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Trends in prescriptions and costs of drugs for mental disorders in England, 1998–2010

  • Stephen Ilyas (a1) and Joanna Moncrieff (a2)

Increasing rates of prescriptions for antidepressants, antipsychotics and stimulants have been reported from various countries.


To examine trends in prescriptions and the costs of all classes of psychiatric medication in England.


Data from the Prescription Cost Analysis 1998–2010 was examined, using linear regression analysis to examine trends.


Prescriptions of drugs used for mental disorders increased by 6.8% (95% CI 6.3–7.4) per year on average, in line with other drugs, but made up an increasing proportion of all prescription drug costs (P = 0.001). There were rising trends in prescriptions of all classes of psychiatric drugs, except anxiolytics and hypnotics (which did not change). Antidepressant prescriptions increased by 10% (95% CI 9.0–11) per year on average, and antipsychotics by 5.1% (95% CI 4.3–5.9). Antipsychotics overtook antidepressants as the most costly class of psychiatric medication, with costs rising 22% (95% CI 17–27) per year.


Rising prescriptions may be partly explained by longer-term treatment and increasing population. Nevertheless, it appears that psychiatric drugs make an increasing contribution to total prescription drug costs, with antipsychotics becoming the most costly. Low-dose prescribing of some antipsychotics is consistent with other evidence that their use may not be restricted to those with severe mental illness.

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Corresponding author
Joanna Moncrieff, Department of Mental Health Sciences, Charles Bell House, Riding House Street, London W1W 7EJ, UK Email:
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Declaration of interest

J.M. is co-chairperson of the Critical Psychiatry Network.

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Trends in prescriptions and costs of drugs for mental disorders in England, 1998–2010

  • Stephen Ilyas (a1) and Joanna Moncrieff (a2)
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Antidepressant prescriptions and suicide rate

Nilamadhab Kar, Consultant Psychiatrist
11 July 2012

One of the findings that stands out in the research by Ilyas and Moncrieff is the considerable increase of antidepressant prescriptions (onaverage 10% per year) in England from 1998 to 2010.1 It is interesting to note that during this period the suicide rate for England decreased gradually from 19.8 in males and 5.8 in females in 1998, to 15.1 and 4.7 in 2010 respectively (Source: Office for National Statistics), although inthe last three years from 2008 the trend reversed probably due to the economic downturn. The observation of decrease of suicide rates over the years while there was increase in antidepressant prescription is in line with other reports from many different countries.

In Hungary the suicide rate was inversely related to the increased use of antidepressants in both genders during 1999-2005. The strongest association was found in the oldest age groups, where the increase in antidepressant use was highest. Antidepressant prescription rate was related to suicide rate after controlling for rates of divorce or unemployment, but not after controlling for alcohol consumption rate.2 Another study in Hungary found that during 1998-2006 there was a significant correlation between the steadily increasing antidepressant prescription (113%) and continuous decline in total national suicide rate (23%) both in females and males (21 and 23%, respectively); and this relationship was 8-fold stronger in males. Increasing antidepressant utilization was also associated with significantly decreased seasonality of suicides though only among males.3

In Japan during 1999-2003, annual increases in prescribing of newer antidepressant medications, mainly selective-serotonin-reuptake-inhibitors(SSRIs), were associated with annual decreases in suicide rates, particularly among males who experienced a greater increase in antidepressant use. An increase of 1 defined daily dose of SSRI use/1000 population/day was associated with a 6% decrease in suicide rate. Changes in unemployment and alcohol consumption rates did not explain the association.4

The suicide rate in the United States fell 13.5% from 1985 to 1999, with a greater decline among women (females received twice as many antidepressant prescriptions compared with males); and antidepressant prescription rates increased over 4-fold during the period, with the increase mostly due to SSRIs. Even after adjusting for unemployment and alcoholic beverage consumption rates, SSRI antidepressant prescription rates remained inversely associated with the national suicide rate.5 Thereare a few other studies from United States, linking lower suicide rates across the country with increases in prescriptions for SSRIs and other new-generation non-SSRIs; and higher suicide rates in rural areas with fewer antidepressant prescriptions. Higher SSRI prescription rates have also been reported to be associated with lower suicide rates in children and adolescents in United States after adjustment for sex, race, income, access to mental health care and county-to-county variability in suicide rates.

The relationship between increased antidepressant prescriptions with decreased suicide rates is becoming more obvious. Although these observational data preclude a direct causal interpretation of the results;they probably suggest that improved identification and management of depressive disorders with the antidepressant medications have led to the decrease in suicide rate over the years. This association is worth exploring further in England and elsewhere.


1 Ilyas S, Moncrieff J. Trends in prescriptions and costs of drugs for mental disorders in England, 1998-2010. Br J Psychiatry. 2012;200(5):393-8.

2 Kalmar S, Szanto K, Rihmer Z, Mazumdar S, Harrison K, Mann JJ. Antidepressant prescription and suicide rates: effect of age and gender. Suicide Life Threat Behav. 2008;38(4):363-74.

3 Sebestyen B, Rihmer Z, Balint L, Szokontor N, Gonda X, Gyarmati B, Bodecs T, Sandor J. Gender differences in antidepressant use-related seasonality change in suicide mortality in Hungary, 1998-2006. World J Biol Psychiatry. 2010;11(3):579-85.

4 Nakagawa A, Grunebaum MF, Ellis SP, Oquendo MA, Kashima H, Gibbons RD, Mann JJ. Association of suicide and antidepressant prescription rates in Japan, 1999-2003. J Clin Psychiatry. 2007;68(6):908-16.

5 Grunebaum MF, Ellis SP, Li S, Oquendo MA, Mann JJ. Antidepressants and suicide risk in the United States, 1985-1999. J Clin Psychiatry. 2004;65(11):1456-62.

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Conflict of interest: None declared

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The Complex World of Prescribing Behaviour

Sumeet Gupta, Consultant Psychiatrist
06 June 2012

The recent article by Ilyas and Moncrieff 20121, raises some important questions, especially about the way antipsychotic drugs are prescribed in England. They reported that over the past decade the prescriptions of atypical antipsychotic medications have multiplied many folds. In 2010, atypical antipsychotics constituted 69% of total antipsychotic prescriptions. More or less identical picture have been reported in USA and Australia.2,3The first NICE guideline of schizophrenia (2002) promoted atypical antipsychotic agents as the first line treatment, during the same period these drugs were heavily promoted by drug companies. This seems to have led to significant surge in the prescriptions of atypical antipsychotics. NICE patted its back by reporting that in 2007 atypical antipsychotic drugs accounted for 67% of all antipsychotic prescription, surpassing their expectation4. In 2009, based on the results of the CATIE, CUtLASS and a few meta-analyses, NICE placed all antipsychotics on the same pedestal and recommended that antipsychotic medications should be chosen primarily based on their side effect profile. However, from the figure 2 it is clear that despite the change in the NICE's stance, so far there hasnot been any significant change in the prescription pattern. The data alsodid not show increased prescription of typical antipsychotics either, except very slow rise of prescription of amisulpiride. Hence, the impact of NICE guideline or emerging evidence of comparative effectiveness of antipsychotic drugs is doubtful.

The question emerges what is fuelling the prescriptions of atypical antipsychotic drugs; could it be due to inertia of prescribing behaviour or marketing by the pharmaceutical companies. In December 2003, Janssen'spatent on risperidone expired .During the same time sudden decline in risperidone prescriptions was seen. In 2010 quetiapine and aripiprazole, only atypical antipsychotic drugs, which were still in their patent period, were responsible for half of the prescription costs.

As author suggested that the increased prescription of atypical antipsychotics could be due to their use in non-psychotic disorder, for both licensed and unlicensed indications. Bipolar illness is a common illness, not a relatively rare condition as the author reported and atypical antipsychotics are prescribed in the all phases of the disorder. Even their superiority in treatment of mania has been challenged. The "offlabel" uses are mostly not evidence based and usually the outcome of personal experience or peer influence. Therefore, reducing off-label antipsychotic use may generate savings with little impact on patient outcomes.A US study looking at prescription practice in schizophrenia before and after the CATIE trial showed a continued increase prescription of aripiprazole .On the contrary, the prescription of olanzapine decreased slightly. 5Ilyas and Moncrieff 2012 data do not show the similar trend of aripiprazole in England; hence apart from marketing by drug companies, guidelines and large influential studies, there are other factors affecting the prescription behaviour of psychiatrists/GPs. Now time has come to seriously look in to these factors, as apart from improving treatment outcomes this it will also lead to better utilization of finite NHS resources.

1. Ilyas S, Moncrieff J. Trends in prescriptions and costs of drugs for mental disorders in England, 1998-2010. Br J Psychiatry. 2012;200:393-8.

2.Cascade EF, Kalali AH, Lieberman J, Hsiao J, Keefe R, Stroup S. Useof Antipsychotics Pre- and Post-Dissemination of CATIE Data. Psychiatry. (Edgmont)2007;4:21-3.

3.Monshat K, Carty B, Olver J, Castle D, Bosanac P. Trends in antipsychotic prescribing practices in an urban community mental health clinic. Australas Psychiatry 2010;18:238-41.

4 National Institute of Health and Clinical Excellance. NICE implementation uptake report: atypical antipsychotic drugs for the treatment of schizophrenia.2008.(

5.Berkowitz RL, Patel U, Ni Q, Parks JJ, Docherty JP. The impact of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) onprescribing practices: an analysis of data from a large midwestern state. J Clin Psychiatry 2012;73:498-503.

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Conflict of interest: None declared

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