L. Kavaliauskienė 1; R. Pečiūra 1; V. Adomaitienė 2; R. Masteiková 3
Lithuanian University of Health Sciences, Medical Academy, Faculty of Pharmacy, Department of Drug Technology and Social Pharmacy, Kaunas, Lithuania
1; Lithuanian University of Health Sciences, Medical Academy, Department of Psychiatry, Kaunas, Lithuania
2; University of Veterinary and Pharmaceutical Sciences, Faculty of Pharmacy, Department of Pharmaceutics, Brno, Czech Republic
Čes. slov. Farm., 2010; 59, 199-204
Depression represents one of the most severe health problems. It belongs to the diseases which cause the largest amount of non-fatal disease burden worldwide, and greatly influences the quality of life. The frequency of this disease is connected with the consumption of antidepressants. This study thus aimed to overview the trends of antidepressants consumption in Lithuania, to assess the number of depression cases, when diagnosed for the first time and repeatedly with regard to demographic situation, and to evaluate the impact of this disease on women and the society. All prescribed antidepressants were divided into four groups, according to the ATC classification. Consumption of the preparations from single groups was expressed in defined daily doses (DDD), and utilization was expressed as DDD per 1000 inhabitants per day. The results demonstrate that each year there are more diagnosed cases of depression, which is related mainly with depression relapses. This increase is attended with the growth of antidepressants consumption: from 2004 till 2009 this indicator had increased even by 48%. At the same time, the character of pharmacotherapy has changed – the prescription of tricyclic antidepressants was markedly decreased, and the prescription of bicyclic derivatives (selective serotonin reuptake inhibitors – SSRI) and other more recent preparations increased. The demographic data show that women suffer from depression significantly more – in Lithuania this disease was diagnosed in women four times more than in men, the incidence of depression relapse was often more frequent.
Key words: depression – relapse – consumption of antidepressants – quality of life
is a mood disorder with a significant impact on human life. It is
noticed by specialists and society not only as a disease, which may be
treated, but also as a serious condition of the person, depending on
various psychological and social elements, and having an impact on the whole
society 1, 2). Depressive disorders were estimated to be the fourth
leading cause of disease burden, accounting for 4.4% of total
disability-adjusted life-years in the year 2000, and it causes the largest
amount of non fatal burden, accounting for almost 12% of all total years lived
with disability worldwide 3). Depression was also associated with an
increased mortality risk of 1.81 (1.58–2.07) in a meta-analysis of 25
community surveys involving more than 100,000 subjects 4).
In recent years an increasing number of cases
of recurrent depression is recorded, which greatly increases the overall number
of patients with this disease. The number of suicides also increases together
with the spreading depression, e.g. 59 thousand people killed themselves
because of the impact of depression in 2006 in the whole Europe 5).
the study began to consider depression more broadly and looked for its other
causes, the quality-of-life index began to be employed as well, in the
formation of which the cost of living, culture and relaxation, economics,
environment, level of freedom, health protection, safety and risk, climate are
assessed. The magazine “International Living” published a list of 194
countries, where they are listed according to the quality of-life index in
January 2010. Lithuania was in relatively high, i.e., 22nd, position
Mental health is a key aspect of
well-being and quality of life. Marked differences are found between countries
when overall mental health is considered 7). The highest scores for
good mental health are seen in Norway, the Netherlands, Ireland, Germany,
Denmark, and Sweden. Turkey comes at the bottom, at 47, followed by Malta,
Romania, FYR Macedonia, and Latvia (all between 53 and 55). Lithuania got 58%
of the mean mental health index and is not far from the lowest level countries
of antidepressants has increased in all Western countries during the past 15-20
years. In Finland, the increase between 1990 and 2006 was nearly 8-fold 8),
from 7.09 defined daily doses (DDD) expressed for 1000 inhabitants a day
in 1990 to 55.47 DDDs in 2006. Similar trends have been reported elsewhere 9).
Although the consumption of antidepressant at the population level has
increased notably, population-based studies with all psychotropics and
antidepressants in particular suggest that increased prescribing may not have
markedly improved the mental health of the population. In Scotland, for
example, national development targets have already been made for reducing the
increase in antidepressant use. On the other hand, underutilization of
antidepressants among the depressed remains a constant concern since
epidemiological evidence shows that depressive individuals do not receive the
care they need. Further, the impact of antidepressant utilization rates on
suicides is discussed 10). Person-level and epidemiological data
from Finland suggest that use of antidepressants decreases suicide rates;
however, this association has not been found in all countries 8).
The purpose of this article is to overview the
trends of antidepressant drugs’ consumption in Lithuania, to assess the number
of depression cases, when diagnosed for the first time and repeatedly,
demographically, evaluating the impact of this disease on women and the society
as a whole, and linking with the quality of life.
MATERIAL AND METHODS
Data of general sales of antidepressant drugs in
Lithuania during 2004-2009 were obtained from IMS (Intercontinental Marketing
Service) Health Incorporated. Data were selected as units and price of drugs.
The consumption of drugs was measured as defined daily doses (DDD). Data were
calculated according to DDD methodology and expressed for 1000 inhabitants
a day 11). Data of depression diagnoses were obtained from the
State Mental Health Centre and expressed as the total number of diagnoses, and
according to the type of depression and gender of the patients.
All prescribed antidepressants in this study
were grouped into four groups, according to the ATC classification, while
defining DDD values:
Each year there are more cases of depression diagnosed
in Lithuania (Fig. 2). Moreover, depression prevalence each year is
continuously growing up – during the last six years the increase was from 0.59%
in 2004 to 0.69% in 2009. The statistics of diseases demonstrate
a continuously increasing number of recurrent depression diagnoses
(relapsed depression prevalence grew up from 0.24% to 0.32%), while the number
of first time depressions rose minimally (prevalence grew up from 0.35% to
0.37%). Thus depression diagnosis numbers increase mainly because of depression
relapse rates. According to the data of researchers of the University of
Virginia, USA, this disorder is recurring even for 50 percent of those with
depression and those who have been treated. Other figures are more daunting –
after repetitive treatment of depression, about 70 percent of patients fall
into depression for the third time, and after three treatments – even 90
percent. Each recurring disease means that a previous treatment was
The growth of
patients with depression was followed by a corresponding increase in
antidepressants use: over the years 2004–2009 the total consumption of these
preparations in Lithuania was increased even by 48 percent (Fig. 3). However,
the frequency of prescription of single preparations and defined groups of
antidepressants during this period changed.
For many years,
tricyclic and tetracyclic antidepressants (TCAs) were the first-line treatment
choice for depression in Europe, but recent studies indicate that some changes
occur in the prescribing of antidepressants 13). In Lithuania the
consumption of TCA group medicaments decreased by 42 percent (from 2.03 to 1.18
DDD/1000 inhabitants/day), apart from the fact that in accordance with
recommendations and the priority of antidepressant selection in Lithuania,
amitriptyline was the drug of choice for the treatment of depression 14).
Evidently due to a relatively high toxicity of TCAs, these antidepressants
are now used less frequently and for shorter periods than recommended.
the contrary, the prescription of preparations from the SSRI group increased
significantly (by 45%), from 6.38 to 9.25 DDD/1000 inhabitants/day. This trend
is in accordance with data from other European countries and the United States,
where SSRIs belong to the first-line drugs 15). SSRIs are generally
better tolerated than TCAs and are less likely to be discontinued due to the
side effects 13). Early discontinuation of antidepressant therapy
may increase the risk of relapse or recurrence of depression.
consumption of other more recent antidepressants during the monitored period
increased considerably likewise (from 1.61 to 4.63 DDD/1000 inhabitants/day).
Over the past decade, there has been an increase in the number and types of
antidepressants available. They have a wide range of mechanisms of action.
Current practice guidelines recommend that physicians should choose an
antidepressant drug based on the past experience of treatment, side effects,
patient preference and cost 13). The SSRIs and newer antidepressants
consistently appear more cost-effective than TCAs in many patient groups 16).
increasing statistics of both depression diagnosis and consumption of
antidepressants show that various factors must be assessed during the treatment
of this disease.
When analysing the trends of consumption of
antidepressants, the attention is paid to the gender of patients with this
disease. It is assessed that generally women suffer from this disease twice
more often than men 17). Besides physiological reasons, e.g.,
maturation difficulties, childbearing, menopause, etc., various social
phenomena also influence the susceptibility to depression – inequality between
men and women, cultural stereotypes, violence in family, high burden of
responsibility, etc. Statistics shows that Lithuania does not differ overmuch
in this term from the other countries in the world. Figure 4 shows that
depression was diagnosed for women just about 4 times more often than for men.
The cases of recurrent depression were recorded accordingly. The high incidence
of depression in women must be taken into account. The statistics demonstrate
only recorded diagnoses; however, there is no doubt that there are
significantly more women who suffer from depression.
aforementioned causes of incidence of depression in women, statistical indices
of Lithuania only confirm quite poor social situation of women. In the
beginning of the year 2010, 53.5 percent of women and 46.5 percent of men have
resided in Lithuania, i.e., 1151 women for 1000 men. According to the data of
2009, women in Lithuania live approximately 12 years longer than men, till 78.6
and 67.5 years of age, respectively 18). Thus more women live in
solitude. Nevertheless, a consideration of the association between
family-related factors and depression reveals that, overall, married or those
in a civil relationship have lower levels of depression than divorced,
separated, widowed and single ones 17). Living with a partner
seems to be an important buffer against depression for both genders.
Unemployment statistics show that there were
significantly more employed women than men during the first quarter of 2010 –
unemployment level of men was 23.2%, women – 13.1% 18). However,
although women are noticeably more educated than men, earn significantly less:
the gross average salary in 2009 was 1990 Litas for women and 2349 Litas for
However, women do not experience more mental
illnesses than men; they are simply more prone to depression and anxiety,
whereas men are more likely to have addictive disorders and personality
disorders. The effects of stress, violence, poverty, inequality, sexism, care
giving, relational problems, low self-esteem, and ruminative cognitive styles
probably increase vulnerability to depression in women. Predictive factors for
depression include previous depression, feeling out of control or overwhelmed,
chronic health problems, traumatic events in childhood or young adulthood, lack
of emotional support, lone parenthood, and low sense of mastery. Special
considerations are required for analysing the risk factors influencing the
women’s physical health 14).
Our results confirm the findings in international
research that there is a gender gap in depression across Europe.
Socioeconomic-related factors as well as family-related characteristics moderate
the relationship between gender and depression. The largest gender differences
in depression were found in a number of Southern European countries and in
certain Eastern European countries 17). Until recently, many studies
would have characterized Southern European countries as traditional, male
breadwinner systems. In contrast, the Eastern European countries, especially
the former Soviet Union countries, have a history of socialist policy that
encourages dual-breadwinner households 19). However, both Southern
and Eastern European countries are currently in transition. During the past
decade, the Southern countries have been confronted with a rapid expansion
of women’s employment, which has forced them to be innovative in how they
manage household responsibilities. Changes in men’s behaviour, especially in
relation to the unpaid work of care giving, have nevertheless been relatively
small 20). For example, in Portugal, where we found the largest
gender gap in depression, there is a relatively large number of mothers
who are employed full time and of dual full-time income earners, along with
relatively low levels of formal childcare provision 21).
is often considered as a mental disease, thus, many people simply avoid
talking about it. It is likely that men with the symptoms of depression do not
take medical advice precisely because of the fear of society opinion – more
often they choose suicide.
Since at least 1990, some have claimed that
the SSRIs may induce suicide 22). Since the increased use of
antidepressants in the past 15 years has mostly consisted of SSRIs, one should
expect increasing suicide rates if they induced suicide. Increases have been
found in some countries among younger men 10). Younger men, however,
may be least likely to take antidepressants 23). They are probably
also most likely to have substance abuse as a contributing factor to
suicide 24). The dominant international picture is an overall
decrease in suicide rates. Epidemiological studies comparing the suicide risk
among patients treated with newer antidepressants with the risk in those who
are treated with tricyclic antidepressants have found no difference between
impact of depression on society has not yet been assessed in Lithuania. This
impact is related not only with the lost ability of patients to work,
unavailable income, social services provided, but also with the influence on
the quality of life of the whole family and each of its member individually.
Economic aspects of depression treatment (as well as of improper treatment,
untimely diagnosis) must also be assessed to calculate how much the state pays
for the patients with depression and what preventive means must be taken.
in particular the recurrent one, severely affects the patient’s quality of
life. Increasing consumption of antidepressants and a growing number of
depression diagnoses stimulate the need to have a closer look at the
causes of the disease – the physiological, psychological, and social ones.
the data presented in this article, one might conclude that the high incidence
of depression in women in Lithuania is directly critical for the development of
society as a whole. It is also worth noting that a proper diagnosis
of depression and complete cure is not only the critical task for medics, but
a necessity as well – besides psychological and social loss, high expenses
of depression treatment are experienced too. Proper prescription of drugs and
observation of the progress of the disease are the factors the common
depression treatment management depends on. Individually selected treatment,
which is started in due time, can help the person suffering from depression to
become active and productive again more rapidly, and thus, to improve the
quality of life.
29 September 2010
Accepted 11 October 2010
Address for correspondence:
Assoc. Prof. Ruta
Pharmaceutics, Faculty of Pharmacy, University of Veterinary and Pharmaceutical
Palackého 1/3, 612 42
Brno, Czech Republic
1. European Pact for Mental Health and Well-being. http://ec.europa.eu/health/ph_determinants/life_style/mental/docs/pact_en.pdf (2010.06.30)
2. Murray, C., Lopez, A.: Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study. Lancet, 1997; 349, 1498–1504.
3. Ustun, T., Ayuso-Mateos, J., Chatterji, S., Mathers, C., Murray, C.: Global burden of depressive disorders in the year 2000. Br. J. Psych., 2004; 184, 386–392.
4. Cuijpers, P., Smit, F.: Excess mortality in depression: a meta-analysis of community studies. J. Affect. Dis., 2002; 72, 227–236.
5. Eurostat report on the causes of deaths in the EU (2006). http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-NK-06-010/EN/KS-NK-06-010-EN.PDF (2010.08.14)
7. European Foundation for the improvement of living and working conditions. Second European quality of life survey – first findings. www.eurofound.europa.eu/ pubdocs/2008/52/en/1/EF0852EN.pdf (2010.08.06).
8. Sihvo, S., Isometsa, E., Kiviruusu, O., Hamalainen, J., Suvisaari, J., Perala, J., Pirkola, S., Saarni, S., Lonnqvist, J.: Antidepressant utilisation patterns and determinants of short-term and non-psychiatric use in the Finnish general adult population. J. Affect. Dis., 2008; 110, 94–105.
9. Nomesco (Nordic Medico Statistical Committee), 2004. Medicines consumption in the Nordic countries 1999–2003. Nomesco, Copenhagen. Online access: www.nom-nos.dk (2010.08.06).
10. Isacsson, G., Rich, C.: Antidepressant drug use and suicide prevention. Int. Rev. Psych., 2005; 17, 153–162.
11. World Health Organization. Introduction to Drug Utilization Research. 2003. http://apps.who.int/medicine docs/pdf/s4876e/s4876e.pdf (2010.09.15)
12. New Treatment Strategy for the Prevention of Recurrent Depression. ScienceDaily, Nov. 15, 2006. http://www. sciencedaily.com/releases/2006/11/061106144928.htm (2010.08.06).
13. Bauer, M., Monz, B. U., Montejo, A. L., Quail, D., Dantchev, N., Demyttenaere, K., Garcia/Cebrian, A., Grassi, L., Perahia, D. G. S., Reed, C., Tylee, A.: Prescribing patterns of antidepressants in Europe: Results from the Factors Influencing Depression Endpoints Research (FINDER) study. Eur. Psych., 2008; 23, 66–73.
14. Jakimavičius, M., Sveikata, A., Vainauskas, P., Jankūnas, R., Mikučionytė, L., Sapolienė, A., Šmigelskas, K.: Analysis of antidepressant prescribing tendencies in Lithuania in 2003-2004. Medicina, 2007; 43, 412–418.
15. Ufer, M., Meyer, S., Junge, O., Selke, G., Volz, H., Hedderich, J., Gleiter, C.: Patterns and prevalence of antidepressant drug use in the German state of Baden-Wuerttemberg: a prescription-based analysis. Pharmacoepidemiol. Drug Safety, 2007; 16, 1153–1160.
16. Barren, B., Byford, S., Knapp, M.: Evidence of cost-effective treatments for depression: a systematic review. J. Affect. Dis., 2005; 84, 1–13.
17. Van de Velde, S., Bracke, P., Levecque, K.: Gender differences in depression in 23 European countries. Cross-national variation in the gender gap in depression. Soc. Sci. Med., 2010; 71, 305–313.
18. Data of the State Statistics Department. http://www. stat.gov.lt/lt/ (2010.09.03)
19. Ferrera, M.: The southern model of welfare in social Europe. J. Eur. Soc. Policy, 1996; 1, 17–37.
20. Lewis, J.: Men, women, work, care and policies. J. Eur. Soc. Pol., 2006; 16(4), 387–392.
21. Plantenga, J., Remery, C.: Reconciliation of work and private life: A comparative review of thirty European countries. Brussels: European Communities, 2005.
22. Teicher, M., Glod, C., Cole, J.: Emergence of intense suicidal preoccupation during fluoxetine treatment. Am. J. Psych., 1990; 147, 207–210.
23. Olfson, M., Marcus, S., Druss, B., Elinson, L., Tanielian, T., Pincus, H.: National trends in the outpatient treatment of depression. J. Am. Med. Assoc. 2002; 287, 203–209.
24. Rich, C., Fowler, R., Young, D.: Abuse and suicide: The San Diego study. Ann. Clin. Psych., 1989; 1, 79–85.
25. Jick, H., Kaye, J., Jick, S.: Antidepressants and the risk of suicidal behaviors. J. Am. Med. Assoc., 2004; 292, 338–343.