Users Of Antipsychotic Medications Research Articles

Associations of antipsychotic medication use with mortality, stroke, and myocardial infarction among long‐term nursing home Medicare beneficiaries

AbstractBackgroundIn 2005, the Food and Drug Administration issued a black box warning regarding increased mortality and cardiovascular accidents with the off‐label use of antipsychotic medication (APM) in patients with dementia. To improve the quality of care for patients with dementia in nursing homes (NH), in early 2012, the Centers for Medicare & Medicaid Services launched the National Partnership (NP) aimed at combatting the excessive use of APM. Within five years of the partnership, the number of antipsychotic prescriptions in NHs decreased by 34%. The objective of the present study was to examine how APM use has impacted other outcomes, including mortality and major cardiovascular events such as stroke and myocardial infarction (MI) among NH residents with dementia.MethodWe analyzed Medicare data on a sample of 611,773 long‐term NH residents with dementia, aged 50 years and older, from 2011 through 2016. Residents who had received hospice care during the time period were excluded. Cross‐sectional (by year) logistic regressions were conducted to examine the associations of APM use with death, stroke, and MI in the years 2011‐2016. Regression models were adjusted for demographic and co‐morbidity indicators.ResultLogistic regressions (see results in Table 1) revealed that NH residents prescribed APM had a significantly higher probability of death compared to non‐users from 2011 through 2015. However, in 2016, the probability of death was lower among APM users than non‐users, although the association was weak. Additionally, NH residents who were on APM were less likely to have a stroke or MI than non‐users from 2011 through 2016.ConclusionCurrent study findings suggest that APM use is likely associated with a heightened probability of death among long‐term NH residents, which is consistent with previous literature. The finding that APM use is negatively associated with stroke and MI is inconsistent with prevailing understandings that APM use would lead to higher risks of these outcomes. The shift in the likelihood of death in 2016, and negative associations with stroke and MI warrant further investigation as to the possible contributing factors of death and cardiovascular events in NH residents on antipsychotic medications.

Psychotherapy and Psychiatry Visits in the United States: A Study of MEPS, 2017-2019.

Rates of individuals with a psychotherapy visit has not been well studied, and recent reports lack granularity by age. METHODS: The 2017-2019 Medical Expenditure Panel Survey (MEPS) was used to investigate rates and associations of psychotherapy and psychiatry visits by age/sex and antidepressant/antipsychotic use. RESULTS: The study included all 90,853 individuals, of which 5.2% (95% CI, 4.9-5.4) reported any psychotherapy (excluding psychiatry visits) visit during a year, while 3.6% (95% CI, 3.4-3.8) reported a visit with a psychiatrist. Females were more likely to have a psychotherapy visit than males after 15 years of age. The highest rates of females with a psychotherapy visit were between 15 and 30 years of age, while rates among males were highest between 10 to 25 years of age. For psychiatry visits, males had higher rates than females during preteen years, similar rates through teen years, lower rates though adulthood, and similar rates after 60 years of age. Rates of a psychiatry visit did not vary as much by age as a psychotherapy visit. Among antidepressant or antipsychotic medication users, the rate of either a psychotherapy visit or a psychiatry visit during a year was markedly higher at younger ages and decreased as age advanced. CONCLUSION: Psychotherapy and psychiatry utilization have differences in population level patterns with use being highest among females between 15 to 30 years of age and higher among younger (compared with older) individuals who reported antidepressants or antipsychotics.

Galactorrhea among Female Mentally Ill Patients Using Antipsychotics in a Tertiary Institution in South-South Nigeria

Objective was to determine the prevalence of galactorrhea among respondents, to determine the correlation between the dose of antipsychotic and the presence of galactorrhea, to determine the relationship between the duration of drug use and the prolactin level, to determine the relationship between class of antipsychotic and galactorrhea, and to determine the predictors of galactorrhea among the respondents. This is a cross-sectional study. From 81 consenting patients taking prescribed antipsychotic medications and all of whom have met the inclusion criteria, a sociodemographic interview schedule was administered. Next, the venous blood sample was collected for the estimation of the serum prolactin level. The prevalence of galactorrhea was 50.6%, there was a correlation between galactorrhea and chlorpromazine equivalent dose of antipsychotics (r = 0.356, p = 0.001), there is an association between galactorrhea and the use of typical antipsychotics, there was also an association between the duration of antipsychotic use and galactorrhea, and the greatest predictor of galactorrhea was found to be the duration of antipsychotic medication usage. Galactorrhea can result from the use of atypical or typical antipsychotics, and the duration of antipsychotic use was the greatest predictor of galactorrhea.

Educating Nursing Home Staff in Dementia Sensitive Communication: Impact on Antipsychotic Medication Use

ObjectivesAn educational program to enhance communication in nursing home dementia care increased person-centered communication by staff and resulted in reduced resident behavioral symptoms measured as resistiveness to care. The purpose of this analysis was to evaluate effects on resident antipsychotic medication use in participating nursing homes. The National Partnership to Improve Dementia Care set a goal of reducing antipsychotic medications in nursing homes by 15% during the study period. DesignA post hoc analysis of Nursing Home Compare data was used to evaluate change in antipsychotic medication rates in nursing homes receiving the communication education versus the corresponding statewide average change. Setting and ParticipantsEleven nursing homes participated in a cluster-randomized controlled trial from 2011 to 2013 in one Midwestern state. MeasuresAntipsychotic medication rates were abstracted from Nursing Home Compare data sets. Antipsychotic medication rates were compared for each participating nursing home for the 2 quarters before and the 2 quarters after the communication intervention. To control for other factors supporting reduction in antipsychotic use, changes in the participating nursing homes were compared to the state average change for the corresponding quarters using a 1-sample t test. ResultsAntipsychotic medication use decreased on average by 4.88 percentage points (22.9%) in participating nursing homes compared to the state average decrease of 0.68 percentage points (2.7%) during the same period (P = .06). ConclusionsA clinically meaningful reduction in antipsychotic medication usage occurred in the nursing homes that received communication education. Measurable changes in communication and behavioral symptoms were reflected in reductions in antipsychotic medication usage. Improving staff communication has the potential to reduce inappropriate antipsychotic medication use in long-term care.

Predicting Future High-Cost Schizophrenia Patients Using High-Dimensional Administrative Data.

The burden of serious and persistent mental illness such as schizophrenia is substantial and requires health-care organizations to have adequate risk adjustment models to effectively allocate their resources to managing patients who are at the greatest risk. Currently available models underestimate health-care costs for those with mental or behavioral health conditions. The study aimed to develop and evaluate predictive models for identification of future high-cost schizophrenia patients using advanced supervised machine learning methods. This was a retrospective study using a payer administrative database. The study cohort consisted of 97,862 patients diagnosed with schizophrenia (ICD9 code 295.*) from January 2009 to June 2014. Training (n = 34,510) and study evaluation (n = 30,077) cohorts were derived based on 12-month observation and prediction windows (PWs). The target was average total cost/patient/month in the PW. Three models (baseline, intermediate, final) were developed to assess the value of different variable categories for cost prediction (demographics, coverage, cost, health-care utilization, antipsychotic medication usage, and clinical conditions). Scalable orthogonal regression, significant attribute selection in high dimensions method, and random forests regression were used to develop the models. The trained models were assessed in the evaluation cohort using the regression R2, patient classification accuracy (PCA), and cost accuracy (CA). The model performance was compared to the Centers for Medicare & Medicaid Services Hierarchical Condition Categories (CMS-HCC) model. At top 10% cost cutoff, the final model achieved 0.23 R2, 43% PCA, and 63% CA; in contrast, the CMS-HCC model achieved 0.09 R2, 27% PCA with 45% CA. The final model and the CMS-HCC model identified 33 and 22%, respectively, of total cost at the top 10% cost cutoff. Using advanced feature selection leveraging detailed health care, medication utilization features, and supervised machine learning methods improved the ability to predict and identify future high-cost patients with schizophrenia when compared with the CMS-HCC model.

Antipsychotic treatment: experiences of fully recovered service users

Background: There is lack of long-term controlled studies evaluating treatment effects of antipsychotic medication. A complete investigation should include the service user perspective.Aims: To investigate experiences of clinically recovered service users of antipsychotic medications during and after a first episode of psychosis.Method: We used a thematic analytic approach within an interpretative-phenomenological framework. 20 clinically recovered service users were interviewed.Results: Themes: (1) Antipsychotic drugs reduce mental chaos during the acute phase, (2) Non-stigmatizing environments were perceived to increase chances of successful use, (3) Antipsychotic drugs beyond the acute phase – considered to compromise the contribution of individual effort in recovery, (4) Prolonged use – perceived to reduce likelihood of functional recovery, (5) Antipsychotic medication was considered as a supplement to trustful relationships.Conclusions: Acute phase antipsychotic treatment was mostly perceived as advantageous by this sample, who was in clinical recovery. However, costs were often seen as outweighing benefits beyond the acute stage. Findings clearly emphasize the need for a collaborative approach to be integrated across all phases of care. This study underscores the need to investigate sub-group differences with regard to long-term antipsychotic treatment.

Multiple Antipsychotic Medication Use in Autism Spectrum Disorder.

The purpose of this study was to explore the use of multiple antipsychotic medications in patients with autism spectrum disorder (ASD) by reviewing the longitudinal medication management of 1100 patients consecutively treated for behavioral symptoms associated with ASD at a tertiary care specialty clinic. We identified all patients with ASD treated with daily doses of two or more antipsychotics for at least two visits at our clinic. For each patient meeting inclusion criteria, diagnostic and demographic data were collected. To evaluate clinical need and effectiveness of antipsychotic medications in this sample, we reviewed symptoms targeted with each antipsychotic medication and concomitant medications prescribed. Clinical Global Impressions-Severity (CGI-S) and Clinical Global Impressions-Improvement (CGI-I) scale ratings had been completed at the time of each visit, and the duration of treatment with antipsychotic medications was determined. To evaluate the safety and tolerability of antipsychotic medication use in ASD, we reviewed reported adverse effects and calculated body mass index (BMI) change with treatment. Seventy patients met the inclusion criteria (6.4% of our sample). The majority of patients were moderately to severely ill Caucasian males, as determined by baseline mean CGI-S of 4.7 (SD = 0.8), and were diagnosed with autistic disorder and comorbid intellectual disability. The mean age was 15.1 years (SD = 10.9), the primary targeted symptoms were agitation/irritability, physical aggression, and self-injury. The majority of patients remained on two or more antipsychotics for >1 year. In this population, patients demonstrated greater symptomatic improvement and generally tolerated treatment without significant adverse effects. The use of two or more antipsychotic medications may be increasingly common in patients with ASD. This retrospective study demonstrates that this treatment approach may be of some clinical benefit, and is generally well tolerated. Prospective studies focusing on the efficacy and safety of concomitant antipsychotic medication usage in ASD should be considered.

New users of antipsychotic medication: A population-based cohort study of occupational outcome measures in relation to antipsychotic on-label and off-label prescribing practices

BackgroundTreatment with antipsychotic medication is thoroughly investigated in schizophrenia and bipolar disorder but is also widely applied for a diversity of off-label conditions, despite an uncertain risk-benefit ratio. This study examined the relationship between antipsychotic prescribing patterns and labor market affiliation, considering both authority approved and off-label prescriptions and the relation to polypharmacy. MethodsRegister-based cohort study using a dataset of 71,254 new antipsychotic users with a psychiatric diagnosis. Labor market affiliation and duration of welfare payments were analyzed using linear regression models and duration analysis. The analyses were adjusted for the following confounding variables: age, gender, diagnosis, marital status, length of education, and utilization of mental health care services. ResultsThe majority of new antipsychotic users received welfare payments for prolonged periods of time during the observation period, even more so for individuals treated with antipsychotic polypharmacy or other antipsychotic combination regimens. The risk of permanently leaving the labor market was also associated with antipsychotic combination regimen. ConclusionsAntipsychotic treatment, especially in combination with other antipsychotics or other psychotropic drugs, could serve as a marker of subjects with increased need for support to maintain the labor market affiliation. However, causality cannot be inferred from an observational study because of residual confounding that could not be adjusted for in this study.

Incident users of antipsychotics: who are they and how do they fare?

In Denmark, as well as in many other countries, consumption of antipsychotics is on the rise, partly due to increasing off-label use. The aim of this study was to analyze and quantify the extent of off-label use and polypharmacy in incident users of antipsychotic medication, and to examine initial antipsychotic prescribing patterns and associated use of mental health care services. Population-based cohort study linking the following Danish national registers: the Central Psychiatric Research Register, the Register of Medicinal Product Statistics, and Statistics Denmark. From 2007 to 2012, 154,351 Danish subjects initiated treatment with antipsychotics. Among these, 71,254 (46 %) subjects had a psychiatric diagnosis recorded. The most frequent diagnoses were reaction to severe stress and adjustment disorders (10,106; 14 %), depressive episode (8876; 12 %), and recurrent depressive disorder (6810; 10 %). We found high antipsychotic discontinuation rates during the first few months (45 % in 4 months) and frequent antidepressant co-prescribing from treatment onset (47 %). Significantly greater likelihood of psychiatric hospitalization was observed for antipsychotic polypharmacy (HR 1.38; 95 % CI 1.32-1.45), whereas antipsychotic discontinuation was associated with decreased hospitalization risk in most off-label conditions. The brief duration of most antipsychotic prescriptions suggests that antipsychotics are prescribed more liberally than recommended. As a consequence of the range of adverse effects associated with antipsychotic drug use, the documented widespread off-label prescribing practices warrant careful monitoring for adverse effects and prompt discontinuation in case of an unfavorable risk-benefit ratio.

Subcortical brain alterations in major depressive disorder: findings from the ENIGMA Major Depressive Disorder working group.

The pattern of structural brain alterations associated with major depressive disorder (MDD) remains unresolved. This is in part due to small sample sizes of neuroimaging studies resulting in limited statistical power, disease heterogeneity and the complex interactions between clinical characteristics and brain morphology. To address this, we meta-analyzed three-dimensional brain magnetic resonance imaging data from 1728 MDD patients and 7199 controls from 15 research samples worldwide, to identify subcortical brain volumes that robustly discriminate MDD patients from healthy controls. Relative to controls, patients had significantly lower hippocampal volumes (Cohen's d=−0.14, % difference=−1.24). This effect was driven by patients with recurrent MDD (Cohen's d=−0.17, % difference=−1.44), and we detected no differences between first episode patients and controls. Age of onset ⩽21 was associated with a smaller hippocampus (Cohen's d=−0.20, % difference=−1.85) and a trend toward smaller amygdala (Cohen's d=−0.11, % difference=−1.23) and larger lateral ventricles (Cohen's d=0.12, % difference=5.11). Symptom severity at study inclusion was not associated with any regional brain volumes. Sample characteristics such as mean age, proportion of antidepressant users and proportion of remitted patients, and methodological characteristics did not significantly moderate alterations in brain volumes in MDD. Samples with a higher proportion of antipsychotic medication users showed larger caudate volumes in MDD patients compared with controls. This currently largest worldwide effort to identify subcortical brain alterations showed robust smaller hippocampal volumes in MDD patients, moderated by age of onset and first episode versus recurrent episode status.

First-episode affective psychosis and lipid monitoring: survival analysis of the first abnormal lipid test.

This study aimed to assess the probability of developing a lipid test abnormality over time, among first-time users of antipsychotic medications with affective psychosis. Survival analysis was used to analyse data from an early intervention in psychosis programme for the first 53 consecutive and eligible cases of patients between the ages of 14 and 40 years who had a diagnosis of affective psychosis. Data on initiation of antipsychotic medications and lipid laboratory test results were abstracted from chart reviews. Within the first 18 months of receiving antipsychotic medications, the probability of surviving without an abnormal lipid test was only 25% (confidence interval 95%: 13.1%, 40.4%). The median time to the development of an abnormal test was 8 months for males and 12 months for females (P < 0.001). Additional studies are needed to document the incidence over time of abnormal lipid tests to inform clinicians about the optimal frequency of monitoring.

Adherence to Oral Diabetes Medications Among Users and Nonusers of Antipsychotic Medication

This study compared adherence to oral diabetes medications among users and nonusers of oral antipsychotic medications. Adherence to oral antidiabetics and antipsychotics among antipsychotic users was also compared. Texas Medicaid prescription claims data from July 1, 2008, to December 31, 2011, were used to examine adherence to oral antidiabetics among users and nonusers of antipsychotics for 12 months after the first prescription for oral diabetes medication. Users and nonusers of antipsychotics were matched on the basis of their chronic disease score (CDS). Medication adherence was measured by proportion of days covered (PDC), and patients with a PDC value ≥.80 were considered to be adherent. Bivariate and multivariate analyses were used to compare adherence between cohorts. A total of 1,821 patients from each group were matched. The mean PDC for oral antidiabetics was significantly higher among antipsychotic users (.63) than nonusers (.55) (p<.001). About 37% (N=678) of antipsychotic users and 24% (N=473) of nonusers were adherent to oral antidiabetics. After adjustment for age, gender, CDS, and number of prescriptions, antipsychotic users were 2.10 times more likely than nonusers to be adherent to oral antidiabetics (p<.001). Antipsychotic users had higher mean PDC values for antipsychotic medications than for oral antidiabetics (.78±.25 versus .63±.29, p<.001). Adherence to oral antidiabetics in the Texas Medicaid population was better among antipsychotic medication users than nonusers, but overall adherence was poor for both groups. Low adherence rates highlight the need for interventions to help improve medication management.

Metabolic Alterations Associated With Antipsychotic Use–A Descriptive Study and Comparison between Haloperidol and Olanzapine in Schizophrenic and Bipolar Patients

Introduction: Antipsychotic drugs are essential to psychiatric health in many conditions, such as schizophrenia and bipolar disorder. However, they present several side effects, such as motor dystonia and “Parkinson-like” behavior (especially in first generation antipsychotics) and metabolic alterations leading to increased body weight, type 2 diabetes and dyslipidemias. Second generation antipsychotics are widely regarded as more damaging in metabolic side effects, though there are few studies comparing if first generation antipsychotics can provoke similar changes in metabolism. Methods: An observational-transversal-descriptive study was conducted in a total of 63 patients in use of their first generation (haloperidol–N=27) or second generation antipsychotic–olanzapine–N=36). Blood samples were collected to assess the following parameters–Fasting Glucose, HDL Cholesterol, LDL Cholesterol, Triglycerides and Basal Insulin. Anthropometric measurements of abdominal and neck circumference, as well as weight were also taken and compared between both groups. Statistical analyses: If variables were considered of normal distribution, the Student t-test and variance analyses (ANOVA) were performed to test for significant differences between groups. If samples were considered non-parametric, U Mann-Whitney test, Kruskal-Wallis test, Qui-square for extensive table, or Fish’s test were utilized. Statistical significance was considered 5% on all analyzes (p<0.05). Results: There were no statistically significant differences between both groups using either first and second generation antipsychotics., in relation to anthropometric measurements (abdominal circumference measurements p=0.56, U Mann-Whitney test), metabolic status (HOMA index p=0.12 , HDL cholesterol p=0.27, basal glycemia p=0.08 , BMI p=0.51, triglycerides p=0.12, Chi-square for extensive tables). Discussion: Metabolic alterations occurred in both groups, which support the literature findings which show a high prevalence of metabolic alteration in antipsychotic medication users.

PHS48 - Adherence to oral anti-diabetic medications in antipsychotic medication users and non-users

To compare adherence to oral anti-diabetic (OAD) medications in users and non-users of antipsychotic medications. Among antipsychotic users, adherence to OADs and antipsychotics was compared. This was a retrospective database analysis using Texas Medicaid prescription claims data. Adult patients (18-64 years) newly initiated on OADs were identified and followed for one-year. Medication adherence to OADs was evaluated in all patients, and adherence to antipsychotics was measured in the antipsychotic user cohort. Proportion of Days Covered (PDC) was used as the medication adherence measurement, with optimal adherence defined as PDC ≥ 0.8. Bivariate and multivariate analyses were used to compare adherence between treatment groups. A total of 18,999 patients met the study inclusion criteria of which 1,956 (10.30%) were prescribed antipsychotics during the study period. The overall mean (SD) PDC was 0.57 (0.28) for the OADs, and 0.78 (0.25) for antipsychotics. The mean PDC for OADs was significantly higher for antipsychotic users compared to non-users (0.62 vs. 0.57; p<0.0001). About 37% of antipsychotic users and 27% of non-users were adherent to OADs (p<0.0001). After controlling for age, gender, and pre-index chronic disease score, patients prescribed antipsychotics were 1.6 times more likely to be adherent compared to non-users (p<0.0001). In the subgroup of patients prescribed both medication types, higher PDC values were associated with antipsychotic drugs than with OADs (0.78 [0.25] vs 0.62 [0.29], p<0.05). OAD medication adherence was better among antipsychotic users compared to non-users in the Texas Medicaid population. However, overall adherence to OADs and antipsychotics was suboptimal in this population. The low adherence rates highlight need for interventions to help improve medication management for patients.

Adverse Events in Elderly Users of Antipsychotic Pharmacotherapy in the Province of Manitoba

Antipsychotic medications have been widely used in elderly patients for treatment of a variety of diagnoses. The aim of our study was to compare the incidence of cerebrovascular and cardiac events as well as mortality in elderly persons treated with second-generation antipsychotics (SGAs) with that of elderly persons treated with conventional first-generation agents (FGAs) in the province of Manitoba. A population-based retrospective cohort study of all residents of Manitoba aged 65 and older, who were dispensed antipsychotic medications for the first time during the period from April 1, 2000, to March 31, 2007, was conducted using Manitoba Health administrative databases. Cox proportional hazards models were used to compare risks of adverse events in FGA and SGA users. After controlling for potential confounders (demographics, comorbidity, and medication use), SGA use was not associated with a significantly greater risk of cerebrovascular events, cardiac arrhythmia, and congestive heart failure compared to FGA use (adjusted hazard ratios [HR], respectively: 1.136; 95% CI, 0.961-1.344; 0.865; 95% CI, 0.336-2.232; 1.127, 95% CI, 0.902-1.409). Second-generation antipsychotics users were found to be at a lower risk of mortality (adjusted HR, 0.683; 95% CI, 0.577-0.809), but at a higher risk of myocardial infarction (adjusted HR, 1.614; 95% CI, 1.024-2.543) compared to FGA users. Among elderly users of antipsychotic medications, the risk of cerebrovascular events, cardiac arrhythmia, and congestive heart failure was similar in FGA and SGA users. Whereas SGA users were at a higher risk of nonfatal myocardial infarction, the use of FGAs was associated with an increased risk of death. Antipsychotic pharmacotherapy in older persons needs to be chosen with careful consideration of all risks and benefits.

Metabolic Syndrome: Relative Risk Associated with Post-Traumatic Stress Disorder (PTSD) Severity and Antipsychotic Medication Use

In recent years, numerous lines of converging evidence have revealed an association between post-traumatic stress disorder (PTSD) and impaired physical health outcomes, including cardiovascular disease and metabolic syndrome. Although these findings have been interpreted as indicating a direct association of PTSD with metabolic syndrome and obesity, previous studies have not addressed the important confound of antipsychotic drug usage in this population. Second generation antipsychotic medications themselves are associated with metabolic syndrome and obesity, and it is unclear whether the common utilization of these drugs in PTSD may account for some if not all of the observed metabolic problems. The present study examined the relative contributions of PTSD severity and use of antipsychotic medications to risk of metabolic syndrome among veterans. Cross-sectional clinical data, including five factors representing metabolic syndrome, psychiatric diagnoses, and medications were gathered from 253 veterans enrolling in mental health services. We used a logistic regression model to measure the relative association of antipsychotic medication use and PTSD severity on risk of metabolic syndrome. We found that antipsychotic medication usage was not uniquely associated with elevated risk of metabolic syndrome (Wald = 0.30, ns) when PTSD severity and other sociodemographic, psychiatric, and behavioral variables were accounted for. Furthermore, PTSD severity continued to be a significant and unique predictor of risk for metabolic syndrome (Wald = 4.04, p < 0.05). These findings suggest that chronic and moderately severe PTSD, independent of antipsychotic medications, is associated with increased risk of metabolic syndrome.

Haloperidol Doubles Risk of Death in Nursing Home Residents

C with risperidone, haloperidol appeared to double the risk of death among elderly nursing home patients, while quetiapine was associated with a 20% decreased risk and some other antipsychotics appeared uniformly safe, Krista F. Huybrechts, Ph.D., and her colleagues wrote in BMJ (2012;344:e977). “The evidence accumulated so far implies that use of haloperidol in this vulnerable population cannot be justified because of the excess harm,” wrote Dr. Huybrechts of Brigham and Women’s Hospital, Boston. “If the clinician faces a situation in which the use of these drugs seem inevitable, our findings underscore the importance of always prescribing the lowest possible dose and of closely monitoring patients, especially shortly after the start of treatment.” Dr. Huybrechts and her coauthors reviewed medication and mortality data on 75,445 nursing home residents who were aged 65 or older and new users of antipsychotic medications from 2001– 2005. About 60% of the group had some form of dementia. Other psychiatric diagnoses included depression, anxiety, delirium, and psychotic disorders. The study examined the use of haloperidol, aripiprazole, olanzapine, risperidone, and ziprasidone. Other medications, like thioridazine and chlorpromazine, were excluded from the analysis because they were infrequently prescribed in the group. There were 6,598 deaths (9% of the study cohort) during the first 180 days. In a regression analysis, those taking haloperidol were twice as likely to die from any cause as those taking risperidone. The risk was strongest in the first 40 days of treatment (hazard ratio 2.34) and declined thereafter. Conversely, patients taking quetiapine were significantly less likely to die (HR, 0.81), and that risk remained fairly constant throughout the 180-day study period. No significant or clinically meaningful mortality trend was associated with the use of aripiprazole, olanzapine, risperidone, or ziprasidone. The investigators found no tie between the drug administered and the cause of death. “The increased risk of death with haloperidol and the decreased risk with quetiapine were observed for all causes examined,” they said. Every drug except quetiapine showed a dose-response relationship with allcause mortality. The relationship was most pronounced for haloperidol, with an 84% increased risk in those taking a high dose, and a 40% increased risk for those taking a medium dose, compared with those taking a low dose. The study emphasizes the need to use alternative behavioral management tools for as long as possible in nursing home patients, the authors said. “Guidelines universally agree that the first-line treatment for behavioral and psychological symptoms in dementia should be non–drug based, [but also] recommend the careful use of antipsychotics in the treatment of agitation, aggression, or psychosis that fails to respond to other measures and that reaches various severity thresholds, typically severe distress or serious risk to self or others,” Dr. Jenny McCleery said in an accompanying editorial (BMJ 2012;344:e1093). She is a consulting psychiatrist for the Oxford (England) Health National Health Systems Foundation Trust. Despite recommendations to limit the drugs’ use, however, antipsychotics are still widely prescribed for elderly patients with dementia or those who are institutionalized. “Few clinical problems place doctors in as tangled a web of clinical evidence, social policy, and ethical concerns as how to manage behavioral problems in patients with dementia,” Dr. McCleery wrote. Studies hint that doctors feel pressured to prescribe anything that might help and that they believe alternative therapies are hard to implement, she added. “The Food and Drug Administration, and the Agency for Healthcare Research and Quality funded the study. None of the authors reported any financial conflict of interest. Dr. McCleery said she has acted as a local investigator for Eli Lilly. CfA

A questionnaire survey of critical care nurses’ attitudes to delirium assessment before and after introduction of the CAM-ICU

Nurses are usually the first to identify delirium in ICU patients. We aimed to assess the attitudes of Australian critical care nurses when we introduced the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We surveyed all 174 nurses in our ICU using two questionnaires: first after a one-month period of mandated but unstructured delirium assessments, and then following one month of CAM-ICU assessments. We also quantified antipsychotic medication usage by inspecting pharmacy records. The first survey response rate was 65/174 (37%). Most nurses (73%) thought active delirium assessment was important, and 93% thought their assessments were worth the time required. These assessments were largely unstructured, as only 20% knew a formal delirium test, and only 7% sometimes used one. The second survey response rate was 45/174 (26%). Most (89%) still thought delirium assessment was important, but only 75% thought the CAM-ICU worth the time required (p=0.01 compared to unstructured assessments). Similar proportions (75% and 73%) were confident in the accuracy of their assessments. Many (33%) found the CAM-ICU 'quite' or 'very' hard to perform, but despite this, 82% wanted to continue to use it. Free-text answers suggested this was because medical staff paid more attention to the CAM-ICU. Supporting this, prescriptions of antipsychotic medications increased significantly in the CAM-ICU period. Critical care nurses in our Australian ICU who responded to our survey think delirium assessment is important. Although they find unstructured assessments easier to perform, they wanted to persist with the CAM-ICU, in part because it facilitated more appropriate pharmacological treatment of delirium for their patients. We recommend the CAM-ICU as a tool to improve communication between nurses and physicians in the management of delirium.

Variation in Antipsychotic Treatment Choice Across US Nursing Homes

Despite serious safety concerns, antipsychotic medications continue to be used widely in US nursing homes. The objective of this study was to quantify the variation in antipsychotic treatment choice across US nursing homes, and to characterize its correlates. Prescribing practices were assessed in a cohort of 65,618 patients 65 years or older in 45 states who initiated treatment with an antipsychotic medication after nursing home admission between 2001 and 2005, using merged Medicaid; Medicare; Minimum Data Set; and Online Survey, Certification, and Reporting data. We fit mixed-effects logistic regression models to examine how antipsychotic treatment choice at the patient-level depends on patient and nursing home fixed and random effects. Among antipsychotic medication users, 9% of patients initiated treatment with a conventional agent. After adjustment for case-mix and facility characteristics, 95% of nursing homes had a predicted conventional antipsychotic prescribing rate between 2% and 20%. Individually, patient characteristics accounted for 36% of the explained variation, facility characteristics for 23%, and nursing home prescribing tendency for 81%. Results were consistent in the subgroup of nursing home patients with a diagnosis of dementia. The prescribing physician was not considered as a determinant of treatment choice owing to data limitations. These findings indicate that antipsychotic treatment choice is to some extent influenced by a nursing home's underling prescribing "culture." This culture may reveal strategies for targeting quality improvement interventions. In addition, these findings suggest that a nursing home's tendency for specific antipsychotics merits further exploration as an instrumental variable for improved confounding adjustment in comparative effectiveness studies.

Behavioral and cardiac responses to emotional stroop in adults with autism spectrum disorders: influence of medication

Researchers have recently hypothesized that autism spectrum disorders (ASD) may be partly characterized by physiological over-arousal. One way to assess physiological arousal is through autonomic measures. Here heart period (HP) and parasympathetic activity measured by respiratory sinus arrhythmia (RSA) were examined in adults with ASD and matched controls at rest and during performance of an emotional Stroop task. Resting HP and RSA were lower in adults with ASD than in matched controls, consistent with hypothesized over-arousal in ASD. However, dividing the ASD group on the basis of antipsychotic medication usage revealed that group differences in autonomic arousal may be related to the effects of these medications or their correlates. Autonomic adjustments for Stroop performance were comparable across groups, but in the control group, larger RSA reductions were correlated with faster responding (i.e., better performance). This relation was reversed in the unmedicated ASD group and absent in the medicated ASD group. Findings highlight the importance of considering medication status in the recently burgeoning area of psychophysiological studies of autism.