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Season of treatment initiation with antidepressants and suicidal behavior: A population-based cohort study in Sweden
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Psychiatry, University Hospital.
Karolinska Inst, Karolinska Univ Hosp, Dept Med Solna, Ctr Pharmacoepidemiol, Stockholm, Sweden..
Karolinska Inst, Karolinska Univ Hosp, Dept Med Solna, Ctr Pharmacoepidemiol, Stockholm, Sweden..
Norwegian Inst Publ Hlth, Oslo, Norway..
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2017 (English)In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 215, p. 245-255Article in journal (Refereed) Published
Abstract [en]

Background: Decreased binding capacity of SERT in the prefrontal cortex has been observed in both suicide victims and suicide attempters. Moreover, some studies have shown that SERT has a seasonal variation with lower binding capacity in the spring and summer, which coincides with a seasonal peak of suicides. Our aim was to explore whether the season of treatment initiation with antidepressants is associated with suicide or suicide attempt and compare it with the underlying suicide seasonality in the general population.

Methods: Using Swedish registers, patients who initiated treatment with an antidepressant were followed up to three months for suicidal behavior. Cox regression analyses were used.Results were compared with the underlying seasonal pattern by calculating standardized mortality ratios (SMRs) for suicides and standardized incidence ratios (SIRs) for suicide attempts.

Results: Patients aged years had higher risk for suicide when initiating antidepressant treatment in the summer, and also a higher risk for suicide attempt when initiating treatment in the spring and summer. Young patients (0-24 years) presented a higher risk for suicide attempt when initiating treatment in the autumn. Patients with previous suicide attempt had a seasonal pattern, with a higher risk to carry out a suicide attempt in the summer and autumn. Results from the SMR and SIR calculations numerically support these findings.

Limitations: We used information of filling an antidepressant prescription as a proxy of actual antidepressant treatment. Patients with combination, augmentation therapy or those switching antidepressant during followup were excluded. Thus, our results refer to less complicated psychopathology.

Conclusions: Our results indicate an interaction between biological and health care-related factors for the observed seasonal pattern of suicidal behavior in the elderly, whereas psychological and societal factors may be more important for the seasonality observed in the younger patients.

Place, publisher, year, edition, pages
ELSEVIER SCIENCE BV , 2017. Vol. 215, p. 245-255
National Category
Psychiatry
Identifiers
URN: urn:nbn:se:uu:diva-326206DOI: 10.1016/j.jad.2017.03.028ISI: 000401213300034PubMedID: 28343052OAI: oai:DiVA.org:uu-326206DiVA, id: diva2:1129895
Funder
Swedish Society of Medicine, SLS-175701Available from: 2017-08-07 Created: 2017-08-07 Last updated: 2017-10-15Bibliographically approved
In thesis
1. Suicide Seasonality: Theoretical and Clinical Implications
Open this publication in new window or tab >>Suicide Seasonality: Theoretical and Clinical Implications
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Although suicide seasonality has been well-documented, surprisingly little is known about its underlying mechanisms.

Methods: In this thesis, data from three Swedish registers (Cause of Death Register, National Patient Register, Prescribed Drugs Register) and data from the Swedish Meteorological and Hydrological Institute were used.

In Study I, the amplitude of suicide seasonality was estimated in completed suicides in 1992-2003 in individuals with different antidepressant medications or without antidepressants.

In Study II, monthly suicide and sunshine data from 1992-2003 were used to examine the association between suicide and sunshine in groups with and without antidepressants.

In Study III, the relationship between season of initiation of antidepressant treatment and the risk of suicidal behavior was explored in patients with a new treatment episode with antidepressant medication.

In Study IV, the complex association between sunshine, temperature and suicidal behavior was investigated in patients with a new treatment episode with an antidepressant in two exposure windows (1-4 and 5-8 weeks) before the event.

Findings: Study I: Higher suicide seasonality was found in individuals treated with selective serotonin reuptake inhibitors (SSRIs) compared with those given a different antidepressant treatment or those without any antidepressant treatment.

Study II: In individuals treated with SSRIs, there was a positive association between sunshine and suicide, with the association stronger in men treated with SSRIs compared with men treated with other antidepressants. An effect modification by age was observed.

Study III: The elderly (65+) had a higher risk of suicide when initiating antidepressant treatment in summer and a higher risk of suicide attempt when starting antidepressant therapy in spring and summer. Younger patients (0-24) demonstrated a higher risk of suicide attempt when treatment was initiated in autumn.

Study IV: In the elderly (65+), a harmful association was observed between the risk of suicide attempt and the average daily temperature during the four weeks before the suicide attempt, as well as with average daily sunshine during both exposure windows (1-4 and 5-8 weeks) before the suicide attempt.

Significance: Our results provide epidemiological support for the role of the serotonergic system in seasonality of suicide in which both medication and climate may be involved.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2017. p. 74
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1383
Keywords
suicide, season, antidepressants, sunshine, temperature
National Category
Neurosciences
Research subject
Psychiatry
Identifiers
urn:nbn:se:uu:diva-330907 (URN)978-91-513-0108-2 (ISBN)
Public defence
2017-12-07, Gunnesalen, Ing 10, Akademiska sjukhuset, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2017-11-16 Created: 2017-10-15 Last updated: 2018-03-07

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Makris, Georgios D.Ekselius, LisaPapadopoulos, Fotios

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