Abstracts

INTRODUCTION

Antidepressants (AD) are considered the treatment of choice in acute manifestations of moderate to severe depression for improvement or complete remission of symptoms.⁹9 Fleck MP, Berlim MT, Lafer B, Sougey EB, Del Porto JA, Brasil MA, et al. Revisão das diretrizes da Associação Médica Brasileira para o tratamento da depressão (Versão integral). Rev Bras Psiquiatr. 2009;31Suppl 1:7-17. DOI:10.1590/S1516-44462009000500003 AD are also used in the management of other health problems, including anxiety disorders and chronic pain.¹⁵15 Lieberman JA. History of the Use of Antidepressants in Primary Care. J Clin Psychiatry. 2003;5 Suppl 7:6-10.

International population-based studies have identified growth in AD use, both in the general adult population²2 Barbui C, Campomori A, D’Avanzo B, Negri E, Garattini S. Antidepressant drug use in Italy since the introduction of SSRIs: national trends, regional differences and impact on suicide rates. Soc Psychiatry Psychiatr Epidemiol. 1999;34(3):152-6. DOI:10.1007/s001270050127^,1717 Middleton N, Gunnell D, Whitley E, Dorling D, Frankel F. Secular trends in antidepressant prescribing in the UK, 1975-1998. J Public Health Med. 2001;3(4):262-7. DOI:10.1093/pubmed/23.4.262 and among older adults.⁸8 Desplenter F, Caenen C, Meelberghs J, Hartikainen S, Sulkava R, Bell JS. Change in psychotropic drug use among community-dwelling people aged 75 years and older in Finland: repeated cross-sectional population studies. Int Psychogeriatr. 2011;23(8):1278-84. DOI:10.1017/S1041610211000718^,1212 Grunenbaum MF, Oquendo MA, Manly JJ. Depressive symptoms and antidepressant use in a random community sample of ethnically diverse, urban elder persons. J Affect Disord. 2008;105(1-3):273-7. DOI:10.1016/j.jad.2007.04.022 This growth is due to greater use of selective serotonin reuptake inhibitors, which are gradually replacing tricyclic AD as the most commonly used chemical subgroup.²2 Barbui C, Campomori A, D’Avanzo B, Negri E, Garattini S. Antidepressant drug use in Italy since the introduction of SSRIs: national trends, regional differences and impact on suicide rates. Soc Psychiatry Psychiatr Epidemiol. 1999;34(3):152-6. DOI:10.1007/s001270050127^,1313 Hansen DG, Rosholm JU, Gichangi A, Vach W. Increased use of antidepressants at the end of life: population-based study among people aged 65 years and above. Age Ageing. 2007;36(4):449-54. DOI:10.1093/ageing/afm056^,1717 Middleton N, Gunnell D, Whitley E, Dorling D, Frankel F. Secular trends in antidepressant prescribing in the UK, 1975-1998. J Public Health Med. 2001;3(4):262-7. DOI:10.1093/pubmed/23.4.262

To date, only one Brazilian study²⁰20 Rodrigues MAP, Facchini LA, Lima MS. Modificações nos padrões de consumo de psicofármacos em localidade do Sul do Brasil. Rev Saude Publica. 2006;40(1):107-14. DOI:10.1590/S0034-89102006000100017 has evaluated the trends in AD consumption among different population groups. It was conducted in a mid-sized city in Southern Brazil, and it evaluated the use of psychotropic drugs in the adult population aged ≥ 15 years between 1994 and 2003. The authors reported a significant increase from 8.4% to 31.6% in AD use. However, this difference was not adjusted for sample characteristics that could be associated with the consumption of AD. Other Brazilian studies have investigated AD use at the population level in terms of prevalence and associated factors. However, they evaluated the overall adult population.⁶6 Brunoni AR, Nunes MA, Figueiredo R, Barreto SM, Fonseca MJM, Lotufo PA, et al. Patterns of benzodiazepine and antidepressant use among middle-aged adults: the Brazilian longitudinal study of adult health (ELSA-Brasil). J Affect Disord. 2013;151(1):71-7. DOI:10.1016/j.jad.2013.05.054^,1010 Garcias CMM, Pinheiro RT, Garcias GL, Horta BL, Brum CB. Prevalence of antidepressant use and associated factors among adults in Pelotas, Rio Grande do Sul State, Brazil, 2006. Cad Saude Publica. 2008;24(7):1565-71. DOI:10.1590/S0102-311X2008000700011^,1919 Quintana MI, Andreoli SB, Moreira FG, Ribeiro WS, Feijo MM, Bressan RA, et al. Epidemiology of psychotropic drug use in Rio de Janeiro, Brazil: gaps in mental illness treatments. PLoS ONE. 2013;8(5):e62270. DOI:10.1371/journal.pone.0062270

The presence of chronic comorbidities is a common condition among older adults, and depression is among the chronic diseases that often affects this population.⁵5 Boing AF, Melo GR, Boing AC, Moretti-Pires RO, Peres KG, Peres MA. Associação entre depressão e doenças crônicas: um estudo populacional. Rev Saude Publica. 2012;46(4):617-23. DOI:10.1590/S0034-89102012005000044 Older adults are the main consumers of AD⁶6 Brunoni AR, Nunes MA, Figueiredo R, Barreto SM, Fonseca MJM, Lotufo PA, et al. Patterns of benzodiazepine and antidepressant use among middle-aged adults: the Brazilian longitudinal study of adult health (ELSA-Brasil). J Affect Disord. 2013;151(1):71-7. DOI:10.1016/j.jad.2013.05.054^,2020 Rodrigues MAP, Facchini LA, Lima MS. Modificações nos padrões de consumo de psicofármacos em localidade do Sul do Brasil. Rev Saude Publica. 2006;40(1):107-14. DOI:10.1590/S0034-89102006000100017^,2323 Ufer M, Meyer SM, Junge O, Selke G, Volz HP, Hedderich J, et al. Patterns and prevalence of antidepressant drug use in the German state of Baden-Wuerttemberg: a prescription-based analysis. Pharmacoepidemiol Drug Saf. 2007;16(10):1153-60. DOI:10.1002/pds.1405 and consumption among older adults is higher than that in their younger counterparts.³3 Barbui C, Broglio E, Laia AC, D’Agostino S, Enrico F, Ferraro L, et al. Cross-sectional Database Analysis of Antidepressant Prescribing in Italy. J Clin Psychopharmacol. 2003;23(1):31-4. DOI:10.1097/00004714-200302000-00006 Considering the rapid aging of the Brazilian population, the challenges this phenomenon poses to pharmaceutical care, and the limited number of studies on this topic, this study aimed to evaluate the trend and factors associated with AD use among older adults.

METHODS

This study is a substudy of the Bambuí Project, a longitudinal study investigating the incidence and predictors of health outcomes among older adults in a community living situation. Details of the methodology used have been presented in a previous publication.¹⁶16 Lima-Costa MF, Firmo JOA, Uchoa E. The Bambuí Cohort Study of Aging: methodology and health profile of participants at baseline. Cad Saude Publica. 2011;27Suppl 3:327-35. DOI:10.1590/S0102-311X2011001500002

The aforementioned study¹⁶16 Lima-Costa MF, Firmo JOA, Uchoa E. The Bambuí Cohort Study of Aging: methodology and health profile of participants at baseline. Cad Saude Publica. 2011;27Suppl 3:327-35. DOI:10.1590/S0102-311X2011001500002 was conducted in the city of Bambuí, located in Southwestern state of Minas Gerais, with 15,000 inhabitants in 1997, when the baseline cohort was evaluated by a census of older adults living in the city. In the present study, the older adults considered eligible to participate were aged between 75 and 89 years who were among the baseline of the 1997 cohort (born between 1908 and 1922), herein designated the 1997 cohort, and the survivors of this same cohort in 2012, herein designated the 2012 cohort, in the same age group (born between 1923 and 1937).

The dependent variable was AD use reported by participants in interviews when the drug label and medical prescription were also examined. The medications were identified and their active principles were classified according to the Anatomical Therapeutic Chemical Index^aa World Health Organization. Collaborating Centre for Drug Statistics Methodology. ATC/DDD Index 2013. Geneva; 2013. Available from: http://www.whocc.no/atc_ddd_index (ATC).

The medications listed in ATC under code N06A were considered AD. In addition, AD were classified according to their chemical subgroup (ATC level 4) and chemical substance (ATC level 5).

The independent variables included sociodemographic characteristics, health conditions, and descriptors of the use of health care services. Sociodemographic characteristics included sex, age, education (none, 1-3, and ≥ 4 full years), marital status (married/consensual union, widowed, divorced/single), family income (< 2.0, 2.0-3.9, and ≥ 4.0 minimum wage equivalents), and living status (living alone, not living alone). The minimum wage was equivalent to US$120.00 in 1997 and US$333.00 in 2012. The health conditions investigated included the presence of common mental disorders (depression and anxiety), self-assessment of health, number of chronic diseases, and functional disability. The common mental disorders were evaluated using the 12-item version of the General Health Questionnaire (GHQ-12),¹¹11 Goldberg DP, Hillier VF. A scaled version of the General Health Questionnaire. Psychol Med. 1979;9(1):139-45. DOI:10.1017/S0033291700021644 and individuals with scores ≥ 5 points were considered positive. Self-assessment of health was based on the answer to the question: “How would you rate your health?” (very good/good; reasonable; poor). The chronic health conditions evaluated were hypertension, diabetes, Chagas disease, heart attack, and stroke, and they were measured on the basis of the patients’ medical diagnostic reports. With regard to functional capacity, older adults were considered functionally disabled if they experienced difficulty or were unable to perform at least one of the following basic activities of daily living without help: getting out of bed, eating, walking from one room to another, and bathing. Hospitalization history, number of medical consultations over the past 12 months, and health insurance coverage were the descriptor variables related to the use of health care services.

Data were collected in the homes using questionnaires administered by the interviewers. Interviewers were recruited from the community, had education superior to 11 years, and were trained by the research team, ensuring consistency in applying the instruments and collecting the data in 1997 and 2012.

The prevalence of AD use (overall and by chemical subgroup) was calculated separately for each birth cohort by dividing the number of older adults reporting AD consumption by the total number of cohort members. In the evaluation of the chemical subgroups and most commonly used active ingredients, the medication was considered the unit of analysis. Therefore, the ratios were calculated by dividing the total number of AD in each chemical subgroup or active principle by the total number of AD reported. The chemical subgroups considered were selective serotonin reuptake inhibitors (SSRI), tricyclic AD (TCA), and monoamine oxidase inhibitors (MAOI). The Chi-square test was used to compare the two birth cohorts in relation to the variables evaluated. The factors associated with AD use (global) in each birth cohort were evaluated using Poisson regression with robust variance to estimate the prevalence ratios and 95% confidence intervals. The inclusion of a covariate in the statistical model was not influenced by the results of the univariate analyses. The same analytical strategy was used to test the hypothesis of association between the year of the cohort and AD use (overall and by chemical subgroup). However, to determine the differences in the prevalence of use between the 1997 and the 2012 cohorts, only the variables independently associated with AD use in at least one of the cohorts were included in the multivariate model. In all analytical steps, a significance level of 5% was used. Data analysis was performed using Stata^® version 10 statistical software (Stata Corp., College Station, USA).

The Bambuí Project was approved by the Research Ethics Committee of the René Rachou Research Center (Opinion 346,329 – CAAE 01082212.7.0000.5091). All participants from both cohorts signed a free and informed consent form.

RESULTS

The 1997 cohort (n = 351) and the 2012 cohort (n = 462) were similar in age (means of 79.8 and 79.9 years, respectively), sex (60.1% and 66.5% were females, respectively), and marital status (50.4% and 57.7% were widowed, respectively). When compared with the 1997 cohort, the 2012 cohort had higher education and income (p < 0.001 for both variables), lower prevalence of depressive disorders, less disability for at least one basic activity of daily living, better self-assessment of health (p < 0.001), better health insurance coverage (p < 0.001), and higher frequency of medical consultations in the past 12 months (p = 0.014), although members of this cohort were hospitalized less during in the same period (p = 0.048). The complete characterization of the two cohorts can be observed in Table 1.

AD use increased from 8.3% in 1997 to 23.6% in 2012, and this trend was observed in both sexes and in all age groups. In both cohorts, consumption was higher among females and increased with age, except among the older male adults of the 1997 cohort, whose consumption was stable across the age groups (Figure).

With regards to the pharmacological classes, changes in the consumption pattern were observed between the two cohorts; the consumption of TCA prevailed in the 1997 cohort, accounting for 69.0% of total AD consumption, whereas the consumption of SSRI prevailed in the 2012 cohort, accounting for 68.1% of total AD consumption. The use of MAOI was observed only in the 1997 cohort and the use of other AD (code N06AX) was restricted to the 2012 cohort. However, in both cohorts, the consumption of these chemical groups was lower than that of TCA and SSRI. Citalopram was the most frequently used active ingredient, corresponding to 31.1% of total consumption in the 2012 cohort, whereas no active ingredient predominated in the 1997 cohort (data not shown).

In the 2012 cohort, the following factors were positively associated (p < 0.05) with AD use after univariate analysis: female sex, age, and family income (among the sociodemographic characteristics), presence of depressive disorders, self-assessment of health as poor (among the health conditions), having two or more medical consultations, and type of health insurance coverage (among the characteristics pertaining to the use of health care services). The following variables were positively associated with AD use after multivariate analysis: female sex, family income ≥ 4 minimum wage equivalents, self-assessment of health as reasonable, and having five or more medical consultations in the last 12 months (Table 2). In the 1997 cohort, having five or more medical consultations was the only variable positively associated with AD use using both univariate and multivariate analyses (OR = 4.41, 95%CI 1.21;16.1) (data not shown).

Table 3 shows the results of univariate and multivariate analyses for the association between birth cohorts and AD use (overall and for the two most commonly used chemical subgroups). Even after adjusting for sex, age, family income, self-assessment of health, and number of medical consultations, the overall consumption of AD and SSRI was significantly higher in the 2012 cohort. However, no significant difference was observed in the consumption of TCA between the two cohorts. Considering that AD use differed between older males and females, a trend analysis was conducted to evaluate medication use stratified by sex. However, the results obtained within each stratum did not differ from those observed in the total population.

DISCUSSION

This study identified a significant increase in AD use between 1997 and 2012, primarily due to increased consumption of SSRI. In both cohorts and in all age groups, consumption of AD was higher among females. In the 2012 cohort, in addition to females, increased age and income, self-assessment of health as reasonable, and attending five or more medical consultations in the past 12 months were positively associated with AD use.

Between 1997 and 2012, the consumption of AD by older adults from Bambuí significantly increased approximately three fold, regardless of the characteristics associated with their use in this cohort. Growth in the consumption of AD has also been observed in higher-income countries among the general adult²2 Barbui C, Campomori A, D’Avanzo B, Negri E, Garattini S. Antidepressant drug use in Italy since the introduction of SSRIs: national trends, regional differences and impact on suicide rates. Soc Psychiatry Psychiatr Epidemiol. 1999;34(3):152-6. DOI:10.1007/s001270050127^,1717 Middleton N, Gunnell D, Whitley E, Dorling D, Frankel F. Secular trends in antidepressant prescribing in the UK, 1975-1998. J Public Health Med. 2001;3(4):262-7. DOI:10.1093/pubmed/23.4.262 and older adult population.⁴4 Blazer DG, Hybels CF, Fillenbaum GG, Pieper CF. Predictors of antidepressant use among older adults: have they changed over time? Am J Psychiatry. 2005;162(4):705-10. DOI:10.1176/appi.ajp.162.4.705^,88 Desplenter F, Caenen C, Meelberghs J, Hartikainen S, Sulkava R, Bell JS. Change in psychotropic drug use among community-dwelling people aged 75 years and older in Finland: repeated cross-sectional population studies. Int Psychogeriatr. 2011;23(8):1278-84. DOI:10.1017/S1041610211000718^,1212 Grunenbaum MF, Oquendo MA, Manly JJ. Depressive symptoms and antidepressant use in a random community sample of ethnically diverse, urban elder persons. J Affect Disord. 2008;105(1-3):273-7. DOI:10.1016/j.jad.2007.04.022^,1313 Hansen DG, Rosholm JU, Gichangi A, Vach W. Increased use of antidepressants at the end of life: population-based study among people aged 65 years and above. Age Ageing. 2007;36(4):449-54. DOI:10.1093/ageing/afm056 A Brazilian population-based study showed a significant increase in AD use from 8.4% to 31.6% but included not only the older groups but all residents aged ≥ 15 years.²⁰20 Rodrigues MAP, Facchini LA, Lima MS. Modificações nos padrões de consumo de psicofármacos em localidade do Sul do Brasil. Rev Saude Publica. 2006;40(1):107-14. DOI:10.1590/S0034-89102006000100017

Previous studies have elucidated the reasons for the growing AD use, and these reasons are not mutually exclusive. The most obvious reason is the increased prevalence of depression in the older population.¹1 Atlantis E, Sullivan T, Sartorius N, Almeida OP. Changes in the prevalence of psychological distress and use of antidepressants or anti-anxiety medications associated with comorbid chronic diseases in the adult Australian population, 2001-2008. Aust N Z J Psychiatry. 2012;46(5):445-56. DOI:10.1177/0004867411433218 In fact, in addition to improved diagnosis of depressive disorders by healthcare professionals,²2 Barbui C, Campomori A, D’Avanzo B, Negri E, Garattini S. Antidepressant drug use in Italy since the introduction of SSRIs: national trends, regional differences and impact on suicide rates. Soc Psychiatry Psychiatr Epidemiol. 1999;34(3):152-6. DOI:10.1007/s001270050127^,2020 Rodrigues MAP, Facchini LA, Lima MS. Modificações nos padrões de consumo de psicofármacos em localidade do Sul do Brasil. Rev Saude Publica. 2006;40(1):107-14. DOI:10.1590/S0034-89102006000100017 depression in the final stage of life is a common event among older adults owing to the presence of chronic diseases, impaired functional capacity, loneliness, and decreased social support network.¹1 Atlantis E, Sullivan T, Sartorius N, Almeida OP. Changes in the prevalence of psychological distress and use of antidepressants or anti-anxiety medications associated with comorbid chronic diseases in the adult Australian population, 2001-2008. Aust N Z J Psychiatry. 2012;46(5):445-56. DOI:10.1177/0004867411433218^,1313 Hansen DG, Rosholm JU, Gichangi A, Vach W. Increased use of antidepressants at the end of life: population-based study among people aged 65 years and above. Age Ageing. 2007;36(4):449-54. DOI:10.1093/ageing/afm056 Another cause would be extended drug treatment for depression, particularly among those with a history of multiple depressive episodes. This has also been observed in international studies, whether based on primary data¹⁴14 Harris T, Carey IM, Shah SM, DeWilde S, Cook DG. Antidepressant prescribing in older primary care patients in community and care home settings in England and Wales. J Am Med Dir Assoc. 2012;13(1):41-7. DOI:10.1016/j.jamda.2010.09.005^,2121 Sihvo S, Wahlbeck K, McCallum A, Sevon T, Arffman M, Haukka J, et al. Increase in the duration of antidepressant treatment from 1994 to 2003: a nationwide population-based study from Finland. Pharmacoepidemiol Drug Saf. 2010;19(11):1186-93. DOI:10.1002/pds.2017^,2222 Soudry A, Dufouil C, Ritchie K, Dartigues JF, Tzourio C, Alpérovitch A. Factors associated with antidepressant use in depressed and non-depressed community-dwelling elderly: the three-city study. Int J Geriatr Psychiatry. 2008;23(3):324-30. DOI:10.1002/gps.1890 or on databases of consultations and medical prescriptions.¹⁸18 Moore M, Yuen HM, Dunn N, Mullee MA, Maskell J, Kendrick T. Explaining the rise in antidepressant prescribing: a descriptive study using the general practice research database. BMJ. 2009;339:b3999. DOI:10.1136/bmj.b3999 A third cause is growing acceptance among healthcare professionals and patients of the new generation of AD such as SSRI, which have fewer side effects and are better tolerated and safer than TCA and MAOI (older class), particularly in overdose situations.¹⁴14 Harris T, Carey IM, Shah SM, DeWilde S, Cook DG. Antidepressant prescribing in older primary care patients in community and care home settings in England and Wales. J Am Med Dir Assoc. 2012;13(1):41-7. DOI:10.1016/j.jamda.2010.09.005 The fact that depressive older adults are commonly treated with drugs at the expense of other therapeutic options, such as psychotherapy, also should not be discarded.²⁴24 Unützer J, Katon W, Callahan CM, Williams Jr JW, Hunkeler E, Harpole L, et al. Depressed treatment in an sample of 1,801 depressed old adults in primary care. J Am Geriatr Soc. 2003;51(4):505-14. DOI:10.1046/j.1532-5415.2003.51159.x

In line with the results of international population-based studies,²2 Barbui C, Campomori A, D’Avanzo B, Negri E, Garattini S. Antidepressant drug use in Italy since the introduction of SSRIs: national trends, regional differences and impact on suicide rates. Soc Psychiatry Psychiatr Epidemiol. 1999;34(3):152-6. DOI:10.1007/s001270050127^,1717 Middleton N, Gunnell D, Whitley E, Dorling D, Frankel F. Secular trends in antidepressant prescribing in the UK, 1975-1998. J Public Health Med. 2001;3(4):262-7. DOI:10.1093/pubmed/23.4.262^,2525 Zhang Y, Chow V, Vitry AI, Ryan P, Roughead EE, Caughey GE, et al. Antidepressant use and depressive symptomatology among older people from the Australian Longitudinal Study of Ageing. Int Psychogeriatr. 2010;22(3):437-44. DOI:10.1017/S1041610209991554 the increased consumption of AD in Bambuí was primarily due to the increased use of SSRI, considering that the consumption of TCA was similar between the two cohorts. The prevalence of SSRI among AD used by the 2012 cohort is consistent with that observed in Brazil⁶6 Brunoni AR, Nunes MA, Figueiredo R, Barreto SM, Fonseca MJM, Lotufo PA, et al. Patterns of benzodiazepine and antidepressant use among middle-aged adults: the Brazilian longitudinal study of adult health (ELSA-Brasil). J Affect Disord. 2013;151(1):71-7. DOI:10.1016/j.jad.2013.05.054^,1919 Quintana MI, Andreoli SB, Moreira FG, Ribeiro WS, Feijo MM, Bressan RA, et al. Epidemiology of psychotropic drug use in Rio de Janeiro, Brazil: gaps in mental illness treatments. PLoS ONE. 2013;8(5):e62270. DOI:10.1371/journal.pone.0062270 and other countries.²²22 Soudry A, Dufouil C, Ritchie K, Dartigues JF, Tzourio C, Alpérovitch A. Factors associated with antidepressant use in depressed and non-depressed community-dwelling elderly: the three-city study. Int J Geriatr Psychiatry. 2008;23(3):324-30. DOI:10.1002/gps.1890 This result indicates the possibility that among the older people of Bambuí, increased consumption of AD results from greater acceptance of SSRI by professionals and patients. After the appearance of this chemical subgroup, general practitioners have more frequently prescribed AD, a practice that used to be restricted to psychiatrists.¹⁷17 Middleton N, Gunnell D, Whitley E, Dorling D, Frankel F. Secular trends in antidepressant prescribing in the UK, 1975-1998. J Public Health Med. 2001;3(4):262-7. DOI:10.1093/pubmed/23.4.262 It is noteworthy that only 1.0% of the population consulted a psychiatrist. Furthermore, a negative correlation was observed between the increased prevalence of AD consumption and depression in the 2012 cohort. This may be due to adequate treatment among older adults in the 2012 cohort, resulting in improvement or remission of depressive symptoms and consequently a negative rating for the GHQ-12. This may also be a consequence of AD use in the management of other health problems, such as anxiety disorders and other chronic diseases.⁴4 Blazer DG, Hybels CF, Fillenbaum GG, Pieper CF. Predictors of antidepressant use among older adults: have they changed over time? Am J Psychiatry. 2005;162(4):705-10. DOI:10.1176/appi.ajp.162.4.705

The identification of independent factors associated with AD use was largely confined to the 2012 cohort. In the 1997 cohort, the only characteristic associated with AD use after multiple adjustments was the number of medical consultations.

The consumption of AD was higher among females. International¹²12 Grunenbaum MF, Oquendo MA, Manly JJ. Depressive symptoms and antidepressant use in a random community sample of ethnically diverse, urban elder persons. J Affect Disord. 2008;105(1-3):273-7. DOI:10.1016/j.jad.2007.04.022^,1414 Harris T, Carey IM, Shah SM, DeWilde S, Cook DG. Antidepressant prescribing in older primary care patients in community and care home settings in England and Wales. J Am Med Dir Assoc. 2012;13(1):41-7. DOI:10.1016/j.jamda.2010.09.005^,1717 Middleton N, Gunnell D, Whitley E, Dorling D, Frankel F. Secular trends in antidepressant prescribing in the UK, 1975-1998. J Public Health Med. 2001;3(4):262-7. DOI:10.1093/pubmed/23.4.262^,2525 Zhang Y, Chow V, Vitry AI, Ryan P, Roughead EE, Caughey GE, et al. Antidepressant use and depressive symptomatology among older people from the Australian Longitudinal Study of Ageing. Int Psychogeriatr. 2010;22(3):437-44. DOI:10.1017/S1041610209991554 and Brazilian studies⁶6 Brunoni AR, Nunes MA, Figueiredo R, Barreto SM, Fonseca MJM, Lotufo PA, et al. Patterns of benzodiazepine and antidepressant use among middle-aged adults: the Brazilian longitudinal study of adult health (ELSA-Brasil). J Affect Disord. 2013;151(1):71-7. DOI:10.1016/j.jad.2013.05.054^,1010 Garcias CMM, Pinheiro RT, Garcias GL, Horta BL, Brum CB. Prevalence of antidepressant use and associated factors among adults in Pelotas, Rio Grande do Sul State, Brazil, 2006. Cad Saude Publica. 2008;24(7):1565-71. DOI:10.1590/S0102-311X2008000700011^,1919 Quintana MI, Andreoli SB, Moreira FG, Ribeiro WS, Feijo MM, Bressan RA, et al. Epidemiology of psychotropic drug use in Rio de Janeiro, Brazil: gaps in mental illness treatments. PLoS ONE. 2013;8(5):e62270. DOI:10.1371/journal.pone.0062270 have shown an association between females and AD use. Some authors argue that the higher consumption of AD among females is due to the increased prevalence of depressive disorders in this group.⁶6 Brunoni AR, Nunes MA, Figueiredo R, Barreto SM, Fonseca MJM, Lotufo PA, et al. Patterns of benzodiazepine and antidepressant use among middle-aged adults: the Brazilian longitudinal study of adult health (ELSA-Brasil). J Affect Disord. 2013;151(1):71-7. DOI:10.1016/j.jad.2013.05.054^,1010 Garcias CMM, Pinheiro RT, Garcias GL, Horta BL, Brum CB. Prevalence of antidepressant use and associated factors among adults in Pelotas, Rio Grande do Sul State, Brazil, 2006. Cad Saude Publica. 2008;24(7):1565-71. DOI:10.1590/S0102-311X2008000700011^,1717 Middleton N, Gunnell D, Whitley E, Dorling D, Frankel F. Secular trends in antidepressant prescribing in the UK, 1975-1998. J Public Health Med. 2001;3(4):262-7. DOI:10.1093/pubmed/23.4.262 However, in the present study, the association between females and AD use remained significant regardless of the presence of depressive disorders. Grunenbaum¹²12 Grunenbaum MF, Oquendo MA, Manly JJ. Depressive symptoms and antidepressant use in a random community sample of ethnically diverse, urban elder persons. J Affect Disord. 2008;105(1-3):273-7. DOI:10.1016/j.jad.2007.04.022 (2008) draws attention to the possibility of feminization of depression, because females identify psychiatric conditions and pursue treatment for these disorders more intensely than males. In this study, the consumption of AD did not significantly differ between males and females presenting with depressive disorders, but was significantly different among those without depressive disorders (data not shown). This result could indicate that, in Bambuí, older females use AD to treat health problems other than depression, such as anxiety disorders, sleep disturbances, physical problems, and even social problems caused by the difficulties experienced in daily life.²⁵25 Zhang Y, Chow V, Vitry AI, Ryan P, Roughead EE, Caughey GE, et al. Antidepressant use and depressive symptomatology among older people from the Australian Longitudinal Study of Ageing. Int Psychogeriatr. 2010;22(3):437-44. DOI:10.1017/S1041610209991554 Alternatively, females may adhere to the pharmacological treatment of depression more often than males.

Other sociodemographic characteristics associated with AD use were increased age and higher income. A positive association between age and AD use was observed in other older groups.¹³13 Hansen DG, Rosholm JU, Gichangi A, Vach W. Increased use of antidepressants at the end of life: population-based study among people aged 65 years and above. Age Ageing. 2007;36(4):449-54. DOI:10.1093/ageing/afm056^,2525 Zhang Y, Chow V, Vitry AI, Ryan P, Roughead EE, Caughey GE, et al. Antidepressant use and depressive symptomatology among older people from the Australian Longitudinal Study of Ageing. Int Psychogeriatr. 2010;22(3):437-44. DOI:10.1017/S1041610209991554 General practitioners have reported depression at the end of life as a spectrum that includes loneliness, lack of social network, and impaired functionality.¹³13 Hansen DG, Rosholm JU, Gichangi A, Vach W. Increased use of antidepressants at the end of life: population-based study among people aged 65 years and above. Age Ageing. 2007;36(4):449-54. DOI:10.1093/ageing/afm056 As for the positive association between income and AD use, increased access to medications could be due to greater ability to bear health costs among those with better socioeconomic status.¹⁰10 Garcias CMM, Pinheiro RT, Garcias GL, Horta BL, Brum CB. Prevalence of antidepressant use and associated factors among adults in Pelotas, Rio Grande do Sul State, Brazil, 2006. Cad Saude Publica. 2008;24(7):1565-71. DOI:10.1590/S0102-311X2008000700011 In Bambuí, the prevalence of depressive disorders was higher among the lower income strata (data not shown), which raises concerns about possible inequalities in mental health care in this population segment due to its limited access to mental health care services.⁶6 Brunoni AR, Nunes MA, Figueiredo R, Barreto SM, Fonseca MJM, Lotufo PA, et al. Patterns of benzodiazepine and antidepressant use among middle-aged adults: the Brazilian longitudinal study of adult health (ELSA-Brasil). J Affect Disord. 2013;151(1):71-7. DOI:10.1016/j.jad.2013.05.054

In the case of descriptive variables related to health conditions and use of health care services, only the self-assessment of health (in the first case) and the number of medical consultations (in the second) were associated with AD use after adjusting for other covariables. The positive association between consumption of AD and worse self-assessment of health (even restricted to assessment as “reasonable”) is consistent with results observed among older Australian adults²⁵25 Zhang Y, Chow V, Vitry AI, Ryan P, Roughead EE, Caughey GE, et al. Antidepressant use and depressive symptomatology among older people from the Australian Longitudinal Study of Ageing. Int Psychogeriatr. 2010;22(3):437-44. DOI:10.1017/S1041610209991554 and indicates the importance of subjective assessment of health in determining AD use. The positive association between consumption of AD and the number of medical consultations is related to the need for a prescription from a medical professional in order to obtain the drug.

One limitation of this study is the inability to assess the appropriate AD use with regard to drug indication and dosage, owing to the lack of use of a gold standard method for diagnosing depression as well as the unavailability of data on duration of use/dosage for medications and access to psychotherapy. The GHQ-12¹¹11 Goldberg DP, Hillier VF. A scaled version of the General Health Questionnaire. Psychol Med. 1979;9(1):139-45. DOI:10.1017/S0033291700021644 screening tool used to evaluate common mental disorders in the study population showed the same accuracy as the 30-item Geriatric Depression Scale (GDS-30) in diagnosing depressive symptoms.⁷7 Costa E, Barreto SM, Uchoa E, Firmo JOA, Lima-Costa MF, Prince M. Is the GDS-30 better than the GHQ-12 for screening depression in elderly people in the community? The Bambuí Health Aging Study (BHAS). Int Psychogeriatr. 2006;18(3):493-503. DOI:10.1017/S1041610205002954 However, the GHQ-12 only verifies the presence of symptoms of depression and does not define clinical diagnosis. Moreover, the cutoff value used to classify the participants as positive did not allow differentiation between mild or severe symptoms. For the first case, psychotherapy is indicated, whereas drug therapy is the first choice in cases of severe depression.⁹9 Fleck MP, Berlim MT, Lafer B, Sougey EB, Del Porto JA, Brasil MA, et al. Revisão das diretrizes da Associação Médica Brasileira para o tratamento da depressão (Versão integral). Rev Bras Psiquiatr. 2009;31Suppl 1:7-17. DOI:10.1590/S1516-44462009000500003 Another limitation is the impossibility of verifying whether AD was prescribed by a psychiatrist. The present results cannot be generalized to other older groups, particularly those attending geriatric day hospitals or nursing homes. However, the study has advantages, particularly when compared with studies on drug dispensing or those based on prescriptions because it uses data on drug use. In addition, the accuracy of the measurements was ensured by the verification of drug label and prescription. The population-based strategy adopted, the minimum loss of information on the medications used by the eligible participants, and uniform procedures for data collection between the cohorts ensured the reliability and internal validity of the study. Furthermore, to the best of our knowledge, this is the first Brazilian population-based study that evaluated the trends in AD consumption among older adults.

In summary, the increased consumption of AD and the predominance of new generation drugs were consistent with findings observed in international studies of different populations and experimental designs. The positive association observed between AD consumption and income may indicate potential inequalities in accessing mental health services. Further studies employing different methodologies and designs (e.g., qualitative and longitudinal epidemiological studies) are necessary to deepen knowledge concerning AD use among older people. Furthermore, it can support interventions that will improve access to pharmaceutical care services with coverage and quality that are adequate for managing health problems of psychological origin in this population segment.

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