THE EPIDEMIOLOGY OF DEPRESSION AND SUICIDE

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					 THE EPIDEMIOLOGY OF
DEPRESSION AND SUICIDE
    Stephen C. Newman, MD, MSc, CCFP
     Professor, Department of Psychiatry
            University of Alberta
  Overview of Presentation
Morbidity and mortality due to depression
Suicide
Attempted suicide
Antidepressants
Proposed study
Morbidity and Mortality
 Due to Depression
            Period Prevalence Rates *
              of Major Depression
            Edmonton, Ages 18+, 1983-86
                    (N= 3,284)

Period                            Rate (%)
                   Male          Female        Both sexes
One month            1.7           2.9               2.3
One year             3.4            5.9              4.6
Lifetime             5.9           11.4              8.6



  * Proportion of population with disorder during period
          Standardized Mortality Ratios*
              for Major Depression
  Alberta Mental Health Clinics, All Ages, 1976-85
                    (N= 4,022)


Cause of death           Number of deaths                SMR
All causes                    326                         2.3
Suicide                        96                        26.0


* SMR = observed number of deaths in cohort divided by
        expected number of deaths (based on Alberta population)
 Disability Adjusted Life Years*, Both Sexes
   “Established Market Economies”, 1990
        (adapted from Global Burden of Disease, 1996)

Disease category               Proportion of all DALYs (%)
Psychiatric                               26.0
Cardiovascular                            18.6
Cancer                                          15.0
Unintentional injuries                          8.7
Respiratory                                      4.8
Gastrointestinal                                 4.4
Musculoskeletal                                  4.2

    * DALY = years of actual life spent in a disabled state plus
             years of life lost due to premature mortality
  Disability Adjusted Life Years, Both Sexes
   “Established Market Economies”, 1990
        (adapted from Global Burden of Disease, 1996)


Psychiatric condition             Proportion of all DALYs (%)
Major depression                                    6.7
Alcohol abuse                                       4.7
Dementia                                            2.9
Schizophrenia                                       2.3
Self-inflicted injury                               2.2
Bipolar disorder                                    1.7

     * DALY = years of actual life spent in a disabled state plus
              years of life lost due to premature mortality
Suicide
    Number of Suicides,
Edmonton and Canada, 1989-99
    Year   Edmonton   Canada
    1989     125      3,492
    1991     140      3,592
    1993     148      3,802
    1995     121      3,970
    1997     100      3,681
    1999     130        ---
                  Death Rates* (per 100,000)
                   Males, Canada, 1997

                                                  182      Heart attack
                           71                              Lung cancer
                      52                                   Stroke
                 38                                        Unint. injuries
             32                                            Pneumonia, flu
            29                                             Prostate cancer
        24                                                 Bowel cancer
       20
                                                           Suicide


0                 50            100    150           200

    * Rate = number of deaths divided by number in population
                Death Rates* (per 100,000)
                 Females, Canada, 1997

                                                    94     Heart attack
                               43                          Stroke
                         34                                Lung cancer
                    28                                     Breast cancer
               20                                          Pneumonia, flu
           17                                              Unint. injuries
          16                                               Bowel cancer
    5                                                      Suicide


0          20             40        60    80         100
    * Rate = number of deaths divided by number in population
                 Death Rates* (per 100,000)
                 Both sexes, Canada, 1997
    (excluding breast cancer and prostate cancer)


                                                132         Heart attack
                    49                                      Lung cancer
                    47                                      Stroke
            24                                              Pneumonia, flu
           19                                               Bowel cancer
      12                                                    Suicide
      11
                                                            MVA


0                  50              100                150
    * Rate = number of deaths divided by number in population
     Proportion of Deaths Due to Suicide (%)
                  Canada, 1998
30
                26
25

20                        19
                     17
                                           Males
15
                                           Females
10                             9


 5                                 4
       2                               2
           1
 0
        <15     15-24     25-44    45-64
     Potential Years of Life Lost* (per 100,000)
               Males, Canada, 1997

                                                 1028          Unint. injuries
                                           891                 Heart attack
                                   684                         Suicide
                       480                                     Lung cancer
         163                                                   Stroke
         154                                                   Bowel cancer
    79                                                         Pneumonia, flu
    60                                                         Prostate cancer


0        200     400         600     800     1000       1200


    * PYLL = sum of years between age at death and age 75
       Potential Years of Life Lost* (per 100,000)
               Females, Canada, 1997

                                                     362       Breast cancer
                                                   354         Unint. injuries
                                                 340           Lung cancer
                                       267                     Heart attack
                            177                                Suicide
                      139                                      Stroke
                    118                                        Bowel cancer
         54                                                    Pneumonia, flu


0             100           200           300            400


    * PYLL = sum of years between age at death and age 75
Age-Standardized Suicide Rates (per 100,000)
 Both Sexes, Canada and Provinces, 2001
                                                                       Canada
       25                                                              Nfld
                                                                       PEI
       20                                                         19
                                                                       NS
                                    17
                                                                       NB
       15                                               14
Rate




                              13                                       Quebec
            11                                11   11
                     10                                      10        Ontario
       10                 9
                                         8
                 7                                                     Manitoba

        5                                                              Sask
                                                                       Alberta
        0                                                              BC
                                   Province                            Yukon


                                   NWT = 21
                                   Nunavut = 80
 Age-Standardized Suicide Rates (per 100,000)
      Both Sexes, Canada and Alberta
       20

       18                         Alberta

       16
Rate




       14

       12                          Canada

       10
            1966   1971   1976   1981   1986   1991   1996   2001
                                    Time
   Age-Standardized Suicide Rates (per 100,000)
               Canada, All ages
       30


                                   Males
       20
Rate




                                   Females
       10



        0
            1961   1966     1971   1976    1981   1986   1991   1996   2001
                                           Time

                          Male : female ratio = 3 (approximately)
Age-Specific Suicide Rates (per 100,000)
            Canada, 1992
 50

                               Males
 40                            Females

 30


 20


 10


  0
      15-24 25-34 35-44 45-54 55-64 65-74 75-84   85+
                    Suicide Rates (per 100,000)
                      Canada, Ages 15-19
       40


       30
                                           Males
Rate




       20


       10                                 Females


        0
            1961   1966   1971   1976   1981   1986   1991   1996   1998
                                        Time
                     Suicide Rates (per 100,000)
                       Canada, Ages 45-49
       40


                                          Males
       30
Rate




       20
                                         Females

       10


        0
            1961   1966   1971   1976   1981   1986   1991   1996   1998
                                        Time
                   Suicide Rates (per 100,000)
                     Canada, Ages 65-69
       40


       30
                                 Males
Rate




       20

                            Females
       10


        0
            1961   1966   1971      1976   1981   1986   1991
                                    Time
 “Suicide is the Leading Cause of
   Violent Deaths Worldwide”
        (quote from “President’s New Freedom
        Commission on Mental Health, 2003”)


Cause          Proportion of violent deaths (%)
Suicide                         49
Homicide                        31
War-related                     19
Attempted Suicide
Suicide Attempts* and Suicide Attempters
            Edmonton, 1997

       Sex                      Number of
                           Attempts Attempters
       Males                   840                 691
       Females                1,269                969
       Both sexes             2,109               1,660


   * ER visit for intentional self-injury regardless of lethality
    Rate of Attempted Suicide (per 1000)
              Edmonton, 1997
8

                                       Males
6
                                       Females


4



2



0
    15-24   25-34   35-44   45-54   55-64   65+   All ages
Age-standardized Rates of Attempted Suicide (per 1000)
 Edmonton, 1997 and Top 10 (of 15) WHO Sites, 1989
                    Both Sexes

                                             Edmonton
                                             Pointoise
                                             Oxford
                                             Helsinki
                                             Stockholm
                                             Odense
                                             Szeged
                                             Bordeaux
                                             Sort-Trondelag
                                             Berne
                                             Umea

0         1         2          3         4
Antidepressants
A Lot of People Take an Antidepressant

 WHO (2004) conducted a survey of adults in 6 European countries:
 4% had taken an antidepressant in past year

 Patten et al. (in press) conducted a survey of adults in Alberta:
 7% currently taking an antidepressant

 Hemels et al (2002) analyzed IMS data for Canada, 1981-2000:
 rate of antidepressant use increasing, especially in 1990s
Even More People Probably Should

Patten (2002) analyzed data from the National Population Health
Survey:
33% of Canadians with DSM-IV major depression had taken an
antidepressant in past month
   Who Prescribes Antidepressants,
          and What For?

There are no Canadian studies answering this question

McManus et al (2003) analyzed data from a national prescription
registry in Australia:
85% of prescriptions for antidepressants were written by “general
practitioners”

Orenstein et al. (2000) analyzed data from a national family practice
registry in the US:
57% of antidepressant prescriptions were for “depression”
The Proposed Study
(which is really two studies in one)
           Observational Study
Primary aim
To determine the conditions for which family physicians prescribe
   antidepressants:
   Major depression
   “Mild” depression
   Dysthymia
   Generalized anxiety disorder
   Panic disorder
   Adjustment disorder with depressed mood
   Adjustment disorder with mixed anxiety and depressed mood
   Nonpsychiatric conditions (sleep disorders, pain syndromes, …)
           Observational Study
Eligibility criteria
   Patient presenting to a community pharmacy with a prescription
   from a family physician for an antidepressant
   First such prescription in past 6 months

Recruitment
  Pharmacist obtains verbal consent by phone using a script to
  allow an interviewer to make contact
  Interviewer makes contact, arranges a face-to-face meeting, and
  obtains informed consent
      Observational Study

Data Collection
  Face-to-face interviews conducted using psychiatric
  questionnaires (1-2 hours)
  Diagnostic checklist mailed to family physician

Sample size
  631 subjects recruited over 1 year
       Randomized Controlled Trial
Primary aim
To compare the effectiveness on treatment persistence of a brief,
   illustrative psycho-educational tool offered by pharmacists to
   patients receiving an antidepressant

Eligibility criterion
   Subject in the observational study
   Diagnosis of a depressive syndrome

Sample size
  106 subjects needed (53 intervention, 53 usual care)
Thank You

				
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