Trends in the consumption of psychotropic drugs by French soldiers during the COVID-19 epidemic | BMC Medicine
Our study reveals significant associations between the evolution of psychotropic drugs dispensed and the COVID-19 pandemic among French military personnel. In this study, which to our knowledge is the first to address the important topic of mental health in the military during the COVID-19 pandemic, we observed both temporary and global effects. The first week of the first lockdown was associated with a rapid increase in psychotropic medications dispensed, followed by a decrease during the rest of the lockdown. However, these effects were temporary and overall trends show an increase in the rate of psychotropic medications dispensed since the start of the pandemic despite the downward trend in 2019. This overall increase suggests that the pandemic and associated containment measures have had a significant negative impact on the mental health of the military, which remains a hypothesis to be confirmed by other studies. Over our study period, the rate ratio (2019 vs 2020-2021) increased by 3% for dispensed anxiolytics, 12% for antidepressants and 13% for hypnotics. These increases are a key observation in our work. One could hypothesize that fewer consultations with health professionals specializing in mental health could partly explain our results. In addition, due to the nature of military activity, most military personnel have jobs that are not compatible with telework (collective sports and combat training in the field, technical activities on site such as equipment maintenance), and some operations were maintained during the lockdown despite the difficult conditions. On the contrary, some soldiers were unable to continue their usual activities, and the face-to-face training necessary for operational preparation was also impacted by the confinements, in particular the first. Overall, however, the closures probably had the biggest effect on free time.
The initial transitory phenomenon observed during the first confinement could correspond to a “replenishment” effect following the government’s announcement of the imminence of confinement. This effect has also been observed in the general population , and it may have particularly involved people who were already on treatment. Certain measures have been put in place to avoid a break in the continuity of treatment for patients suffering from chronic diseases and unable to consult as usual during the pandemic. For example, the Ministry of Health quickly authorized the delivery of treatments (in particular antidepressants), from expired prescriptions, which may have affected the behavior of patients. It should be noted that the replenishment phenomenon was not observed during the second confinement, which was not as strict . Therefore, it may be that the sudden introduction of the first lockdown, which was new to most people, and the fear of drug shortages led to the trend seen at the very beginning of the pandemic. The subsequent temporary drop in reimbursement rates for psychotropic drugs during the same initial lockdown may correspond to the use of drugs purchased earlier and limited access to general practitioners or specialists during this period. Although unlikely given the increase in insomnia, depressive symptoms and anxiety over this period in the general population we cannot completely exclude that the decrease in drug distribution may have been the result of a brief decrease in consumption.
Global trends of increasing consumption of psychotropic drugs after the start of the COVID-19 epidemic have been verified in several studies although not all . The EPIPHARE study, a pharmacoepidemiological study conducted by French public institutions and including data on the entire French population since 2018, reported changes in the consumption of drugs in outpatient settings and in particular a significant trend to the decline in the consumption of anxiolytics, hypnotics and antidepressants until 2019, but which was interrupted in 2020 at the start of the pandemic . Although we observed an increase in the use of antidepressants among the military, who are generally healthy young adults, the generalization of these results must be considered with caution. For example, in the general population, a temporary decrease in the reimbursement of antidepressants was also observed at the start of the pandemic, but this was followed by a rapid return to pre-crisis levels in August 2020 . Therefore, the general population did not have the same increase in dispensed antidepressants that we observed among the military population. Other recent work by our team has underscored the challenge of drawing firm conclusions about the overall effects of the outbreak. For example, our analysis of suicide attempts in the general population in France indicated that there was a decrease in hospitalizations for self-harm both during the first lockdown  and during the second phase of the COVID-19 pandemic , except in adolescent girls. It is therefore essential to take into account the specificities of the study population, and healthy young individuals from the general active population must be studied specifically before extrapolating our results.
It has been shown that the COVID-19 epidemic has directly or indirectly affected the mental health of various populations through different mechanisms, including increased stress at the family, professional or financial level, fear of contamination or the effects of social isolation. [30, 31]. In addition, mental health disorders due to the COVID-19 epidemic are risk factors for suicidal ideation or self-harm . It can therefore be expected that the epidemic will result in longer-term effects on the consumption of health care for this selected population. Any interpretation of these effects must be made in the light of all the health measures that have been put in place in the army and in the general population to curb the epidemic. In addition, the side effects of antipsychotics are not to be overlooked. It is questionable whether even a small increase in the long-term consumption of these drugs could have long-term consequences (ischemic heart disease or acute stroke) [33, 34]. This obviously remains a hypothesis that will have to be the subject of more in-depth studies.
Further studies are needed to help differentiate the effects of the factors involved, such as the epidemic itself, but also government measures (lockdowns and deprivation measures), taking into account professional characteristics and individual vulnerabilities as well as different factors. other potential confounding factors. Additionally, further studies should consider occupational characteristics and individual vulnerabilities as well as other potential confounders that could not be accounted for in this study. Specific mental preparation has been shown to help medical professionals experience fewer mental health effects due to the pandemic. It is likely that a method of this type could also be successfully applied to military personnel. .
This study is based on comprehensive national healthcare reimbursement data from the SNDS. It was thus possible to precisely describe the evolution of healthcare consumption by active military personnel in the civilian healthcare system thanks to the comprehensiveness of the database (no sample data).
Nevertheless, we recognize that there are limitations to this work. First of all, although all drugs dispensed by pharmacies are taken into account because they are systematically collected, we did not have access to data on drug consumption during hospital stays in the SNDS database. The SNDS database does not allow the identification of military personnel in operation or the various armed forces (army, air force, navy, etc.) and the outpatient reimbursement base includes limited clinical data or data relating to the mode of life. However, the SNDS database includes information on some comorbidities through input from other databases, including the Long-Term Illness Database, the Hospital Information Database (PMSI), and the drug dispensing database. Military personnel are subject to strict medical screening and monitoring. They are therefore rarely affected by the chronic comorbidities of the ALD database because these are most often incompatible with the performance of their duties. Moreover, although the database specifies the delivery of the drugs, the actual consumption and therefore compliance cannot be assessed, even though these are important factors for the study of psychiatric conditions. Due to their specific healthcare system, French soldiers have access to a separate chain of care since their outpatient medical care can be provided within their unit of origin. Finally, from a statistical point of view, we used age groups in our analyses, which is common practice, but we did not study within each group.