Psychotropic medicine prescribing and polypharmacy for people with dementia entering residential aged care: the influence of changing general practitioners.

OBJECTIVE: To examine relationships between changing general practitioner after entering residential aged care and overall medicines prescribing (including polypharmacy) and that of psychotropic medicines in particular. DESIGN: Retrospective data linkage study. SETTING, PARTICIPANTS: 45 and Up Study participants in New South Wales with dementia who were PBS concession card holders and entered permanent residential aged care during January 2010 - June 2014 and were alive six months after entry. MAIN OUTCOME MEASURES: Inverse probability of treatment-weighted numbers of medicines dispensed to residents and proportions of residents dispensed antipsychotics, benzodiazepines, and antidepressants in the six months after residential care entry, by most frequent residential care GP category: usual (same as during two years preceding entry), known (another GP, but known to the resident), or new GP. RESULTS: Of 2250 new residents with dementia (mean age, 84.1 years; SD, 7.0 years; 1236 women [55%]), 625 most frequently saw their usual GPs (28%), 645 saw known GPs (29%), and 980 saw new GPs (44%). The increase in mean number of dispensed medicines after residential care entry was larger for residents with new GPs (+1.6 medicines; 95% CI, 1.4-1.9 medicines) than for those attended by their usual GPs (+0.7 medicines; 95% CI, 0.4-1.1 medicines; adjusted rate ratio, 2.42; 95% CI, 1.59-3.70). The odds of being dispensed antipsychotics (adjusted odds ratio [aOR], 1.59; 95% CI, 1.18-2.12) or benzodiazepines (aOR, 1.69; 95% CI, 1.25-2.30), but not antidepressants (aOR, 1.32; 95% CI, 0.98-1.77), were also higher for the new GP group. Differences between the known and usual GP groups were not statistically significant. CONCLUSIONS: Increases in medicine use and rates of psychotropic dispensing were higher for people with dementia who changed GP when they entered residential care. Facilitating continuity of GP care for new residents and more structured transfer of GP care may prevent potentially inappropriate initiation of psychotropic medicines.

Patient access to chronic medications during the Covid-19 pandemic: Evidence from a comprehensive dataset of US insurance claims.

Patient access and adherence to chronic medications is critical. In this work, we evaluate whether disruptions related to Covid-19 have affected new and existing patients' access to pharmacological therapies without interruption. We do so by performing a retrospective analysis on a dataset of 9.4 billion US prescription drug claims from 252 million patients from May, 2019 through August, 2020 (about 93% of prescriptions dispensed within those months). Using fixed effect (conditional likelihood) linear models, we evaluate continuity of care, how many days of supply patients received, and the likelihood of discontinuing therapy for drugs from classes with significant population health impacts. Findings indicate that more prescriptions were filled in March 2020 than in any prior month, followed by a significant drop in monthly dispensing. Compared to the pre-Covid era, a patient's likelihood of discontinuing some medications increased after the spread of Covid: norgestrel-ethinyl estradiol (hormonal contraceptive) discontinuation increased 0.62% (95% CI: 0.59% to 0.65%, p<0.001); dexmethylphenidate HCL (ADHD stimulant treatment) discontinuation increased 2.84% (95% CI: 2.79% to 2.89%, p<0.001); escitalopram oxalate (SSRI antidepressant) discontinuation increased 0.57% (95% CI: 0.561% to 0.578%, p<0.001); and haloperidol (antipsychotic) discontinuation increased 1.49% (95% CI: 1.41% to 1.57%, p<0.001). In contrast, the likelihood of discontinuing tacrolimus (immunosuppressant) decreased 0.15% (95% CI: 0.12% to 0.19%, p<0.001). The likelihood of discontinuing buprenorphine/naloxone (opioid addiction therapy) decreased 0.59% (95% CI: 0.55% to 0.62% decrease, p<0.001). We also observe a notable decline in new patients accessing these latter two therapies. Most US patients were able to access chronic medications during the early months of Covid-19, but still were more likely to discontinue their therapies than in previous months. Further, fewer than normal new patients started taking medications that may be vital to their care. Providers would do well to inquire about adherence and provide prompt, nonjudgmental, re-initiation of medications. From a policy perspective, opioid management programs seem to demonstrate a robust ability to manage existing patients in spite of disruption.

Improving Access to Psychological Therapies for older adults: auditing management of newly diagnosed mild and moderate depression in six general practices within the Birmingham and Solihull CCG.

BACKGROUND: The first-line treatments for mild-moderate and moderate-severe depression according to the National Institute for Health and Care Excellence clinical guidelines for the management of depression in adults are psychological therapies followed by or alongside pharmacological treatment. We conducted an audit of patient records (as recorded by general practitioners (GPs)) to compare practice to the guidelines. METHODS: Incident cases were retrospectively identified from electronic primary care records (SystmOne). From 40 320 registered patients, cases were identified based on previously coded new diagnoses of depression in the 2016-2017 and 2017-2018 Quality and Outcomes Framework (QOF) years. Patient notes were screened for exclusion criteria (mental health problems that would alter management pathway) and for records of management discussions (pharmacological or psychological therapies) at the diagnostic appointment. RESULTS: In 2016-2017 (n=315), psychological therapies for depression were discussed at 63.2% of diagnostic appointments, they were most discussed at appointments with those aged 18-29 years (70.8%), but this decreased with age to 56.3% of appointments with those aged ≥65 years. In 2017-2018 (n=244), psychological therapies were discussed at 70.9% of diagnostic appointments but were discussed at more appointments with those aged 18-29 years (81.6%) and at less appointments with those aged ≥65 years (39.4%). Discussion of pharmacological management was similar for all age groups in 2016-2017 (89.9%) and 2017-2018 (93.0%). IMPLICATIONS: For patients aged ≥65 years, psychological therapies are featuring less in management discussions with GPs or are not being recorded. Recommendations for change implemented at the practice included feedback of results and professional reminders throughout the 2019-2020 QOF year.

Neuronarratives of Affliction: Antidepressants, Neuropolitics and the "Entrepreneur of Oneself".

The dramatic increase in the consumption of antidepressants is one indicator, among others, of the contemporary cerebralization of human affliction. This process has been led by expert systems, creating new biosocialities or neurosocialities, and new models of self as well: the neural self. While some research minimizes the neuro-colonization of the self and its impact on lay knowledge systems, here I argue that synergy between neuropolitics and figures characteristic of neoliberal governamentality such as the "entrepreneur of oneself" can give rise to an interiorized, cerebralized, centripetal, inwardly-oriented self. This paper, based on long-term fieldwork among consumers of antidepressants in Catalonia, analyses the emergence of neuronarratives of affliction (NoAs). NoAs privilege neurochemical dysfunction as the source of distress, shortcircuiting an awareness of the social sources of suffering while at the same time obscuring the fact of this concealment. NoAs transform the self into structure and reduce the social world to event.

Development and validation of an analytical procedure to detect spatio-temporal differences in antidepressant use through a wastewater-based approach.

Wastewater-based epidemiology applies the analysis of human metabolic excretion products of xenobiotics in wastewater to estimate the community-wide use of these compounds. A new bioanalytical method was developed, optimised and validated for the analysis of a broad range of antidepressants and their metabolites at trace concentrations in influent wastewater. The assay was based on solid-phase extraction and liquid chromatography coupled to tandem mass spectrometry. For most compounds, Oasis® HLB cartridges were used for sample preparation. Oasis® MCX cartridges were used for extraction of normirtazapine, moclobemide, sertraline, and melitracen in particular. The Kinetex XBC18 column with a gradient elution resulted in appropriate separation for the analytes under investigation. Validation was done according to the European Medicines Agency guidelines on bioanalytical method validation. For 27 compounds, the performance criteria met the requirements for method validation. For these analytes, the lower limit of quantification (LLOQ) ranged between 1 and 25 ng/L. Furthermore, all targeted biomarkers showed high in-sample stability during 24 h, with the exception of mianserin. The validated assay was applied to influent wastewater samples collected from four wastewater treatment plants in Belgium. Among these four locations, a total of 18 out of 27 biomarkers for antidepressant use were present in the samples in concentrations above the LLOQ. Additionally, the proposed methodology proved capable of analysing high resolution spatio-temporal trends. Mann-Kendall trend analyses showed that antidepressant use is stable throughout the week, except for trazodone which increased throughout the week.

Presence of melatonin in human tears / Presencia de melatonina en lágrimas humanas

No disponible

Antidepressant sales and regional variations of suicide mortality in Germany.

Suicides account for over one million deaths per year worldwide with depression among the most important risk factors. Epidemiological research into the relationship between antidepressant utilization and suicide mortality has shown heterogeneous and contradictory results. Different methodological approaches and limitations could at least partially explain varying results. This is the first study assessing the association of suicide mortality and antidepressant sales across Germany using complex statistical approaches in order to control for possible confounding factors including spatial dependency of data. German suicide counts were analyzed on a district level (n = 402) utilizing ecological Poisson regressions within a hierarchical Bayesian framework. Due to significant spatial effects between adjacent districts spatial models were calculated in addition to a baseline non-spatial model. Models were adjusted for several confounders including socioeconomic variables, quality of psychosocial care, and depression prevalence. Separate analyses were performed for Eastern and Western Germany and for different classes of antidepressants (SSRIs and TCAs). Overall antidepressant sales were significantly negatively associated with suicide mortality in the non-spatial baseline model, while after adjusting for spatially structured and unstructured effects the association turned out to be insignificant. In sub-analyses, analogue results were found for SSRIs and TCAs separately. Suicide risk shows a distinct heterogeneous pattern with a pronounced relative risk in Southeast Germany. In conclusion, the results reflect the heterogeneous findings of previous studies on the association between suicide mortality and antidepressant sales and point to the complexity of this hypothesized link. Furthermore, the findings support tailored suicide preventive efforts within high risk areas.

Depresión post ictus: una actualización / Post-stroke depression: an update

Introducción: La depresión post ictus (DPI) es el trastorno afectivo más frecuente tras un ictus y el principal factor que limita la recuperación y rehabilitación de los pacientes, además de poder incrementar su mortalidad hasta 10 veces. Desarrollo: La DPI se presenta en uno de cada 3 pacientes con ictus y en más de la mitad de los casos no se diagnostica ni se trata. En su etiopatogenia son varios los mecanismos implicados: biológicos, conductuales y sociales. Los síntomas suelen aparecer en los primeros 3 meses tras el ictus (DPI «precoz») y menos frecuentemente más tarde (DPI «tardía»). Los síntomas son similares a los de otras depresiones, aunque con algunas diferencias, como presentar más trastornos del sueno, síntomas vegetativos e introversión para las relaciones sociales. Para su diagnóstico se recomienda mantener una actitud vigilante y emplear herramientas diagnósticas específicas, como el Patient Health Questionaire-2 (PHQ-2). Finalmente, el tratamiento de elección son los inhibidores selectivos de la recaptación de serotonina (ISRS). No obstante, aún son muchas las cuestiones por resolver en el tratamiento de la DPI, como cuándo es el mejor momento para iniciar el tratamiento o el efecto de los antidepresivos sobre la cognición y la función motora, entre otros. Conclusiones: Los neurólogos desempenan un papel fundamental en la recuperación de los enfermos con ictus. Es necesario que estén familiarizados con la detección temprana y el tratamiento de la DPI, para así facilitar la recuperación funcional del paciente, su reinserción social y la mejora en la calidad de vida del enfermo y su familia

Introduction: Post-stroke depression (PSD) is the most common mood disorder following a stroke, and also the main factor limiting recovery and rehabilitation in stroke patients. In addition, it may increase mortality by up to ten times. Development: PSD occurs in 1 in 3 stroke patients and more than half of all cases are neither diagnosed nor treated. Several mechanisms, including biological, behavioral, and social factors, are involved in its pathogenesis. Symptoms usually occur within the first three months after stroke (early onset PSD), and less frequently at a later time (late onset PSD). Symptoms resemble those of other types of depression, although there are some differences: PSD patients experience more sleep disturbances, vegetative symptoms, and social withdrawal. For PSD diagnosis, we recommended vigilance and use of specific diagnostic tools such as the Patient Health Questionnaire-2 (PHQ-2). The treatments of choice are selective serotonin reuptake inhibitors (SSRI). However, there are still many unanswered questions in the treatment of PSD, such as the best time to start treatment or the effects of antidepressants on cognition and motor function, among others. Conclusions: Neurologists play a pivotal role in the care and management of patients recovering from stroke. They must be familiar with methods for early detection and treatment ofPSD, as this can facilitate a patient’s functional recovery and social reintegration, and improve quality of life for patients and their families

Chronic diseases, lack of medications, and depression among Syrian refugees in Jordan, 2013-2014.

INTRODUCTION: Studying mental and physical health problems in refugees facilitates providing suitable health care, thus improving their quality of life. We studied depression tendency in Syrian refugees in Jordan in the light of chronic diseases and medication availability. Also, depression prevalence and depression comorbidity with chronic diseases were identified. METHODS: In this multicenter cross-sectional survey, data from Syrian refugees attending Caritas centers in 6 Jordanian cities from November 2013 through June 2014 were analyzed. Participants' demographics, depression, previously diagnosed chronic diseases, and newly diagnosed chronic diseases and the availability of medications were studied. Logistic regression was used to examine predictors for depression. RESULTS: Of 765 refugees who participated, about one-third demonstrated significant depression as measured by the Beck Depression Inventory. Descriptive analyses showed that depression was comorbid in 35% of participants with previously diagnosed chronic diseases and in 40% of participants with newly diagnosed chronic diseases. Newly diagnosed chronic diseases and lack of medications significantly contributed to depression, but the regression model as a whole explained less than 5% of the variance. CONCLUSION: Because the regression model showed low effect size, we concluded that newly diagnosed chronic diseases and medication shortages could not predict depression in Syrian refugees residing in Jordan. Therefore, further studies of additional factors are recommended. Prompt measures have to be taken to prevent the spread of chronic diseases and improve mental health in this fragile population.

Evidências sobre a combinação de antidepressivos na depressão maior / Evidence on the combination of antidepressants in major depression

O objetivo desta revisão narrativa é avaliar as evidências científicas do emprego de combinação de antidepressivos no tratamento da depressão maior. Foram avaliadas duas modalidades de combinação: a introdução da combinação desde o início do tratamento e a associação de um segundo antidepressivo em pacientes que não apresentaram resposta satisfatória com o primeiro antidepressivo. Foram pesquisadas as principais bases de dados até outubro de 2012, sem restrição de língua (PubMed, Cochrane Library, Embase, PsycINFO, Lilacs, registros de ensaios clínicos e bancos de teses) e referências secundárias. Foram utilizadas revisões sistemáticas recentes, ensaios clínicos não contemplados pelas revisões e artigos de revisão sobre o tema. Ambas as formas de combinação de antidepressivos foram muito pouco estudadas. De maneira geral, os ensaios incluíram número muito pequeno de sujeitos e apresentaram problemas metodológicos significativos. Os resultados são controversos. As evidências existentes não permitem conclusões sólidas acerca da eficácia e tolerabilidade do emprego de associações de antidepressivos.

Declining differences in response rates with antidepressants versus placebo: a modest proposal for another contributing cause.

This column discusses declining differences in response rates between sequentially introduced selective serotonin reuptake inhibitors (SSRI) and placebo. Although discussions of this phenomenon in the literature have largely focused on increasing placebo response rates, the author proposes that another factor may be responsible. That factor is an order effect, meaning that response rates have been declining as a function of the number of SSRIs on the market when the next SSRI is in development. The rationale is that the pool of potential clinical trial participants likely to respond to a drug with this mechanism of action (MOA) becomes progressively smaller with the introduction of each new agent with the same MOA, because many patients will already have been treat- ed and responded to an earlier member of the class. This phenomenon is not limited to the SSRIs but generalizes to any class of treatments that shares the same MOA.

The association between lifting an administrative restriction on antidepressant dispensing and treatment patterns in Iceland.

PURPOSE: On March 1st 2009, restrictions on the dispensing of selective serotonin reuptake inhibitors (SSRI) in Iceland were lifted. Incident rates and changes in early discontinuation and switching before and after the change were investigated. METHODS: New users of antidepressants between March 1st 2006 and March 1st 2010 were selected from the Icelandic Prescriptions Database. The study population was split into one intervention cohort (2009) and three comparison cohorts (2006, 2007, and 2008). Incidence rate ratios (IRR) and odds ratios (OR) were used to compare incidence rates and early discontinuation. RESULTS: The overall incidence rates of antidepressant use decreased from 33.10 to 28.71 per 1000 persons per year (IRR 0.87; 95% confidence interval (CI), 0.78-0.97) from the 2006 to the 2009 cohort. The incidence rate for SSRIs did not change over the period. Early discontinuation for SSRIs increased from 30.2% in 2006 to 34.1% in 2009 (OR 1.19; 95% CI 1.06-1.33). CONCLUSIONS: The change in reimbursement does not seem to have affected incidence rates but it may be related to increased early discontinuation, which can lead to increased drug wastage. It might be more clinically rational to initiate patients on smaller supply, allowing for more frequent check-up visits.

[Suicide attempt with antidepressants ordered from the Internet]. / Tentamen suicidii met antidepressiva besteld via het internet.

BACKGROUND: Since its launch, the Internet has developed into a mass medium with 1.6 billion people using it worldwide. Due to anonymity, its wide reach and the infinite stream of information from the Internet, almost anything can be found on it. This includes medicines that can normally only be acquired by way of a doctor's prescription. CASE DESCRIPTION: A 27-year-old man made a suicide attempt using psychoactive drugs he got from an illegal website in India. This caused him to develop status epilepticus, rhabdomyolysis, renal insufficiency and pulmonary oedema for which he had to be admitted to intensive care. The patient was treated with medicine, cardioversion, ventilation and haemofiltration and recovered. He was referred to a psychiatric centre. CONCLUSION: The number of illegal online pharmaceutical websites on the Internet has increased drastically in the last decade. These websites sell medicines without prescription to consumers and the traditional doctor/patient consultation does not therefore take place. Many medicines that are delivered contain the wrong concentration or the wrong active ingredient and are often contaminated with other substances. The ease with which this life-threatening medicine can be ordered online without a doctor's supervision is a possible risk to public health.

Relationship between antidepressant medication possession and treatment response.

OBJECTIVE: To estimate the correlation between antidepressant medication possession ratios (MPR) measured from administrative pharmacy data and changes in self-reported depression symptoms. METHODS: The sample includes 360 primary care patients enrolled in a randomized trial of collaborative care in the Department of Veterans Affairs. Treatment response at 6 months was defined as a 50% improvement in symptoms as measured by the Hopkins Symptom Checklist (SCL-20). MPRs were calculated from administrative pharmacy data. Logistic regression analysis (controlling for intervention status and casemix) was used to test the hypothesis that MPR was significantly associated with treatment response. RESULTS: Seventy percent of the patients filled an antidepressant prescription and the average MPR was 0.46. A fifth (19.2%) of the patients responded to treatment. Having an MPR > or = 0.9 was significantly correlated with treatment response (OR=2.43, CI(95)=1.29-4.57, P=.006). CONCLUSIONS: If the predictive validity of antidepressant MPR measured from administrative pharmacy data is validated in other patient populations, it could be used to estimate treatment response rates whenever it is not feasible to collect symptom data directly from patients. Thus, the effectiveness of quality improvement programs designed to increase rates of antidepressant initiation and adherence could potentially be evaluated routinely at the population or system level.

Risk factors for suicide in Hungary: a case-control study.

BACKGROUND: Hungary previously had one of the highest suicide rates in the world, but experienced major social and economic changes from 1990 onwards. We aimed to investigate the antecedents of suicide in Hungary. We hypothesised that suicide in Hungary would be associated with both risk factors for suicide as identified in Western studies, and experiences related to social and economic restructuring. METHODS: We carried out a controlled psychological autopsy study. Informants for 194 cases (suicide deaths in Budapest and Pest County 2002-2004) and 194 controls were interviewed by clinicians using a detailed schedule. RESULTS: Many of the demographic and clinical risk factors associated with suicide in other settings were also associated with suicide in Hungary; for example, being unmarried or having no current relationship, lack of other social contacts, low educational attainment, history of self-harm, current diagnosis of affective disorder (including bipolar disorder) or personality disorder, and experiencing a recent major adverse life event. A number of variables reflecting experiences since economic restructuring were also associated with suicide; for example, unemployment, concern over work prospects, changes in living standards, practising religion. Just 20% of cases with evidence of depression at the time of death had received antidepressants. CONCLUSION: Suicide rates in Hungary are falling. Our study identified a number of risk factors related to individual-level demographic and clinical characteristics, and possibly recent societal change. Improved management of psychiatric disorder and self-harm may result in further reductions in suicide rates.

The unlicensed lives of antidepressants in India: generic drugs, unqualified practitioners, and floating prescriptions.

Antidepressant uses have been rising rapidly over the past decades. Two main theories have been advanced to explain this. One claims that socio-economic change causes a global rise of depressive illness. The other holds that European and North American corporations are aggressively marketing antidepressants to expand their global reach. Both theories assume that multinational capitalism drives rising depression rates. Based on ethnographic data from India, this article shows that antidepressants are increasingly used in this country as well, but for reasons than have been little explored yet. Taking fluoxetine (Prozac) as the main example, it is argued that the spread of antidepressants in India is ;unlicensed' by Euro-American corporations in at least three ways: (i) drug marketing is driven by Indian generic producers; (ii) fluoxetine is given by practitioners who have no license to do so; and (iii) knowledge of fluoxetine is spread through unlicensed ;floating' prescriptions that patients take from one prescriber to another.