Linda Wijlaars

Trends and patterns of antidepressant use in children and adolescents from five western countries, 2005-2012

Following the FDA black box warning in 2004, substantial reductions in antidepressant (ATD) use were observed within 2 years in children and adolescents in several countries. However, whether these reductions were sustained is not known. The objective of this study was to assess more recent trends in ATD use in youth (0-19 years) for the calendar years 2005/6-2012 using data extracted from regional or national databases of Denmark, Germany, the Netherlands, the United Kingdom (UK), and the United States (US). In a repeated cross-sectional design, the annual prevalence of ATD use was calculated and stratified by age, sex, and according to subclass and specific drug. Across the years, the prevalence of ATD use increased from 1.3% to 1.6% in the US data (+26.1%); 0.7% to 1.1% in the UK data (+54.4%); 0.6% to 1.0% in Denmark data (+60.5%); 0.5% to 0.6% in the Netherlands data (+17.6%); and 0.3% to 0.5% in Germany data (+49.2%). The relative growth was greatest for 15-19 year olds in Denmark, Germany and UK cohorts, and for 10-14 year olds in Netherlands and US cohorts. While SSRIs were the most commonly used ATDs, particularly in Denmark (81.8% of all ATDs), Germany and the UK still displayed notable proportions of tricyclic antidepressant use (23.0% and 19.5%, respectively). Despite the sudden decline in ATD use in the wake of government warnings, this trend did not persist, and by contrast, in recent years, ATD use in children and adolescents has increased substantially in youth cohorts from five Western countries.

Suicide-Related Events in Young People Following Prescription of SSRIs and Other Antidepressants: A Self-Controlled Case Series Analysis

Objectives We aimed to examine the temporal association between selective serotonin reuptake inhibitors (SSRI) and tricyclic antidepressant (TCA) prescriptions and suicide-related events in children and adolescents. Design Self-controlled case series. Setting Electronic health records were used from 479 general practices in The Health Improvement Network (THIN) UK primary care database from 1995 to 2009. Participants 81 young people aged 10–18 years with a record of completed suicide, 1496 who attempted suicide, 1178 with suicidal ideation and 2361 with intentional self-harm. Main outcome measures Incidence Rate Ratios (IRRs) for completed and attempted suicide, suicidal ideation and intentional self-harm. Results For non-fatal suicide-related behaviour, IRRs were similar for the time the person was prescribed either SSRIs or TCAs: IRRs increased during pre-exposure, peaked on prescription day, were stable up to the fourth prescription-week, and decreased after the prescriptions were stopped. For both types of antidepressants, IRRs were lower or similar to pre-exposure levels during the period of prescription. For SSRIs, there was an increase in the IRR for completed suicide on the day of prescription (N=5; IRR=42.5, 95% CI 4.5 to 403.4), and during the fourth week of SSRI prescription (N=2; IRR=11.3, 95% CI 1.1 to 115.6). Conclusions We found that a very small number of young people were prescribed antidepressants and that there was an absence of a sustained increase in rates of suicide-related events in this group. There were no systematic differences between the association of TCAs and SSRIs and the incidence risk ratios for attempted suicide, suicidal ideation or intentional self-harm and, apart from the day of prescription, rates did not exceed pre-exposure levels. The pattern of IRR for suicide for SSRIs was similar to that found in non-fatal suicide-related events. Our results warrant a re-evaluation of the current prescription of SSRIs in young people. We recommend the creation of a pragmatic registry for active pharmacovigilance.

Trends in ADHD medication use in children and adolescents in five western countries, 2005-2012

Over the last two decades, the use of ADHD medication in US youth has markedly increased. However, less is known about ADHD medication use among European children and adolescents. A repeated cross-sectional design was applied to national or regional data extracts from Denmark, Germany, the Netherlands, the United Kingdom (UK) and the United States (US) for calendar years 2005/2006-2012. The prevalence of ADHD medication use was assessed, stratified by age and sex. Furthermore, the most commonly prescribed ADHD medications were assessed. ADHD medication use prevalence increased from 1.8% to 3.9% in the Netherlands cohort (relative increase: +111.9%), from 3.3% to 3.7% in the US cohort (+10.7%), from 1.3% to 2.2% in the German cohort (+62.4%), from 0.4% to 1.5% in the Danish cohort (+302.7%), and from 0.3% to 0.5% in the UK cohort (+56.6%). ADHD medication use was highest in 10-14-year olds, peaking in the Netherlands (7.1%) and the US (8.8%). Methylphenidate use predominated in Europe, whereas in the US amphetamines were nearly as common as methylphenidate. Although there was a substantially greater use of ADHD medications in the US cohort, there was a relatively greater increase in ADHD medication use in youth in the four European countries. ADHD medication use patterns in the US differed markedly from those in western European countries.

Making a hash of data: what risks to privacy does the NHS's care.data scheme pose?

Care.data proposes to link individual level hospital episode statistics (HES) and general practice data at the Health and Social Care Information Centre. As is currently the case for HES, linked data will be pseudoanonymised before being released to researchers.1 A proposed alternative is for identifiers (such as NHS number, date of birth) to be pseudoanonymised at source,2 using an encrypted hash, before linkage is performed.3 4 Pseudoanonymisation …

Child mortality in England compared with Sweden: a birth cohort study

Summary Background Child mortality is almost twice as high in England compared with Sweden. We aimed to establish the extent to which adverse birth characteristics and socioeconomic factors explain this difference. Methods We developed nationally representative cohorts of singleton livebirths between Jan 1, 2003, and Dec 31, 2012, using the Hospital Episode Statistics in England, and the Swedish Medical Birth Register in Sweden, with longitudinal follow-up from linked hospital admissions and mortality records. We analysed mortality as the outcome, based on deaths from any cause at age 2–27 days, 28–364 days, and 1–4 years. We fitted Cox proportional hazard regression models to estimate the hazard ratios (HRs) for England compared with Sweden in all three age groups. The models were adjusted for birth characteristics (gestational age, birthweight, sex, and congenital anomalies), and for socioeconomic factors (maternal age and socioeconomic status). Findings The English cohort comprised 3 932 886 births and 11 392 deaths and the Swedish cohort comprised 1 013 360 births and 1927 deaths. The unadjusted HRs for England compared with Sweden were 1·66 (95% CI 1·53–1·81) at 2–27 days, 1·59 (1·47–1·71) at 28–364 days, and 1·27 (1·15–1·40) at 1–4 years. At 2–27 days, 77% of the excess risk of death in England was explained by birth characteristics and a further 3% by socioeconomic factors. At 28–364 days, 68% of the excess risk of death in England was explained by birth characteristics and a further 11% by socioeconomic factors. At 1–4 years, the adjusted HR did not indicate a significant difference between countries. Interpretation Excess child mortality in England compared with Sweden was largely explained by the unfavourable distribution of birth characteristics in England. Socioeconomic factors contributed to these differences through associations with adverse birth characteristics and increased mortality after 1 month of age. Policies to reduce child mortality in England could have most impact by reducing adverse birth characteristics through improving the health of women before and during pregnancy and reducing socioeconomic disadvantage. Funding The Farr Institute of Health Informatics Research (through the Medical Research Council, Arthritis Research UK, British Heart Foundation, Cancer Research UK, Chief Scientist Office, Economic and Social Research Council, Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institute for Social Care and Health Research, and the Wellcome Trust).

Emergency admissions and long-term conditions during transition from paediatric to adult care: a cross-sectional study using Hospital Episode Statistics data

Objective To determine whether changes in emergency admission rates during transition from paediatric to adult hospital services differed in children and young people (CYP) with and without underlying long-term conditions (LTCs). Design Cross-sectional study. Setting Emergency admissions between 2009 and 2011 recorded in the Hospital Episode Statistics Admitted Patient Care data in England. Participants 763 199 CYP aged 10–24 years with and without underlying LTCs (LTCs were defined using the International Classification of Diseases, 10th Revision codes recorded in the past 5 years). Primary and secondary outcome measures We calculated emergency admission rates before (10–15 years) and after transition (19–24 years), stratified by gender, LTC and primary diagnosis. We used negative binomial regression to estimate adjusted incidence rate ratios (IRRs). Results We included 1 109 978 emergency admissions, of which 63.2% were in children with LTCs. The emergency admission rate increased across the age of transition for all CYP, more so for those with LTCs (IRRLTC: 1.55, 99% CI 1.47 to 1.63), compared with those without (IRRnoLTC: 1.21, 99% CI 1.18 to 1.23). The rates increased most rapidly for CYP with mental health problems, MEDReG (metabolic, endocrine, digestive, renal, genitourinary) disorders, and multiple LTCs (both genders) and respiratory disorders (female only). Small or no increased rates were found for CYP without LTCs and for those with cancer or cardiovascular disease. Increases in length of stay were driven by long admissions (10+ days) for a minority (1%) of CYP with mental health problems and potentially psychosomatic symptoms. Non-specific symptoms related to abdominal pain (girls only), gastrointestinal and respiratory problems were the most frequent primary diagnoses. Conclusions The increased rates and duration of emergency admissions and predominance of non-specific admission diagnoses during transition in CYP with underlying LTCs may reflect unmet physical or mental health needs.

Emergency admissions across the transition from paediatric to adult care: cross-sectional analysis of English hospital data

Abstract Background Transition from paediatric to adult health services is often sub-optimally achieved for children with long-term conditions. We investigated trends in emergency admissions across the transition from paediatric to adult care. Methods Using Hospital Episodes Statistics data, we analysed 1 186 392 emergency admissions between April 1, 2009, and March 31, 2012, in children and young people aged 10–24 years. We calculated emergency admission rates for this cohort before (10–15 years), during (16–18), and after transition (19–24) using mid-year population estimates as denominators. We stratified analyses by underlying long-term conditions, which we defined by validated International Classification of Diseases 10th revision codes. We excluded injury-related and maternity-related admissions. We used negative binomial regression to determine incidence rate ratios (IRRs). Findings Prevalence rates for emergency admissions increased 64% for girls (29/1000 before transition to 48/1000 after transition) and 17% for boys (26/1000 to 31/1000). This increase overwhelmingly occurred during transition (16–18 years), when rates increased 4·0/1000 per year for girls and 2·3/1000 for boys. At the same time, average length of hospital stay increased from 2·1 to 2·9 days for girls, and 1·8 to 5·0 days for boys (increases of 38% and 186% for girls and boys, respectively). Disparities in admission rates increased during transition, with children and young people from the most deprived quintile more likely than those from the least deprived quintile to have an emergency admission (IRR 1·63, 95% CI 1·60–1·66), and more so than before transition (1·51, 1·45–1·56). The increase in admission rates was driven by underlying long-term conditions: overall, rates increased 14% (IRR 1·14, 95% CI 1·13–1·14), but for children and young people with long-term conditions rates increased 46% (1·46, 1·46–1·47). Rates increased most rapidly for mental health problems, metabolic and endocrine disorders, multiple long-term conditions (both sexes), and respiratory disorders (girls only). Interpretation Our results show that emergency admission rates, duration, and inequalities increase across transition, especially in children and young people with underlying long-term conditions. The extent to which this increase is due to transition within the health service, rather than other developments, requires further research. Our results are in keeping with the widely recognised difficulties that young people face when they transition to adult health services. Funding LPMMW and JW were supported by funding from the Department of Health Policy Research Programme through funding to the Policy Research Unit in the Health of Children, Young People and Families (grant reference 109/0001). RG is supported by awards establishing the Farr Institute of Health Informatics Research at University College London Partners from the Medical Research Council and a consortium of funders (MR/K006584/1).