outweigh their concerns. New users of antidepressants have been found to discontinue therapy to a large extent (Lu and Roughead, 2012), and it is probable that this is even more common among those who do not perceive the medication as necessary for their health. A low perceived necessity and a high perceived concern about antidepressant medication has been associated with poor adherence (Maidment et al., 2002; Hunot et al., 2007; Fawzi et al., 2012). Thus, to efficiently target efforts in clinical practice, it is important to identify the groups who express low necessity or high concerns. Half of our participants worried about becoming too dependent on antidepressants, a proportion larger than that previously reported in a study of depressed persons aged 55+ (Fawzi et al., 2012). Psychoeducation (Sherrill et al., 1997) on antidepressant medication is vital to increase patients’ knowledge and understanding of these drugs. In the current study, we did not find increased concerns in those who were new users of antidepressants. This was somewhat surprising as there is evidence that those lacking prior treatment are more likely to have concerns about harmfulness (Aikens et al., 2008). However, it should be noted that questions on beliefs were asked at the follow-up interview, one year after the suicide attempt. Harmful beliefs may have dissipated during the follow-up period, as was observed in a previous depression treatment trial (Aikens and Klinkman, 2012). In our population, 98% were prescribed antidepressants at discharge and many had perceived the positive effects of the medication when interviewed about a year later. The relation of major depression with a higher score on the necessity scale parallels earlier results on the severity of depressive symptoms in a mixed age clinical cohort (Aikens et al., 2008). Concerning other covariates studied, lower education was associated with greater necessity. The literature on this is sparse, but an opposite trend was observed in a clinical sample of migraineurs, although that result was not significant (Hedenrud et al., 2008). Individuals with a high score on the extroversion scale perceived antidepressants to have low necessity. A negative relation between extroversion and adherence to antidepressant medication was found in a previous study that employed the fivefactor model to measure personality traits (Cohen et al., 2004). A larger study is needed to determine the relationship between personality, beliefs about antidepressant medication, and adherence.
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
1800
E. Lesén et al.
Table 2. Median values for Beliefs about the necessity and concerns of antidepressant medicines among older suicide attempters at one-year follow-up (N = 44), by sociodemographic and clinical variables NECESSITY SCALE MEDIAN
(IQR)
CONCERNS SCALE
P-VALUE
MEDIAN
(IQR)
P-VALUE
............................................................................................................................................................................................................................................................................................................................
Total sample 18 (10) Sociodemographic variables Age at follow-up (years) 71–80 18 (7) 81–90 15 (11) 0.18 Sex Men 18 (9) Women 15 (10) 0.87 Education Only mandatory 18 (7) More than mandatory 13 (12) 0.023 Medication Antidepressant prescription at index attempta Yes 18 (9) No 14 (11) 0.040 Psychiatric examination Major depression at index attempt Yes 18 (10) No 14 (9) 0.041 Major depression at follow-up Yes 21 (7) No 16 (10) 0.091 History of psychiatric treatment at index attempt Yes 20 (7) No 12 (9) 0.001 Perceived hopelessness at index attempt Yes 18 (9) No 16 (10) 0.49 Perceived hopelessness at follow-up Yes 18 (7) No 17 (10) 0.72 Suicide attempt prior to index attempt Yes 21 (9) No 16 (10) 0.034 Alcohol/tablet misuse or dependence at index attempt, lifetime Yes 18 (9) No 17 (9) 0.78 a Prior
12 (10)
10 (7) 12 (10)
0.75
13 (11) 10 (8)
0.27
12 (9) 11 (10)
0.99
13 (8) 9 (10)
0.23
13 (8) 10 (9)
0.13
17 (10) 10 (9)
0.062
10 (9) 12 (9)
0.58
12 (8) 12 (10)
0.74
13 (8) 10 (9)
0.038
9 (8) 13 (8)
0.074
10 (10) 12 (9)
0.76
to the index attempt. Notes: IQR: Interquartile range. P-values were calculated with Mann–Whitney test for medians.
Hopelessness at follow-up was the only covariate statistically associated with perceived concerns about antidepressants. Hopelessness has been suggested to represent a trait (Rifai et al., 1994; Szanto et al., 1998), reflecting vulnerability, and high levels of hopelessness have been found among suicide attempters (Szanto et al., 1998). The clinical relevance of the identified difference in concerns about antidepressants, between those perceiving hopelessness and not, must be further evaluated. It could be that these individuals are important to identify in clinical practice in order to e.g. encourage treatment adherence, since high perceived concern about
antidepressant medication has been associated with poor adherence (Maidment et al., 2002; Hunot et al., 2007; Fawzi et al., 2012). Some of the participants reported that they had suicidal feelings during the one-year followup period. The study was not sufficiently powered to determine whether beliefs in this group differed from those of persons without suicidal feelings. Further, a larger study would be needed to examine beliefs among older persons with bipolar disorders, a vulnerable patients group (Pompili et al., 2012). The existing literature does not provide figures suitable for direct comparison with the BMQ scale scores in the present study. Previous studies
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
Beliefs about antidepressants among suicide attempters
1801
Table 3. Correlations with Beliefs about the necessity and concerns of antidepressant medicines among older suicide attempters at one-year follow-up (N = 44) NECESSITY SCALE
P-VALUE
a
CONCERNS SCALE
P-VALUE
............................................................................................................................................................................................................................................................................................................................
Number of prescribed medicines At baseline interview − 0.07 At follow-up interview 0.19 Anxiety symptom burdenb At index attempt 0.43 At follow-up 0.19 Personality traitsc Neuroticism 0.25 Extroversion − 0.30 a Spearman’s
0.664 0.213
− 0.14 − 0.13
0.36 0.41
0.004 0.220
0.24 0.07
0.12 0.66
0.108 0.047
0.06 0.12
0.69 0.46
rank correlation. index attempt and the month prior to the follow-up.
b The month prior to the c At baseline interview.
analyzing beliefs about medicines in a population using antidepressant medication (Maidment et al., 2002; Brown et al., 2005; Hunot et al., 2007; Fawzi et al., 2012) have either not presented a mean or a median score (Maidment et al., 2002; Brown et al., 2005; Fawzi et al., 2012), or they have used a modified version of the BMQ (Hunot et al., 2007). Few studies have analyzed beliefs about specific types of medication in older populations (Schuz et al., 2011; Ruppar et al., 2012), and only one of them, which focused on antihypertensive medication used the full BMQ scale (Ruppar et al., 2012). Mean scores for both necessity and concerns scales were somewhat higher in the latter study in comparison with our own. However, it should be noted that both studies have small sample sizes. Strengths and limitations The high age of the participants, together with the fact that all interviews were carried out by the same psychologist, are major strengths of this study. Further, we used a validated and clinically relevant instrument for quantifying psychiatric symptom burden (CPRS) in older persons (Van Der Laan et al., 2005). The original small sample size and the progressive loss of subjects are major limitations which entail low precision; hence results must be interpreted with caution. Cases were recruited in the hospital setting and attempters not treated in hospital might be expected to have more negative beliefs about medicines and less own experience of antidepressant treatment. Further, those who did not continue to take their antidepressant may have more negative beliefs toward antidepressants compared to those who persisted. A single question was used to examine hopelessness and this must be seen as a limitation. A more specific instrument would have been more reliable. Further, one
limitation is the lack of a validated measure of adherence, which would have added relevance and important knowledge to the study. Finally, as only persons with a working knowledge of Swedish were included results cannot be generalized to those with different cultural backgrounds.
Conclusion The majority of older persons in treatment after a suicide perceived the necessity of their antidepressant medicine to outweigh their concerns. The BMQ specific for antidepressants might be a valuable tool in clinical practice for physicians who treat persons who attempt suicide in late life, but studies using objective measures of adherence are called for.
Conflict of interest The study was supported by grants from the Swedish Research Council (2005–21X-14598– 03A, 2009–62X-2079–01–3), the Swedish Council for Working Life and Social Research (2002– 0153), the Söderström-König Foundation, the Thuring Foundation, the Hjalmar Svensson Foundation, the Organon Foundation, the Axel Linder Foundation and the Wilhelm and Martina Lundgren Foundation. None of the funders have had any role in the research.
Description of authors’ role Eva Lesén was involved in data analysis and interpretation, and contributed to the draft and final manuscript. Stefan Wiktorsson collected all data at baseline and at follow-up. He was involved in the
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
1802
E. Lesén et al.
interpretation of data, contributed to the original manuscript and prepared the revised manuscript. Eva Lesén and Stefan Wiktorsson are joint first authors. Anders Carlsten was involved in the design of the study and preparing the final manuscript. Margda Waern designed and supervised the original study, and carried out the Swedish translation of the BMQ for antidepressants. Further she was involved in data interpretation and contributed to the final manuscript. Tove Hedenrud was involved in the Swedish translation of the BMQ for antidepressants. Further she was involved in data interpretation and has contributed to the final manuscript.
Acknowledgments The authors wish to thank all study participants and hospital staff.
References Aikens, J. E. and Klinkman, M. S. (2012). Changes in patients’ beliefs about their antidepressant during the acute phase of depression treatment. General Hospital Psychiatry, 34, 221–226. doi:10.1016/j.genhosppsych.2012.01.004. Aikens, J. E., Nease, D. E. Jr. and Klinkman, M. S. (2008). Explaining patients’ beliefs about the necessity and harmfulness of antidepressants. Annals of Family Medicine, 6, 23–29. doi:10.1370/afm.759. Asberg, M., Montgomery, S. A., Perris, C., Schalling, D. and Sedvall, G. (1978). A comprehensive psychopathological rating scale. Acta Psychiatrica Scandinavica. 57, 5–27. doi: 10.1111/j.1600-0447.1978.tb02357.x. Barbui, C., Esposito, E. and Cipriani, A. (2009). Selective serotonin reuptake inhibitors and risk of suicide: a systematic review of observational studies. CMAJ: Canadian Medical Association Journal, 180, 291–297. doi:10.1503/cmaj.081514. Brown, C. et al. (2005). Beliefs about antidepressant medications in primary care patients: relationship to self-reported adherence. Medical Care, 43, 1203–1207. Cohen, N. L., Ross, E. C., Bagby, R. M., Farvolden, P. and Kennedy, S. H. (2004). The 5-factor model of personality and antidepressant medication compliance. Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie, 49, 106–113. Conwell, Y., Duberstein, P. R. and Caine, E. D. (2002). Risk factors for suicide in later life. Biological Psychiatry, 52, 193–204. Eysenck, H. J. and Eysenck, S. G. G. (1964). Manual of the Eysenck Personality Inventory. London: University of London Press. Fawzi, W. et al. (2012). Beliefs about medications predict adherence to antidepressants in older adults. International Psychogeriatrics, 24, 159–169. doi:10.1017/S1041610211001049.
Frances, A. and American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders: DSM-IV: Prepared by the Task Force on DSM-IV. Washington, DC: American Psychiatric Assoc. Gibbons, R. D. et al. (2007). Relationship between antidepressants and suicide attempts: an analysis of the Veterans Health Administration data sets. American Journal of Psychiatry, 164, 1044–1049. doi:10.1176/appi.ajp.164.7.1044. Givens, J. L. et al. (2006). Older patients’ aversion to antidepressants. A qualitative study. Journal of General Internal Medicine, 21, 146–151. doi:10.1111/j.1525-1497.2005.00296.x. Hawton, K. and Van Heeringen, K. (2009). Suicide. Lancet, 373, 1372–1381. doi:10.1016/S0140-6736(09)60372-X. Hedenrud, T., Jonsson, P. and Linde, M. (2008). Beliefs about medicines and adherence among Swedish migraineurs. Annals of Pharmacotherapy, 42, 39–45. doi:10.1345/aph.1K354. Horne, R. and Weinman, J. (1999). Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. Journal of Psychosomatic Research, 47, 555–567. Hunot, V. M., Horne, R., Leese, M. N. and Churchill, R. C. (2007). A cohort study of adherence to antidepressants in primary care: the influence of antidepressant concerns and treatment preferences. Primary Care Companion to the Journal of Clinical Psychiatry, 9, 91–99. Lapierre, S. et al. (2011). A systematic review of elderly suicide prevention programs. Crisis, 32, 88–98. doi:10.1027/0227-5910/a000076. Lu, C. Y. and Roughead, E. (2012). New users of antidepressant medications: first episode duration and predictors of discontinuation. European Journal of Clinical Pharmacology, 68, 65–71. doi:10.1007/s00228-011-1087-3. Maidment, R., Livingston, G. and Katona, C. (2002). Just keep taking the tablets: adherence to antidepressant treatment in older people in primary care. International Journal of Geriatric Psychiatry, 17, 752–757. doi:10.1002/gps.688. Morin, J. et al. (2012). Alcohol use disorder in elderly suicide Attempters: a comparison study. American Journal of Geriatric Psychiatry, 21, 196–203. doi:10.1097/JGP.0b013e3182423b35. Osterberg, L. and Blaschke, T. (2005). Adherence to medication. New England Journal of Medicine, 353, 487–497. doi:10.1056/NEJMra050100. Paykel, E. S., Myers, J. K., Lindenthal, J. J. and Tanner, J. (1974). Suicidal feelings in the general population: a prevalence study. British Journal of Psychiatry, 124, 460–469. Pompili, M. et al. (2012). Temperaments mediate suicide risk and psychopathology among patients with bipolar disorders. Comprehensive Psychiatry, 53, 280–285. doi:10.1016/j.comppsych.2011.04.004. Pompili, M. et al. (2013). Mood disorders medications: predictors of nonadherence - review of the current literature. Expert Review of Neurotherapeutics, 13, 809–825. doi:10.1586/14737175.2013.811976. Rifai, A. H., George, C. J., Stack, J. A., Mann, J. J. and Reynolds, C. F. 3rd. (1994). Hopelessness in suicide
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
Beliefs about antidepressants among suicide attempters attempters after acute treatment of major depression in late life. American Journal of Psychiatry, 151, 1687–1690. Ruppar, T. M., Dobbels, F. and De Geest, S. (2012). Medication beliefs and antihypertensive adherence among older adults: a pilot study. Geriatric Nursing (New York, N.Y.), 33, 89–95. doi:10.1016/j.gerinurse.2012.01.006. Schuz, B. et al. (2011). Medication beliefs predict medication adherence in older adults with multiple illnesses. Journal of Psychosomatic Research, 70, 179–187. doi:10.1016/j.jpsychores.2010.07.014. Sherrill, J. T., Frank, E., Geary, M., Stack, J. A. and Reynolds, C. F. 3rd. (1997). Psychoeducational workshops for elderly patients with recurrent major depression and their families. Psychiatric Services, 48, 76–81. Szanto, K., Mulsant, B. H., Houck, P., Dew, M. A. and Reynolds, C. F. 3rd. (2003). Occurrence and course of suicidality during short-term treatment of late-life depression. Archives of General Psychiatry, 60, 610–617. doi:10.1001/archpsyc.60.6.610. Szanto, K., Reynolds, C. F., 3rd, Conwell, Y., Begley, A. E. and Houck, P. (1998). High levels of hopelessness persist in geriatric patients with remitted depression and a history of attempted suicide. Journal of the American Geriatrics Society, 46, 1401–1406. Szanto, K. et al. (2001). Treatment outcome in suicidal vs. non-suicidal elderly patients. American Journal of Geriatric Psychiatry, 9, 261–268.
1803
Tyrer, P., Owen, R. T. and Cicchetti, D. V. (1984). The brief scale for anxiety: a subdivision of the comprehensive psychopathological rating scale. Journal of Neurology, Neurosurgery and Psychiatry, 47, 970– 975. Van Der Laan, N. C., Schimmel, A. and Heeren, T. J. (2005). The applicability and the inter-rater reliability of the comprehensive psychopathological rating scale in an elderly clinical population. International Journal of Geriatric Psychiatry, 20, 35–40. doi:10.1002/gps.1244. Who Collaborating Centre for Drug Statistics Methodology (2012). Guidelines for ATC Classification and DDD Assignment 2013. Oslo. Wiktorsson, S., Marlow, T., Runeson, B., Skoog, I. and Waern, M. (2011). Prospective cohort study of suicide attempters aged 70 and above: one-year outcomes. Journal of Affective Disorders, 134, 333–340. doi:10.1016/j.jad.2011.06.010. Wiktorsson, S., Runeson, B., Skoog, I., Ostling, S. and Waern, M. (2010). Attempted suicide in the elderly: characteristics of suicide attempters 70 years and older and a general population comparison group. American Journal of Geriatric Psychiatry, 18, 57–67. doi:10.1097/JGP.0b013e3181bd1c13. Yesavage, J. A. et al. (1982). Development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research, 17, 37–49.
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
Beliefs about antidepressants among persons aged 70 years and older in treatment after a suicide attempt ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Eva Lesén,1 Stefan Wiktorsson,2 Anders Carlsten,3 Margda Waern2 and Tove Hedenrud4 1
Nordic Health Economics AB, Gothenburg, Sweden Section of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 3 Medical Products Agency, Uppsala, Sweden 4 Dept. of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 2
ABSTRACT
Background: The use of antidepressants is associated with decreased suicide risk in late life, and these drugs are often prescribed after a suicide attempt. Yet little is known about attitudes to antidepressants in older persons with suicidal behavior. The aim of this study was to assess beliefs about antidepressant medicines in older persons in treatment one year after a suicide attempt. Methods: Forty-four individuals aged 70 years and older, who were treated in emergency wards at five hospitals in western Sweden in connection with a suicide attempt, were interviewed at index attempt and one year later. Beliefs about medicines questionnaire (BMQ) specific for antidepressants were analyzed one year after index attempt, in relation to sociodemographic variables, medication use, psychiatric evaluation, and personality traits. Results: The majority of participants perceived the necessity of their antidepressant medicine to outweigh their concerns. Lower perceived necessity of antidepressants was observed in those who were not on antidepressants at the time of the attempt as well as those with no prior history of suicide attempt before the index attempt. Individuals reporting hopelessness at follow-up had a higher perceived concern about using medication. Conclusions: Beliefs about antidepressants tended to be more positive than negative in older persons taking these drugs in the aftermath of a suicide attempt. Further studies are called for, and should include objective measures of medication adherence. Key words: beliefs about antidepressants, suicide attempt, older persons
Introduction Older persons have particularly high suicide rates compared to younger age groups (Conwell et al., 2002; Hawton and Van Heeringen, 2009). Mental health problems, such as mood disorders, substance misuse, and a history of suicide attempt have been identified as risk factors for suicidal behavior among older people (Conwell et al., 2002). Up to three quarters of those who commit suicide in late life suffer from a current depression, and the recognition and treatment of depression is thus an important target for the prevention of suicide in this age group (Conwell et al., 2002; Lapierre et al., 2011).
Correspondence should be addressed to: Tove Hedenrud, Dept. of Public Health and Community Medicine, P.O. Box 453, 405 30 Gothenburg, Sweden. Phone: +46-31-786 6855. Email: [email protected]. Received 1 Aug 2014; revision requested 17 Oct 2014; revised version received 22 Jan 2015; accepted 27 Jan 2015. First published online 2 March 2015.
There are several studies indicating that the use of antidepressants is associated with decreased suicide risk in older people (Gibbons et al., 2007; Barbui et al., 2009). In the light of this, it is remarkable that we know so little about attitudes to antidepressant medication among older adults at high risk of suicide. Among older persons who are prescribed antidepressants, adherence to treatment may be suboptimal, which is likely to influence treatment results (Maidment et al., 2002; Fawzi et al., 2012; Pompili et al., 2013), and could indeed increase the risk of suicide. Factors associated with poor adherence to medication in general are e.g. depression, side effects, and a lack of belief in the effect of the medicine (Osterberg and Blaschke, 2005). In a qualitative study, older persons with depression, expressing reluctance toward antidepressants, expressed a fear of dependence and prior negative experiences with antidepressants (Givens et al., 2006). Concerning beliefs about
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
1796
E. Lesén et al.
antidepressants, older age and an increased severity of depression have been associated with a perceived necessity of antidepressant medicine, among 18– 75 year-olds with depression (Aikens et al., 2008). Clinical intervention studies for older depressed persons show that those who are suicidal are slower to respond to antidepressant treatment than those who are not. Further, they may require augmentation treatment (Szanto et al., 2001; 2003). Yet knowledge about correlates of beliefs about antidepressant medicines among the suicidal older persons is poor. Recently, we carried out a prospective study on a clinical cohort of persons aged 70 years and above who were treated in hospital in connection with a suicide attempt (Wiktorsson et al., 2010). Almost all were prescribed antidepressants at discharge. The aim of this study was to assess beliefs about antidepressant medicines in this cohort, one year after the index attempt. Another aim was to analyze the association between beliefs about antidepressant medicines and sociodemographic and clinical variables.
Methods Study population The cohort has previously been described in detail (Wiktorsson et al., 2010). Briefly, individuals aged 70 years and older who were treated in hospital in connection with a suicide attempt were eligible for inclusion. Persons with dementia (n = 2), terminal illness (n = 2) and language difficulties (n = 1) were excluded. The participants were identified in emergency wards at five hospitals in western Sweden during 2003–2006. Of the 133 who were invited to participate, 103 accepted (77%) (Figure 1). As previously described (Wiktorsson et al., 2011), 16 died before the one-year followup and two were not possible to trace. Among the remaining 85 individuals, 60 accepted reassessment and gave informed consent for the one-year followup (response rate 71%). The study includes no control group, since virtually all depressed older persons in Sweden who attempt suicide are prescribed antidepressant medication. A psychologist (SW) performed both the baseline and the follow-up interviews. The median duration from the suicide attempt to the baseline interview was 11 days, and 391 days (median) passed from the suicide attempt to the follow-up interview. Participants who reported having a prescription for antidepressant medicine at the 12 month followup interview were eligible for this study (n = 47). Participants’ beliefs about their antidepressant medicine were assessed with the BMQ specific
for antidepressants (Horne and Weinman, 1999). Three persons lacked cognitive ability to respond to the BMQ as determined by the interviewer hence, the study includes 44 individuals. Selfreported antidepressant use was later confirmed in a medical record review. All participants gave written informed consent. All procedures were in accordance with ethical standards and the Helsinki Declaration. The study was approved by the Regional Ethical Review Board in Gothenburg. Beliefs about antidepressant medicines The BMQ specific for antidepressants includes 10 items; 5 items on beliefs about the necessity of using antidepressant medicines (the necessity subscale), and 5 items assessing concerns about using antidepressant medicines (the concerns subscale). Due to the frailty of the participants, the BMQ items were read out loud by the interviewer, and the participants responded orally. Each BMQ item is scored on a 5-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. Separate subscale scores were calculated for the necessity subscale and for the concerns subscale. The scores on each subscale could thus range from 5 to 25 points. A necessity-concerns differential was calculated by subtracting the concerns subscale score from the necessity subscale score. A positive differential indicates that the perceived benefits outweigh the perceived concerns for that patient. The English BMQ specific for antidepressants was translated to Swedish by MW and translated back to English by Language Services in Cambridge, UK. The English back translation was approved by the original author Professor Robert Horne at the UCL School of Pharmacy, London, UK (personal communication). Covariates SOCIODEMOGRAPHIC VARIABLES
Information about age, sex, marital status, cohabitation, and educational level was selfreported by the participants. CLINICAL VARIABLES Medication: Data on prescribed
antidepressant medicines prior to the index attempt was collected by self-report and via medical records. Information on prescriptions at discharge following the index attempt was collected from medical records. The number of prescribed medicines at follow-up was assessed by self-report and included medicines used regularly and as needed. The respondents were also asked if they took the antidepressant as prescribed (yes/no). Ongoing prescriptions were classified according to the Anatomical Therapeutic
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
Beliefs about antidepressants among suicide attempters
1797
Participants in the baseline study (N=103) Died before follow-up (N=16)
Untraceable (N=2) Eligible for the one-year follow-up study (N =85) Declined participation (N=25)
Participants in the follow-up study (N=60) Participants reporting not using antidepressants (N=13)
Participants reporting ongoing prescription of antidepressants (N=47)
Excluded due to cognitive impairment (N=3)
Participants in the current BMQ study (N=44)
Figure 1. (Colour online) Participant flow.
Chemical classification system (Who Collaborating Centre for Drug Statistics Methodology, 2012). Psychiatric examination: Major depression was diagnosed according to the Diagnostic and Statistical Manual of Mental disorders, fourth edition (DSMIV) and minor depression was based on DSM-IV research criteria (Frances and American Psychiatric Association, 1994). The symptom algorithms employed have been shown in detail (Wiktorsson et al., 2010). Information about lifetime history of alcohol or tablet misuse/dependence was assessed by self-report, medical record review and hospital discharge register (Morin et al., 2012). Past month anxiety symptom burden was rated using a slightly modified version of the Brief Scale for Anxiety (BSA) (Tyrer et al., 1984), a subscale of the Comprehensive Psychopathological Rating scale (CPRS) (Asberg et al., 1978). The phobia
question was not included in this version and there were thus 9 items; each scored from 0–6, with higher scores indicating more severe symptoms. History of psychiatric treatment was assessed based on interview data and medical records from primary care, psychiatric clinics, hospital emergency departments and geriatric departments. The item “Do you think your situation is hopeless?” from the Geriatric Depression Scale (Yesavage et al., 1982) was used to assess hopelessness at both interviews. Information about number of suicide attempts prior to index attempt was based on self-report at index attempt and medical record review. The presence of suicidal feelings between index attempt and follow-up were examined using Paykel’s five questions concerning life weariness, death wishes, suicidal thoughts, suicidal plans, and suicide attempts (Paykel et al., 1974).
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
1798
E. Lesén et al.
Table 1. Clinical characteristics of older suicide attempters at baseline and at one-year follow-up (N = 44) BASELINE
n (%)
FOLLOW-UP
n (%)
............................................................................................................................................................................................................................................................................................................................
Medication Antidepressant prescriptiona Concurrent medicinesb ; median (IQR) Psychiatric examination Major depression Minor depression Anxiety symptom burdenc ; median BSAd score (IQR) History of previous psychiatric treatment Perceived hopelessness One or more attempts prior to index attempt Alcohol/tablet misuse or dependence, lifetime Personality traits Eysenck Personality Inventory; median score (IQR) Neuroticism score Extroversion score a Prior to the index attempt. b At baseline interview. c The month prior to the index d Brief
32 (73) 10 (8–11)
44 (100) 10 (7–13)
30 (68) 10 (23) 10 (5–12) 27 (61) 22 (50) 16 (36) 15 (34)
12 (27) 9 (20) 4 (2–6) 9 (20)
10 (6–14) 11 (9–14)
attempt and the month prior to the follow-up.
Scale for Anxiety.
Personality traits: The Eysenck Personality Inventory (EPI) measured two personality dimensions: neuroticism-emotional stability and extroversion– introversion (Eysenck and Eysenck, 1964). Each of the two dimensions comprises 24 dichotomous (yes/no) items. High scores on the neuroticism scale imply emotional reactivity, anxiety and psychosomatic concerns. Impulsive, outgoing persons score high on extroversion.
Statistical analyses The median and interquartile ranges (IQR) were calculated for the necessity and concerns subscale scores. Non-parametric tests were used since data was not normally distributed. Median values were compared between groups with two-tailed Mann–Whitney test with correction for ties. For continuous variables, the median and IQR were calculated, and Spearman’s rank correlation was used to assess the correlation with the necessity and concerns subscale scores, respectively. The statistical significance level was 0.05. Stata 10.1 statistical software (StataCorp, Texas, USA) was used for statistical analyses.
Results Half of the participants were older than 80 years, and the majority (57%) was women. Fifty-five percent had only mandatory education (7 years or less). One-fifth was married or cohabiting. Twentyseven (61%) participants had a history of psychiatric
treatment. Further clinical characteristics are presented in Table 1. Thirty-two participants had an ongoing prescription for antidepressants prior to the index attempt. Among these, 28 participants reported that they took their antidepressants as prescribed. Six persons (21%) used more than one antidepressant at baseline. All participants had a prescription for antidepressant medicine at followup as this was an inclusion criterion for the study; 14 of these (32%) used more than one antidepressant. Two reported that they did not take the prescribed antidepressant. The median number of medicines was 10 at both baseline examination and at followup. The most common type of antidepressant at follow-up was mirtazapine (n = 27, 61%) followed by escitalopram (n = 10, 23%). Other antidepressants were venlafaxine (n = 6), sertraline (n = 5), citalopram (n = 5), duloxetine (n = 2), reboxetine (n = 1), amitriptyline (n = 1), clomipramine (n = 1) and paroxetine (n = 1). Thirty-three (75%) participants had a prescription of hypnotics. The most common was zopiclone (n = 22, 50%) followed by oxazepam (n = 18, 41%). Further, 9 persons were prescribed propiomazine and 7 persons zolpidem. Sedatives were prescribed to 9 persons (21%) as follows; diazepam (n = 3), alprazolam (n = 3), hydroxyzine (n = 2) and promethazine (n = 2). Ten persons had a prescription for antipsychotics. The most common was risperidone (n = 5), followed by olanzapine (n = 3), aripiprazole (n = 2), perphenazine (n = 1), zuclopenthixol (n = 1) and quetiapine (n = 1).
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
Beliefs about antidepressants among suicide attempters
Finally, three persons (7%) had a prescription of mood stabilizers, lamotrigine (n = 3) and lithium (n = 1). The percentage with major depression was lower at follow-up than at index attempt (27% at followup vs. 68% at index attempt; p < 0.001), as was the percentage experiencing hopelessness (20% vs. 50%; p = 0.002). Further, 18 participants (42%) acknowledged having experienced some level of suicidal feelings during the follow-up period (life weariness, n = 13 (30%), death wishes, n = 16 (37%), suicidal thoughts, n = 9 (21%), suicidal plans, n = 4 (9%), and suicide attempts, n = 2 (5%)). As presented in Table 2, the median score was 18 on the necessity subscale of BMQ and 12 on the concerns subscale. A positive necessity-concerns differential was observed among more than half of the participants (median = 2, range −12 to 18), i.e. the perceived necessity outweighed the perceived concerns they had. About half of the participants (48%; n = 21) acknowledged that they were worried about becoming too dependent on their antidepressant. Table 2 shows further that low education, use of antidepressant medicine at index attempt, major depression at index attempt, a history of psychiatric treatment, and previous suicide attempt were associated with a higher perceived necessity of antidepressant medicines. Hopelessness at follow-up was associated with higher perceived concerns. Among the continuous variables (Table 3), higher severity of anxiety symptoms at index attempt was associated with a higher perceived necessity of antidepressant medicines, and a higher score on the extroversion scale was associated with a lower score on the necessity scale.
Discussion This is the first study assessing beliefs about antidepressant medicines in a clinical cohort of older persons at high risk of suicide. The majority of participants perceived the necessity of their antidepressant medicine to outweigh their concerns. Lower perceived necessity of antidepressants was observed in those who were not on antidepressants at the time of the attempt as well as those with no prior history of suicide attempt before the index attempt. Individuals reporting hopelessness at follow-up had a higher perceived concern about using medication. Since a history of suicide attempt is a particularly strong risk factor for completed suicide in late life (Conwell et al., 2002), and the identification and treatment of depression is a priority for suicide
1799
prevention in this age group, it is encouraging that the majority of the participants perceived that the necessity of antidepressants outweigh their concerns. New users of antidepressants have been found to discontinue therapy to a large extent (Lu and Roughead, 2012), and it is probable that this is even more common among those who do not perceive the medication as necessary for their health. A low perceived necessity and a high perceived concern about antidepressant medication has been associated with poor adherence (Maidment et al., 2002; Hunot et al., 2007; Fawzi et al., 2012). Thus, to efficiently target efforts in clinical practice, it is important to identify the groups who express low necessity or high concerns. Half of our participants worried about becoming too dependent on antidepressants, a proportion larger than that previously reported in a study of depressed persons aged 55+ (Fawzi et al., 2012). Psychoeducation (Sherrill et al., 1997) on antidepressant medication is vital to increase patients’ knowledge and understanding of these drugs. In the current study, we did not find increased concerns in those who were new users of antidepressants. This was somewhat surprising as there is evidence that those lacking prior treatment are more likely to have concerns about harmfulness (Aikens et al., 2008). However, it should be noted that questions on beliefs were asked at the follow-up interview, one year after the suicide attempt. Harmful beliefs may have dissipated during the follow-up period, as was observed in a previous depression treatment trial (Aikens and Klinkman, 2012). In our population, 98% were prescribed antidepressants at discharge and many had perceived the positive effects of the medication when interviewed about a year later. The relation of major depression with a higher score on the necessity scale parallels earlier results on the severity of depressive symptoms in a mixed age clinical cohort (Aikens et al., 2008). Concerning other covariates studied, lower education was associated with greater necessity. The literature on this is sparse, but an opposite trend was observed in a clinical sample of migraineurs, although that result was not significant (Hedenrud et al., 2008). Individuals with a high score on the extroversion scale perceived antidepressants to have low necessity. A negative relation between extroversion and adherence to antidepressant medication was found in a previous study that employed the fivefactor model to measure personality traits (Cohen et al., 2004). A larger study is needed to determine the relationship between personality, beliefs about antidepressant medication, and adherence.
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
1800
E. Lesén et al.
Table 2. Median values for Beliefs about the necessity and concerns of antidepressant medicines among older suicide attempters at one-year follow-up (N = 44), by sociodemographic and clinical variables NECESSITY SCALE MEDIAN
(IQR)
CONCERNS SCALE
P-VALUE
MEDIAN
(IQR)
P-VALUE
............................................................................................................................................................................................................................................................................................................................
Total sample 18 (10) Sociodemographic variables Age at follow-up (years) 71–80 18 (7) 81–90 15 (11) 0.18 Sex Men 18 (9) Women 15 (10) 0.87 Education Only mandatory 18 (7) More than mandatory 13 (12) 0.023 Medication Antidepressant prescription at index attempta Yes 18 (9) No 14 (11) 0.040 Psychiatric examination Major depression at index attempt Yes 18 (10) No 14 (9) 0.041 Major depression at follow-up Yes 21 (7) No 16 (10) 0.091 History of psychiatric treatment at index attempt Yes 20 (7) No 12 (9) 0.001 Perceived hopelessness at index attempt Yes 18 (9) No 16 (10) 0.49 Perceived hopelessness at follow-up Yes 18 (7) No 17 (10) 0.72 Suicide attempt prior to index attempt Yes 21 (9) No 16 (10) 0.034 Alcohol/tablet misuse or dependence at index attempt, lifetime Yes 18 (9) No 17 (9) 0.78 a Prior
12 (10)
10 (7) 12 (10)
0.75
13 (11) 10 (8)
0.27
12 (9) 11 (10)
0.99
13 (8) 9 (10)
0.23
13 (8) 10 (9)
0.13
17 (10) 10 (9)
0.062
10 (9) 12 (9)
0.58
12 (8) 12 (10)
0.74
13 (8) 10 (9)
0.038
9 (8) 13 (8)
0.074
10 (10) 12 (9)
0.76
to the index attempt. Notes: IQR: Interquartile range. P-values were calculated with Mann–Whitney test for medians.
Hopelessness at follow-up was the only covariate statistically associated with perceived concerns about antidepressants. Hopelessness has been suggested to represent a trait (Rifai et al., 1994; Szanto et al., 1998), reflecting vulnerability, and high levels of hopelessness have been found among suicide attempters (Szanto et al., 1998). The clinical relevance of the identified difference in concerns about antidepressants, between those perceiving hopelessness and not, must be further evaluated. It could be that these individuals are important to identify in clinical practice in order to e.g. encourage treatment adherence, since high perceived concern about
antidepressant medication has been associated with poor adherence (Maidment et al., 2002; Hunot et al., 2007; Fawzi et al., 2012). Some of the participants reported that they had suicidal feelings during the one-year followup period. The study was not sufficiently powered to determine whether beliefs in this group differed from those of persons without suicidal feelings. Further, a larger study would be needed to examine beliefs among older persons with bipolar disorders, a vulnerable patients group (Pompili et al., 2012). The existing literature does not provide figures suitable for direct comparison with the BMQ scale scores in the present study. Previous studies
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
Beliefs about antidepressants among suicide attempters
1801
Table 3. Correlations with Beliefs about the necessity and concerns of antidepressant medicines among older suicide attempters at one-year follow-up (N = 44) NECESSITY SCALE
P-VALUE
a
CONCERNS SCALE
P-VALUE
............................................................................................................................................................................................................................................................................................................................
Number of prescribed medicines At baseline interview − 0.07 At follow-up interview 0.19 Anxiety symptom burdenb At index attempt 0.43 At follow-up 0.19 Personality traitsc Neuroticism 0.25 Extroversion − 0.30 a Spearman’s
0.664 0.213
− 0.14 − 0.13
0.36 0.41
0.004 0.220
0.24 0.07
0.12 0.66
0.108 0.047
0.06 0.12
0.69 0.46
rank correlation. index attempt and the month prior to the follow-up.
b The month prior to the c At baseline interview.
analyzing beliefs about medicines in a population using antidepressant medication (Maidment et al., 2002; Brown et al., 2005; Hunot et al., 2007; Fawzi et al., 2012) have either not presented a mean or a median score (Maidment et al., 2002; Brown et al., 2005; Fawzi et al., 2012), or they have used a modified version of the BMQ (Hunot et al., 2007). Few studies have analyzed beliefs about specific types of medication in older populations (Schuz et al., 2011; Ruppar et al., 2012), and only one of them, which focused on antihypertensive medication used the full BMQ scale (Ruppar et al., 2012). Mean scores for both necessity and concerns scales were somewhat higher in the latter study in comparison with our own. However, it should be noted that both studies have small sample sizes. Strengths and limitations The high age of the participants, together with the fact that all interviews were carried out by the same psychologist, are major strengths of this study. Further, we used a validated and clinically relevant instrument for quantifying psychiatric symptom burden (CPRS) in older persons (Van Der Laan et al., 2005). The original small sample size and the progressive loss of subjects are major limitations which entail low precision; hence results must be interpreted with caution. Cases were recruited in the hospital setting and attempters not treated in hospital might be expected to have more negative beliefs about medicines and less own experience of antidepressant treatment. Further, those who did not continue to take their antidepressant may have more negative beliefs toward antidepressants compared to those who persisted. A single question was used to examine hopelessness and this must be seen as a limitation. A more specific instrument would have been more reliable. Further, one
limitation is the lack of a validated measure of adherence, which would have added relevance and important knowledge to the study. Finally, as only persons with a working knowledge of Swedish were included results cannot be generalized to those with different cultural backgrounds.
Conclusion The majority of older persons in treatment after a suicide perceived the necessity of their antidepressant medicine to outweigh their concerns. The BMQ specific for antidepressants might be a valuable tool in clinical practice for physicians who treat persons who attempt suicide in late life, but studies using objective measures of adherence are called for.
Conflict of interest The study was supported by grants from the Swedish Research Council (2005–21X-14598– 03A, 2009–62X-2079–01–3), the Swedish Council for Working Life and Social Research (2002– 0153), the Söderström-König Foundation, the Thuring Foundation, the Hjalmar Svensson Foundation, the Organon Foundation, the Axel Linder Foundation and the Wilhelm and Martina Lundgren Foundation. None of the funders have had any role in the research.
Description of authors’ role Eva Lesén was involved in data analysis and interpretation, and contributed to the draft and final manuscript. Stefan Wiktorsson collected all data at baseline and at follow-up. He was involved in the
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
1802
E. Lesén et al.
interpretation of data, contributed to the original manuscript and prepared the revised manuscript. Eva Lesén and Stefan Wiktorsson are joint first authors. Anders Carlsten was involved in the design of the study and preparing the final manuscript. Margda Waern designed and supervised the original study, and carried out the Swedish translation of the BMQ for antidepressants. Further she was involved in data interpretation and contributed to the final manuscript. Tove Hedenrud was involved in the Swedish translation of the BMQ for antidepressants. Further she was involved in data interpretation and has contributed to the final manuscript.
Acknowledgments The authors wish to thank all study participants and hospital staff.
References Aikens, J. E. and Klinkman, M. S. (2012). Changes in patients’ beliefs about their antidepressant during the acute phase of depression treatment. General Hospital Psychiatry, 34, 221–226. doi:10.1016/j.genhosppsych.2012.01.004. Aikens, J. E., Nease, D. E. Jr. and Klinkman, M. S. (2008). Explaining patients’ beliefs about the necessity and harmfulness of antidepressants. Annals of Family Medicine, 6, 23–29. doi:10.1370/afm.759. Asberg, M., Montgomery, S. A., Perris, C., Schalling, D. and Sedvall, G. (1978). A comprehensive psychopathological rating scale. Acta Psychiatrica Scandinavica. 57, 5–27. doi: 10.1111/j.1600-0447.1978.tb02357.x. Barbui, C., Esposito, E. and Cipriani, A. (2009). Selective serotonin reuptake inhibitors and risk of suicide: a systematic review of observational studies. CMAJ: Canadian Medical Association Journal, 180, 291–297. doi:10.1503/cmaj.081514. Brown, C. et al. (2005). Beliefs about antidepressant medications in primary care patients: relationship to self-reported adherence. Medical Care, 43, 1203–1207. Cohen, N. L., Ross, E. C., Bagby, R. M., Farvolden, P. and Kennedy, S. H. (2004). The 5-factor model of personality and antidepressant medication compliance. Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie, 49, 106–113. Conwell, Y., Duberstein, P. R. and Caine, E. D. (2002). Risk factors for suicide in later life. Biological Psychiatry, 52, 193–204. Eysenck, H. J. and Eysenck, S. G. G. (1964). Manual of the Eysenck Personality Inventory. London: University of London Press. Fawzi, W. et al. (2012). Beliefs about medications predict adherence to antidepressants in older adults. International Psychogeriatrics, 24, 159–169. doi:10.1017/S1041610211001049.
Frances, A. and American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders: DSM-IV: Prepared by the Task Force on DSM-IV. Washington, DC: American Psychiatric Assoc. Gibbons, R. D. et al. (2007). Relationship between antidepressants and suicide attempts: an analysis of the Veterans Health Administration data sets. American Journal of Psychiatry, 164, 1044–1049. doi:10.1176/appi.ajp.164.7.1044. Givens, J. L. et al. (2006). Older patients’ aversion to antidepressants. A qualitative study. Journal of General Internal Medicine, 21, 146–151. doi:10.1111/j.1525-1497.2005.00296.x. Hawton, K. and Van Heeringen, K. (2009). Suicide. Lancet, 373, 1372–1381. doi:10.1016/S0140-6736(09)60372-X. Hedenrud, T., Jonsson, P. and Linde, M. (2008). Beliefs about medicines and adherence among Swedish migraineurs. Annals of Pharmacotherapy, 42, 39–45. doi:10.1345/aph.1K354. Horne, R. and Weinman, J. (1999). Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. Journal of Psychosomatic Research, 47, 555–567. Hunot, V. M., Horne, R., Leese, M. N. and Churchill, R. C. (2007). A cohort study of adherence to antidepressants in primary care: the influence of antidepressant concerns and treatment preferences. Primary Care Companion to the Journal of Clinical Psychiatry, 9, 91–99. Lapierre, S. et al. (2011). A systematic review of elderly suicide prevention programs. Crisis, 32, 88–98. doi:10.1027/0227-5910/a000076. Lu, C. Y. and Roughead, E. (2012). New users of antidepressant medications: first episode duration and predictors of discontinuation. European Journal of Clinical Pharmacology, 68, 65–71. doi:10.1007/s00228-011-1087-3. Maidment, R., Livingston, G. and Katona, C. (2002). Just keep taking the tablets: adherence to antidepressant treatment in older people in primary care. International Journal of Geriatric Psychiatry, 17, 752–757. doi:10.1002/gps.688. Morin, J. et al. (2012). Alcohol use disorder in elderly suicide Attempters: a comparison study. American Journal of Geriatric Psychiatry, 21, 196–203. doi:10.1097/JGP.0b013e3182423b35. Osterberg, L. and Blaschke, T. (2005). Adherence to medication. New England Journal of Medicine, 353, 487–497. doi:10.1056/NEJMra050100. Paykel, E. S., Myers, J. K., Lindenthal, J. J. and Tanner, J. (1974). Suicidal feelings in the general population: a prevalence study. British Journal of Psychiatry, 124, 460–469. Pompili, M. et al. (2012). Temperaments mediate suicide risk and psychopathology among patients with bipolar disorders. Comprehensive Psychiatry, 53, 280–285. doi:10.1016/j.comppsych.2011.04.004. Pompili, M. et al. (2013). Mood disorders medications: predictors of nonadherence - review of the current literature. Expert Review of Neurotherapeutics, 13, 809–825. doi:10.1586/14737175.2013.811976. Rifai, A. H., George, C. J., Stack, J. A., Mann, J. J. and Reynolds, C. F. 3rd. (1994). Hopelessness in suicide
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
Beliefs about antidepressants among suicide attempters attempters after acute treatment of major depression in late life. American Journal of Psychiatry, 151, 1687–1690. Ruppar, T. M., Dobbels, F. and De Geest, S. (2012). Medication beliefs and antihypertensive adherence among older adults: a pilot study. Geriatric Nursing (New York, N.Y.), 33, 89–95. doi:10.1016/j.gerinurse.2012.01.006. Schuz, B. et al. (2011). Medication beliefs predict medication adherence in older adults with multiple illnesses. Journal of Psychosomatic Research, 70, 179–187. doi:10.1016/j.jpsychores.2010.07.014. Sherrill, J. T., Frank, E., Geary, M., Stack, J. A. and Reynolds, C. F. 3rd. (1997). Psychoeducational workshops for elderly patients with recurrent major depression and their families. Psychiatric Services, 48, 76–81. Szanto, K., Mulsant, B. H., Houck, P., Dew, M. A. and Reynolds, C. F. 3rd. (2003). Occurrence and course of suicidality during short-term treatment of late-life depression. Archives of General Psychiatry, 60, 610–617. doi:10.1001/archpsyc.60.6.610. Szanto, K., Reynolds, C. F., 3rd, Conwell, Y., Begley, A. E. and Houck, P. (1998). High levels of hopelessness persist in geriatric patients with remitted depression and a history of attempted suicide. Journal of the American Geriatrics Society, 46, 1401–1406. Szanto, K. et al. (2001). Treatment outcome in suicidal vs. non-suicidal elderly patients. American Journal of Geriatric Psychiatry, 9, 261–268.
1803
Tyrer, P., Owen, R. T. and Cicchetti, D. V. (1984). The brief scale for anxiety: a subdivision of the comprehensive psychopathological rating scale. Journal of Neurology, Neurosurgery and Psychiatry, 47, 970– 975. Van Der Laan, N. C., Schimmel, A. and Heeren, T. J. (2005). The applicability and the inter-rater reliability of the comprehensive psychopathological rating scale in an elderly clinical population. International Journal of Geriatric Psychiatry, 20, 35–40. doi:10.1002/gps.1244. Who Collaborating Centre for Drug Statistics Methodology (2012). Guidelines for ATC Classification and DDD Assignment 2013. Oslo. Wiktorsson, S., Marlow, T., Runeson, B., Skoog, I. and Waern, M. (2011). Prospective cohort study of suicide attempters aged 70 and above: one-year outcomes. Journal of Affective Disorders, 134, 333–340. doi:10.1016/j.jad.2011.06.010. Wiktorsson, S., Runeson, B., Skoog, I., Ostling, S. and Waern, M. (2010). Attempted suicide in the elderly: characteristics of suicide attempters 70 years and older and a general population comparison group. American Journal of Geriatric Psychiatry, 18, 57–67. doi:10.1097/JGP.0b013e3181bd1c13. Yesavage, J. A. et al. (1982). Development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research, 17, 37–49.
Downloaded from https:/www.cambridge.org/core. University of Southern Queensland, on 22 Jan 2017 at 16:32:34, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S1041610215000216
