Concomitant Psychotropic Medication Use Research Articles

2.67 Incidence of Psychiatric Comorbidity and Concomitant Psychotropic Medication Use Among Individuals With Neurodevelopmental Disorders Presenting in Distress

Individuals with neurodevelopmental disorders experience an increased risk of developing mental health conditions. Insufficiently treated mental health conditions in this population frequently present with agitation and irritability. Sources of Distress (“Sources”) is an online branching logic questionnaire that aims to address this issue by querying parent and caregivers’ observations and knowledge about the affected individuals.

Michigan Marijuana Legalization: Correlations Among Cannabis Use, Mental Health, and Other Factors.

Introduction: There are health implications with the statewide legalization of recreational marijuana that are still not fully understood and require further examination. This study evaluates the prevalence of marijuana use in patients being treated for a variety of conditions and whether correlations exist between marijuana use, mental health conditions, and concomitant use of psychotropic medications.Methods: Data were collected from an electronic medical record (EMR) as part of a retrospective chart audit. A total of 500 charts were reviewed during a six-month timeframe from December 1, 2018 to May 31, 2019 with the start date approximating the timing of when marijuana became recreationally legalized in the State of Michigan.Results: This study demonstrated a point prevalence of 15.8% since 79 of the 500 charts reviewed had marijuana use documented. Additionally, marijuana users were more likely to have a history of cocaine use, schizophrenia, antipsychotic use, and tobacco use.Conclusion: Trends identified in this study provide a comparison point for the local prevalence of marijuana use immediately post state-wide legalization, with a projected increasing trend due to the removal of legal barriers.

Deuterated dextromethorphan/quinidine for agitation in Alzheimer's disease.

Deuterated dextromethorphan/quinidine for agitation in Alzheimer's disease.

Clinically Significant Drug Interactions Between Psychotropic Agents and Repurposed COVID-19 Therapies.

As many patients with underlying psychiatric disorders may be infected with COVID-19, and COVID-19-affected subjects may frequently experience a new onset of psychiatric manifestations, concomitant use of psychotropic medications and COVID-19 therapies is expected to be highly likely and raises concerns of clinically relevant drug interactions. In this setting, four major mechanisms responsible for drug interactions involving psychotropic agents and COVID-19 therapies may be identified: (1) pharmacokinetic drug–drug interactions mainly acting on cytochrome P450; (2) pharmacodynamic drug–drug interactions resulting in additive or synergistic toxicity; (3) drug–disease interactions according to stage and severity of the disease; and (4) pharmacogenetic issues associated with polymorphisms of cytochrome P450 isoenzymes. In this review, we summarise the available literature on relevant drug interactions between psychotropic agents and COVID-19 therapies, providing practical clinical recommendations and potential management strategies according to severity of illness and clinical scenario.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40263-021-00811-2.

Maintenance phase treatment of psychotic disorders in outpatients from Serbia – focus on long-term benzodiazepine use

Introduction: Prescribing trends in maintenance therapy of patients with primary psychotic disorders (PSD) may vary worldwide. Present study aimed to investigate prescription patterns in a sample of outpatients with PSD from Serbia.Methods: In a sample of 73 PSD outpatients we analysed the rate of antipsychotic polypharmacy and psychotropic polypharmacy, concomitant continual benzodiazepine use, and associations between therapy, psychotic symptoms and quality of life.Results: Maintenance therapy (median daily dose 321 mg of chlorpromazine equivalents) predominantly consisted of monotherapy with second generation antipsychotics (45.2%), followed by antipsychotic polypharmacy based on first and second generation combination (25.0%). The median number of psychotropic drugs was 3. Benzodiazepines were continually prescribed to more than 60% of patients (mean daily dose 2.9 ± 2.0 mg lorazepam equivalents). Patients with benzodiazepine use had significantly more psychotropic medications and more antipsychotic polypharmacy, poorer quality of life and more severe psychopathology in comparison to another group.Conclusion: The present study demonstrated new information regarding the prescription patterns of psychotropic drugs in outpatients with PSD in Serbia, amplified with clinically relevant information. This study also revealed distinct prescription patterns concerning antipsychotic/benzodiazepine polypharmacy. Overall, such findings are likely to contribute to improving clinical practice and care for patients with PSD in general.KeypointsPresent exploratory research aimed to elucidate trends of antipsychotics polypharmacy and concomitant use of psychotropic medications including benzodiazepines in the maintenance treatment of outpatients with schizophrenia and other psychotic disorders, amplified with clinically relevant information (symptoms and quality of life).‘Antipsychotic (AP) polypharmacy’ was defined as concurrent use of more than one AP for at least 1 month; ‘Psychotropic polypharmacy’ was defined as the combination of AP and a different class of psychotropic drugs medication for at least one month.The median number of prescribed psychotropic drugs was 3 (mean 3.1 ± 1.1) and the average AP daily dose was moderate (median 321 mg of chlorpromazine equivalents). However, the rates of AP polypharmacy (45.2%) and benzodiazepine prescription on a continual basis (>60%) found in our sample could be considered relatively high.Outpatients with higher AP daily dose and higher BPRS symptom score were receiving more benzodiazepines.For improvement of the local, as well as general clinical practice and care for patients with psychotic disorders, and for education in psychiatry, such analyses need to be done on a regular basis and on larger samples.

Association Between Parental Medical Claims for Opioid Prescriptions and Risk of Suicide Attempt by Their Children

The rate of youth suicide has increased over the past 15 years in the United States as has the rate of death due to opioid overdose in adults of parental age. To explore the possible connection between parental use of prescription opioids and the increasing rate of youth suicide. A pharmacoepidemiologic study was conducted from January 1, 2010, to December 31, 2016, linking medical claims for parental opioid prescriptions with medical claims for suicide attempts by their children. The study used MarketScan medical claims data covering more than 150 million privately insured people in the United States. The study included 121 306 propensity score-matched 30- to 50-year-old parents who used opioids and parents who did not use opioids and their 10- to 19-year-old children (148 395 children of parents who did not use opioids and 184 142 children of parents who used opioids). Propensity score matching was used to identify relevant control families based on demographic features and concomitant use of psychotropic medication. Opioid use in a parent was defined as having prescription fills covering more than 365 days of an opioid between 2010 and 2016. Suicide attempt rate in the children of parents who used opioids and those who did not use opioids. A total of 148 395 children (75 575 sons and 72 820 daughters; mean [SD] age, 11.5 [1.6] years at the start of follow-up) had parents who did not use opioids and 184 142 children (94 502 sons and 89 640 daughters; mean [SD] age, 11.8 [1.8] years at the start of follow-up) with parents who did use opioids. There were 100 899 children aged 10 to 14 years and 47 496 children aged 15 to 19 years with parents who did not use opioids and 96 975 children aged 10 to 14 years and 87 163 children aged 15 to 19 years with parents who did use opioids. Of the children with parents who did not use opioids, 212 (0.14%) attempted suicide; of the children with parents who did use opioids, 678 (0.37%) attempted suicide. Parental use of opioids was associated with a doubling of the risk of a suicide attempt by their offspring (odds ratio [OR], 1.99; 95% CI, 1.71-2.33). The association remained significant after adjusting for child age and sex (OR, 1.85; 95% CI, 1.58-2.17), addition of child and parental depression and diagnoses of substance use disorder (OR, 1.46; 95% CI, 1.24-1.72), and addition of parental history of suicide attempt (OR, 1.45; 95% CI, 1.23-1.71). Geographical variation in opioid use did not change the association (OR, 2.00; 95% CI, 1.71-2.34). Children of parents who use prescription opioids are at increased risk for suicide attempts, which could be a contributing factor to the time trend in adolescent suicidality. The care of families with a parent who uses opioids should include mental health screening of their children.

Concomitant Use of Psychotropic Medication With Stimulants for the Treatment of ADHD in Children and Adolescents: A Retrospective Insurance Claims Study in the United States

Objective: To evaluate annual concomitant psychotropic medication use among stimulant-treated children/adolescents with ADHD. Method: Children/adolescents with ≥1 primary ADHD diagnosis who had received ≥30 days of stimulant medication were identified from insurance claims for each calendar year (2011-2014). Use of 15 psychotropic medications concomitantly with stimulants was evaluated and their prevalence in each year was calculated overall and by medication category for children (6-12 years) and adolescents (13-17 years). Results: Each year 133,354 to 157,303 children and 95,632 to 111,280 adolescents were included. Annual period prevalence of any concomitant psychotropic medication use was 22.9% to 25.0% for children and 25.2% to 28.2% for adolescents. The most common medication categories included selective serotonin reuptake inhibitors (children: 6.8%-7.9%; adolescents: 12.7%-14.9%), atypical antipsychotics (4.2%-5.4%; 5.3%-6.3%), and guanfacine extended release (5.1%-7.0%; 2.3%-3.6%). Conclusion: Around a quarter of children/adolescents with ADHD were prescribed psychotropic medication concomitant to stimulant treatment, although only 2 of the 15 medication classes studied were Food and Drug Administration (FDA)-approved for adjunctive use.

Patterns of Early Mental Health Diagnosis and Medication Treatment in a Medicaid-Insured Birth Cohort

ImportanceThe increased use of psychiatric services in the US pediatric population raises concerns about the appropriate use of psychotropic medications for very young children.ObjectiveTo assess the longitudinal patterns of psychotropic medication use in association with diagnosis and duration of use in a Medicaid-insured birth cohort.Design, Setting, and ParticipantsA cohort design was applied to computerized Medicaid administrative claims data for 35 244 children born in a mid-Atlantic state in 2007 and followed up for up to 96 months through December 31, 2014. Children were included in the birth cohort if they had an enrollment record at birth or within 3 months of birth and at least 6 months of continuous enrollment from birth. The cohort represents 92.2% of 38 225 Medicaid-insured newborns in 2007.ExposuresMental health treatments from birth through age 7 years.Main Outcomes and MeasuresCumulative incidence of first psychiatric diagnosis and psychotropic medication use (monotherapy or concomitant use of psychotropic medications) from birth through age 7 years, total and by sex, and the cumulative incidence of the use of psychosocial services (age, 0-7 years) as well as the annual duration of medication use (ie, number of days of psychotropic medication use among children 3-7 years of age).ResultsOf the 35 244 children in the cohort, 17 267 were girls and 17 977 were boys. By age 8 years, 4550 children in the birth cohort (19.7% [percentage adjusted for right censoring]) had received a psychiatric diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification codes 290-319); 2624 of these diagnoses (57.7%) were behavioral (codes 312, 313, or 314). Girls were more likely than boys to receive an incident psychiatric diagnosis of adjustment disorder (355 of 1598 [22.2%] vs 427 of 2952 [14.5%]; P < .001) or anxiety disorder (114 of 1598 [7.1%] vs 120 of 2952 [4.1%]; P < .001). By age 8 years, 2196 children in the cohort (10.2% [percentage adjusted for right censoring]) had received a psychotropic medication. Among medication users, 1763 of 2196 (80.5% [percentage adjusted for right censoring]) received monotherapy, 343 of 2196 (16.4% [percentage adjusted for right censoring]) received 2 medication classes concomitantly, and 90 of 2196 (4.3% [percentage adjusted for right censoring]) received 3 or more medication classes concomitantly for 60 days or more (range, 78-180 days). The annual median number of days of psychotropic medication use among medicated children increased with age, reaching 210 of 365 days for children 7 years of age. Among children 7 years of age, the median number of days of use of an antipsychotic (193 days [interquartile range, 60-266 days]), stimulant (183 days [interquartile range, 86-295 days]), or α-agonist (199 days [interquartile range, 85-305 days]) exceeded half of the year.Conclusions and RelevanceMedicaid-insured children received substantial mental health services and had prolonged exposure to psychotropic medications in the early years of life. These findings highlight the need for outcomes research in pediatric populations.

Concurrent Electroconvulsive Therapy and Bupropion Treatment.

Bupropion is associated with a dose-dependent increased risk of seizures. Use of concomitant bupropion and electroconvulsive therapy (ECT) remains controversial because of an increased risk of prolonged seizures. This is the first systematic evaluation of the effect of bupropion on ECT. A case group (n = 119), patients treated with concomitant ECT and bupropion, was compared with an age and gender frequency-matched control group (n = 261), treated with only ECT. Electroconvulsive therapy treatment data including seizure length, number of treatments, and concurrent medications were extracted. Longitudinal mixed models examined ECT versus ECT + bupropion group differences over the course of treatments measured by seizure duration (electroencephalogram [EEG] and motor). Multivariable models examined the total number of treatments and first and last seizure duration. All models considered group differences with ECT treatment measures adjusted for age, gender, benzodiazepine treatment, lead placement, and setting. Electroconvulsive therapy treatment with bupropion led to shorter motor seizure duration (0.047) and EEG seizure duration (P = 0.001). The number of ECT treatments (7.3 vs 7.0 treatments; P = 0.23), respectively, or the probability of a prolonged seizure (P = 0.15) was not significantly different. Benzodiazepine use was significantly more common in control subjects (P = 0.01). This is a retrospective analysis limited in part by unavailable variables (seizure threshold, nature of EEG and motor seizure monitoring, type of ECT device, dosing and formulation of bupropion, and duration of the current depressive illness). This study revealed a significantly shorter duration in seizure length with ECT + concomitant bupropion, but not in the number of required treatments in those treated compared with ECT without bupropion. There remains a critical need to reevaluate the efficacy of concomitant use of psychotropic medications + ECT.

Period prevalence of concomitant psychotropic medication usage among children and adolescents with attention-deficit/hyperactivity disorder during 2009.

Stimulants are recommended as a first-line treatment for attention- deficit/hyperactivity disorder (ADHD); however, a subset of the patient population augments their stimulant treatment with other medications. The objective of this study was to estimate the 1 year period prevalence of concomitant psychotropic medication use among children and adolescents with ADHD during 2009. Patients 6-17 years of age with one or more primary ADHD diagnoses between July 1, 2008 and December 31, 2009 and one or more stimulant prescription fills during 2009 were identified from a large United States commercial claims database. Concomitant psychotropic medication use, defined as 30 days of continuous medication supply overlap between the augmenting agent and stimulant, was evaluated for 14 distinct psychotropic medication categories (6 with a United States Food and Drug Administration (FDA) approved indication for ADHD, 8 without an indication for ADHD). The 1 year period prevalence of concomitant psychotropic medication use (both overall and within each medication category) was calculated and compared between patients with and without psychiatric or neurologic comorbidities. Children (6-12 years) and adolescents (13-17 years) were evaluated separately. A total of 71,201 children and 49,959 adolescents met the inclusion criteria. The 1 year period prevalence of concomitant psychotropic medication use among children and adolescents was 20.3% and 23.4%, with 5.7% and 6.7% augmenting with two or more medication categories, respectively. The most common concomitant medication categories were selective serotonin reuptake inhibitors (SSRIs) (children: 6.2%; adolescents: 11.4%), atypical antipsychotics (5.8%; 6.8%) and clonidine immediate release (5.4%; 2.9%). Children and adolescents with psychiatric or neurologic comorbidities had higher rates of augmentation than did those without comorbidities (all p<0.001). This epidemiologic study found that the prevalence of concomitant psychotropic medication use in children and adolescents ranged from 12.6% for noncomorbid ADHD to 41.7% for comorbid ADHD, in 2009. Future research is warranted to evaluate the rationale for, and clinical benefit of, concomitant psychotropic medication usage in patients with ADHD.

Flexible dosing with paliperidone ER in the treatment of patients with acutely exacerbated schizophrenia: results from a single-arm, open-label study

Objective:To extend findings from fixed-dose, double-blind, placebo-controlled clinical trials in selected patient populations by using flexibly-dosed oral paliperidone extended-release (ER) in a more naturalistic setting.Methods:Adults hospitalized with an acute exacerbation of schizophrenia were prospectively treated with open-label flexibly-dosed paliperidone ER 3–12 mg/day for 6 weeks.Results:Overall, 294 patients were treated. The primary endpoint, defined as ≥30% improvement in Positive and Negative Syndrome Scale total scores from baseline to endpoint, was achieved by 66.3% of patients. The percentage of patients rated as at least ‘markedly ill’ in Clinical Global Impression of Severity scale decreased from baseline (74.1%) to endpoint (20.0%). Patient functioning, assessed by the Personal and Social Performance scale, improved significantly from 50.0 ± 14.3 at baseline to 63.6 ± 14.9 at endpoint (p < 0.0001). Concomitant benzodiazepines were newly initiated in 191 patients (65.0%), and new concomitant medications other than benzodiazepines were started after baseline for 133 patients (45.2%), most frequently paracetamol, zolpidem, and zopiclone. No unexpected adverse events were identified.Conclusions:These data support findings in more selected patient populations treated with fixed-dose paliperidone ER. Flexibly-dosed paliperidone ER administered in a naturalistic hospital setting to a more representative patient population experiencing an acute episode of schizophrenia, was associated with clinically meaningful treatment response. Strength of conclusions is limited by the open-label design and lack of a comparator group. Furthermore, some of the improvements observed may in part be associated with increased attention provided to patients and concomitant use of psychotropic medications, such as benzodiazepines, during this study.

Concomitant Psychotropic Medication Use During Treatment of Schizophrenia Patients: Longitudinal Results from the CATIE Study

This study is a post hoc analysis of additions of antidepressants, anxiolytics, and sedative/hypnotics in treatment of patients randomized to antipsychotic treatment in the CATIE study, which recruited a chronic, "real world" schizophrenia sample and followed patients for up to eighteen months. We examined baseline predictors of initiation, time until initiation, and duration of treatment with antidepressants, anxiolytics, and sedative/hypnotics in CATIE study participants. Psychotropic medication use by 1,449 CATIE study participants was documented at each study visit. Baseline demographic and clinical predictors of initiation, of time to initiation, and of duration of treatment of Concomitant Psychotropic Medications (CPMs) in each category (antidepressant, anxiolytic, and sedative/hypnotics) were identified through multiple regression analyses. Initiation of new CPMs post baseline by CATIE clinicians was moderately frequent, with 14.6% of patients receiving antidepressants, 13.7% receiving anxiolytics, and 11.2% receiving sedative/hypnotics. Predictors of antidepressant initiation (14.6% of group) were being female or white, and having a prior diagnosis of depression or symptoms of depression at baseline. Patients with higher positive symptom scores and younger patients were started on antidepressants sooner. Duration of antidepressant treatment was longer in patients with less education and in those with a history of alcohol abuse/dependence. Predictors of anxiolytic initiation (13.7% of group) were not being of African-American race, being separated/divorced, younger age, higher body mass index, and akathisia. Time to anxiolytic initiation was shorter in patients who were separated or divorced and in patients with better neurocognitive functioning. Duration of anxiolytic treatment was shorter for African Americans and longer in patients with better instrumental role functioning. Predictors of sedative/hypnotic use (11.2% of group) were depressive symptoms and prior diagnosis of an anxiety disorder. Time to initiation of sedative/hypnotics was longer for those with depressive symptoms and shorter for those with a history of alcohol abuse/dependence. Sedative/hypnotics, anxiolytics, and antidepressants were commonly used CPMs in schizophrenia during the CATIE trial, where patients were being seen frequently and antipsychotic treatment was optimized. Randomized, controlled clinical trials examining adjunctive use of antidepressants, anxiolytics and sedative/hypnotics to target symptoms of anxiety, depression, and insomnia in patients with schizophrenia are needed to adequately address the efficacy of these interventions.

The Dynamic Psychiatrist: Internist of the Mind

Abstract As dynamic psychiatrists our main clinical focus is to understand patients' symptoms and character structure through the exploration of their past and present experiences. This occurs within the context of their biopsychosocial environment. We work with tools such as free association, interpretation of transference distortions, and resistance to retrieving unconscious experiences. Yet, in the past 30 years our understanding of the role of the therapeutic relationship and other curative factors has changed. Through personal experience, the author explores these matters, considering more active participation in the treatment sessions, flexible frequency of meetings, modified use of therapeutic techniques, variable length of treatments, and concomitant use of psychotropic medication. More than in the past, the practice of the dynamic psychiatrist is modeled on that of the internist-a physician who integrates into his/her clinical work the current understanding of the function of the brain. The dynamic psychiatrist actively participates in the resolution of a given symptom picture and fosters improvement of the patient's personality structure to maximize functioning.

The Course of Psychiatric and Behavioral Symptoms and the Use of Psychotropic Medication in Patients With Dementia in Norwegian Nursing Homes—A 12-Month Follow-Up Study

This study investigates the natural course of neuropsychiatric symptoms and the concomitant use of psychotropic medication among a large and representative sample of nursing-home patients with dementia. The authors performed two data collections with structured interviews in a 1-year follow-up cohort-study including 26 nursing homes in four counties in two Norwegian health regions. The main outcome measures were baseline and follow-up frequencies, persistence and incidence of neuropsychiatric symptoms, and the change in neuropsychiatric symptoms with regard to the use of psychotropic medication. At baseline a representative sample of 1,163 nursing-home patients participated, of whom 933 had dementia. At the follow-up interview after 1 year, 633 of the patients who had dementia at baseline were assessed. Clinically significant neuropsychiatric symptoms were exhibited by 84% of patients with dementia at the baseline or follow-up interviews. Overall persistence of symptoms was 79%. Individual symptoms, such as depression (58%), delusions (56%), and agitation/aggression (47%) had resolved at a high rate. Persistent use of antidepressants (79%), antipsychotics (75%), or any psychotropic drug (88%) was common. There were no differences between users and nonusers of antipsychotics or antidepressants regarding the course of psychosis, agitation, or depression over the 1-year observation period. Neuropsychiatric symptoms are ubiquitous in nursing home patients with dementia. Overall the symptoms are chronically present, whereas individual symptoms often show an intermittent course. Long-term use of psychotropic medication is extensive. Uncertainty about treatment effects emphasizes the need for further treatment trials.

Transdermal estrogen patches for aggressive behavior in male patients with dementia: a randomized, controlled trial

To investigate the efficacy and tolerability of transdermal estrogen patches for the adjunctive treatment of aggressive behavior in male patients with advanced dementia. The study was designed as an 8-week, randomized, controlled trial in acute aged psychiatry inpatient units and specialized nursing homes in Melbourne, Australia, between 1998 and 1999. The participants were 27 men with established dementia, identified as displaying aggressive behavior not responding to treatment for at least 2 weeks prior to referral. The instruments used to measure aggressive behavior were the Rating Scale for Aggressive Behavior in the Elderly (RAGE), the Cornell Scale for Depression in Dementia (CSDD) and the Mini-mental State Examination (MMSE). Physical examination was performed and biochemistry and serum hormone concentrations were measured at baseline and at 8 weeks. Concomitant psychotropic medication use was recorded and analyzed. There was no significant difference in aggressive behavior at 8 weeks, but significant "rebound" in aggressive behavior (change in scores between week 8 and week 10, p < 0.009) and benzodiazepine use in the estrogen group (p < 0.03), following removal of the patches. Only behavioral items of the CSDD improved in the experimental group (p = 0.031). The use of patches was associated with a significant rise in serum estrogen (p < 0.001) but not with a significant decrease in serum testosterone (p = 0.077). There were no adverse effects associated with their use. The use of transdermal estrogen yielding up to 100 microg per day was not associated with discernable improvement in aggressive behavior in men with advanced dementia. Small subject numbers, multiple variables and a lack of statistical power impair interpretation of these results. However, the tolerability and apparent rebound effect on removal of patches indicate the need for larger studies in this area.

Patterns of Concomitant Psychotropic Medication Use During a 2-Year Study Comparing Clozapine and Olanzapine for the Prevention of Suicidal Behavior

Results from the International Suicide Prevention Trial (InterSePT) indicate that clozapine is more effective than olanzapine in reducing suicidal behavior in schizophrenic and schizoaffective patients. However, because InterSePT allowed the uncontrolled use of concomitant psychotropic medications (CPMs), it is possible that the antisuicidal effect of clozapine may have been influenced by greater use of such agents. This article describes the use patterns of CPMs during InterSePT and examines whether CPM use may have affected study outcome. In this study, 479 patients received clozapine and 477 patients received olanzapine. Concomitant psychotropic medications were grouped into 4 classes: antipsychotics, antidepressants, sedatives/anxiolytics, and mood stabilizers. The doses of each CPM were converted into dosage equivalents of standard reference drugs. An analysis of covariance was performed to compare mean daily doses of CPMs between the 2 groups over the 2-year treatment period. The duration of treatment for each patient was 2 years, with the first patient entering the study in March 1998 and the last patient completing treatment in February 2001. Approximately 90% of patients in both treatment groups received at least 1 CPM. The mean +/- SD number of CPMs per patient was 3.8 +/- 2.90 in the clozapine group and 4.2 +/- 3.16 in the olanzapine group. For each CPM class, the mean daily dose was statistically significantly lower in the clozapine group (antipsychotics, p <.001; antidepressants, p <.01; sedatives/anxiolytics, p <.001; mood stabilizers, p <.05). Analyses of CPM use by study intervals, suicide attempters versus nonattempters, study completers versus noncompleters, and geographic region resulted in similar findings. The results support the conclusion that the effects of clozapine in reducing the risk of suicidal behavior derive from its intrinsic pharmacology and not from the influence of concomitant psychotropic medications.

Discharge and Readmission Rates with Atypical Antipsychotic Agents

Objective Newer atypical antipsychotic agents offer many advantages over conventional antipsychotic agents, including a decreased adverse effect burden, improved compliance, and superior efficacy. However, the atypical antipsychotic agents are considerably more expensive than conventional agents. We conducted a retrospective review to determine whether one atypical antipsychotic agent provided a significant advantage with regard to discharge or readmission rates in the inpatient population of a state psychiatric facility. In addition, we assessed whether one atypical antipsychotic agent was associated with an increased use of concomitant medications. Methods All records for patients started on clozapine, risperidone, or olanzapine at any time during 1997 were reviewed. Each inpatient started on a study medication had his or her records reviewed for 1 full year after the medication start date. Each record was assessed for discharge status and concomitant psychotropic medication use. For those patients discharged, the readmission status was followed. Results Patients treated with clozapine had the highest discharge rate (54%) and lowest readmission rate (16%) compared with risperidone (39% and 26%, respectively; p = 0.75) and olanzapine (39% and 26%, respectively; p = 0.88). Conclusions The highest discharge rate was seen in patients receiving clozapine. Treatment with risperidone was associated with the highest readmission rate and concomitant psychotropic use. Although the results are limited because of a small sample size, these findings provide some insight into the long-term efficacy of atypical antipsychotics and some potential differences in recidivism rates. These findings also suggest the need and importance of further study in this area.

National trends in the use of outpatient psychotherapy.

This article reports recent trends in the use of outpatient psychotherapy in the United States. Data from the household sections of the 1987 National Medical Expenditure Survey and the 1997 Medical Expenditure Panel Survey were analyzed. Trends in the rate of psychotherapy use from these nationally representative samples are presented by age, sex, race/ethnicity, marital status, education, employment status, and income. Psychotherapy users are compared over time by provider specialty, concomitant psychotropic medication use, number of annual visits, and costs. In addition, trends in payment source and primary diagnosis are assessed for psychotherapy visits. Between 1987 and 1997, there was no statistically significant change in the overall rate of psychotherapy use (3.2 per 100 persons in 1987 and 3.6 per 100 in 1997). However, significant increases were observed in psychotherapy use by adults aged 55-64 years and by unemployed adults. Among psychotherapy patients, there was a marked increase in the use of antidepressant medications (14.4% to 48.6%), mood stabilizers (5.3% to 14.5%), stimulants (1.9% to 6.4%), and psychotherapy provided by physicians (48.1% to 64.7%). A smaller proportion of patients made more than 20 psychotherapy visits in 1997 (10.3%) than in 1987 (15.7%). Over this period, psychotherapy visits for mood disorders became more common. In 1997, 9.7 million Americans spent $5.7 billion on outpatient psychotherapy. From 1987 to 1997, access to psychotherapy in the United States remained constant overall but was characterized by increased use by some socioeconomically disadvantaged groups. However, the number of visits per user markedly decreased during this period. Psychotherapy was increasingly administered by physicians and provided in conjunction with psychotropic medications. These changes occurred during a period of expansion in the number of available psychotropic medications and growth in managed behavioral health care.

Fluoxetine and concomitant centrally acting medication use during clinical trials of depression: The absence of an effect related to agitation and suicidal behavior

Concomitant use of psychoactive medications is a common practice in most clinical trials of antidepressant medications. However, the relative therapeutic impact of such use on trial results has not been the subject of much attention. We conducted a meta-analysis to determine whether concomitant use of psychoactive medications confounded the efficacy or safety results of a series of fluoxetine trials. Data were evaluated from 25 randomized, double-blind clinical trials comparing fluoxetine with placebo or a tricyclic antidepressant (TCA) in 4,016 patients with major depression. We compared incidence rates of concomitant use of anxiolytics, sedatives, and antipsychotics between treatments. In addition, we compared the change in total score for the 21-Item Hamilton Depression Rating Scale (HAMD21): incidence rates of any worsening, emergence, or improvement in psychomotor agitation; and incidence of suicidal acts and any worsening, emergence, or improvement in suicidal ideation between treatment groups among patients taking/not taking a sedative. Anxiolytic and antipsychotic drug use was uncommon (8.3% and 0.9% overall use, respectively) and did not substantially increase over time. Sedative drugs were used most often (29.6% overall), but only 29.8% of the fluoxetine-treated patients took one or more doses. Regarding efficacy, fluoxetine was superior to placebo in decreasing HAMD21 total scores among patients taking/not taking sedatives. Effects on safety were assessed by examining agitation and suicidal ideation. Use of sedatives did not affect the change in the HAMD agitation score; scores were similar in patients receiving fluoxetine, placebo, and TCAs. In all treatment groups, anxiolytic use tended to increase as the HAMD anxiety score increased. Fluoxetine was superior to placebo in treating suicidal ideation, and the concomitant use of sedatives did not influence this effect. Overall, concomitant use of psychotropic medications in the fluoxetine depression clinical trials was uncommon. Our meta-analysis demonstrated that the clinical efficacy and safety of fluoxetine were not confounded by the concomitant use of medications. Depression and Anxiety 6:31–39, 1997. © 1997 Wiley-Liss, Inc.

Fluoxetine and concomitant centrally acting medication use during clinical trials of depression: The absence of an effect related to agitation and suicidal behavior

Concomitant use of psychoactive medications is a common practice in most clinical trials of antidepressant medications. However, the relative therapeutic impact of such use on trial results has not been the subject of much attention. We conducted a meta-analysis to determine whether concomitant use of psychoactive medications confounded the efficacy or safety results of a series of fluoxetine trials. Data were evaluated from 25 randomized, double-blind clinical trials comparing fluoxetine with placebo or a tricyclic antidepressant (TCA) in 4,016 patients with major depression. We compared incidence rates of concomitant use of anxiolytics, sedatives, and antipsychotics between treatments. In addition, we compared the change in total score for the 21-Item Hamilton Depression Rating Scale (HAMD21): incidence rates of any worsening, emergence, or improvement in psychomotor agitation; and incidence of suicidal acts and any worsening, emergence, or improvement in suicidal ideation between treatment groups among patients taking/not taking a sedative. Anxiolytic and antipsychotic drug use was uncommon (8.3% and 0.9% overall use, respectively) and did not substantially increase over time. Sedative drugs were used most often (29.6% overall), but only 29.8% of the fluoxetine-treated patients took one or more doses. Regarding efficacy, fluoxetine was superior to placebo in decreasing HAMD21 total scores among patients taking/not taking sedatives. Effects on safety were assessed by examining agitation and suicidal ideation. Use of sedatives did not affect the change in the HAMD agitation score; scores were similar in patients receiving fluoxetine, placebo, and TCAs. In all treatment groups, anxiolytic use tended to increase as the HAMD anxiety score increased. Fluoxetine was superior to placebo in treating suicidal ideation, and the concomitant use of sedatives did not influence this effect. Overall, concomitant use of psychotropic medications in the fluoxetine depression clinical trials was uncommon. Our meta-analysis demonstrated that the clinical efficacy and safety of fluoxetine were not confounded by the concomitant use of medications.