BMJ 1994;309:249-253 (23 July)

Education and debate

Prescribing selective serotonin reuptake inhibitors as strategy for prevention of suicide

N Freemantle, A House, F Song, J M Mason, T A Sheldon 

NHS Centre for Reviews and Dissemination, University of York, York YO1 5DD Centre for Health Economics, University of York, York Y01 5DD Department of Liaison Psychiatry, Leeds General Infirmary, Leeds Correspondence to: Mr Freemantle.

Abstract

Objective : To evaluate a policy to reduce the incidence of suicide by means of changing the prescribing of antidepressants from the older tricyclic antidepressants to the routine first line use of selective serotonin reuptake inhibitors or newer tricyclic and related antidepressants.
Design : Cost effectiveness analysis with sensitivity analyses using observational data on costs, volume of prescribing, deaths, and toxicity.
Setting : United Kingdom primary care. Interventions - Selective serotonin reuptake inhibitors or newer tricyclic and related antidepressants compared with the use of older tricyclics.
Main outcome measures : Cost per life saved and cost per life year saved.
Results : The potential number of lives which may be saved from a switch to the routine first line use of20selective serotonin reuptake inhibitors is between20300 and 450 each year. The cost per life year gained ranges from pounds sterling 19 000 to pounds sterling 173 000, depending on the assumptions used. The cost per life year gained through the use of the newer tricyclic and related antidepressants is considerably lower.
Conclusions : The cost per life year gained through avoiding suicides by the routine first line use20of serotonin reuptake inhibitors is likely to be high. The new tricyclics and related drugs are of similar toxicity to the serotonin reuptake inhibitors but are considerably cheaper and so are more cost effective for this purpose. Further research is required on such prescribing. Because of the great uncertainties the shift to considerably more expensive options must be further investigated.

Clinical implications

  • Clinical implications

  • Selective serotonin reuptake inhibitors are increasingly being prescribed in primary care as routine first line treatment for depression

  • Selective serotonin reuptake inhibitors are neither more effective nor better tolerated than other available antidepressants, many of which are considerably cheaper

  • The potential number of lives which may be saved from a switch in prescribing to the routine first line use of selective serotonin reuptake inhibitors is between 300 and 450 each year

  • The cost of avoiding suicides by prescribing selective serotonin reuptake inhibitors will be high

  • Prescribing the newer tricyclic and related antidepressants as first line treatment for depression will have similar impact on rates of suicide but at considerably less cost


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Relevant Article

Selective serotonin reuptake inhibitors Drugs related to tricyclic antidepressants are a mixed bag
P Cowen, C Thompson, A Roberts, J Nakielny, S Eckett, I Hindmarch, J S Kerr, J J Ashford, J A Henry, A S Hale, D Tracey, R Gonzaga, P Naik, A Brandt, R Bergemann, B K Puri, J H Thakore, N Feemantle, T A Sheldon, F Song, J Mason, and A House
BMJ 1994 309: 1082. [Extract] [Full Text]

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