Guidelines for the rational use of benzodiazepines. When and what to use

Potentially inappropriate use of benzodiazepines and z-drugs in the older population-analysis of associations between long-term use and patient-related factors

Introduction

The long-term use of benzodiazepines (BZD) and z-drugs in older populations is associated with a variety of sociodemographic and health-related factors. Recent studies reported that long-term BZD and z-drugs use is associated with increased age, female sex, and severe negative psychological (e.g., depression) and somatic (e.g., chronic disease) factors. The current study explores the sociodemographic and health-related factors associated with long-term BZD and z-drugs use in the elderly.

Methods

We conducted a cross-sectional survey among randomly selected patients of one health insurance plan (“AOK North-West”) with BZD and z-drugs prescriptions in the past 12 months. The sample was stratified by appropriate German prescription guidelines (yes vs. no) and age (50–65 vs. >65 years). To examine the association of selected sociodemographic and psychological variables (e.g., sex, employment status, quality of life, depression) with long-term use, a binary logistic regression analysis was conducted.

Results

In total, data from 340 patients were analyzed. The mean age was 72.1 (SD = 14.5) years, and the most commonly used substances were zopiclon (38.1%), oxazepam (18.1%), and lorazepam (13.8%). The mean defined daily dose (DDD) was 0.73 (SD = 0.47). Insomnia was the main reason for prescribing BZD and z-drugs. The long-term use of BZD and z-drugs was significantly associated with unemployment (OR = 2.9, 95% CI [1.2–7.1]) and generally problematic medication use (OR = 0.5, 95% CI [0.2–1.0]).

Discussion

Unemployment status and problematic medication use had a significant association with the patient-reported, long-term use of BZD and z-drugs. Divergent prescription patterns might suggest problematic patterns of BZD and z-drugs use. The causal connection between the identified factors and problematic BZD and z-drugs prescription is not discussed in this paper. Nevertheless, employment status and possible evidence of general problematic drug use may be a warning signal to the prescribers of BZD and z-drugs.

Sleep disorders in the elderly: a growing challenge

In contrast to newborns, who spend 16-20 h in sleep each day, adults need only about sleep daily. However, many elderly may struggle to obtain those 8 h in one block. In addition to changes in sleep duration, sleep patterns change as age progresses. Like the physical changes that occur during old age, an alteration in sleep pattern is also a part of the normal ageing process. As people age, they tend to have a harder time falling asleep and more trouble staying asleep. Older people spend more time in the lighter stages of sleep than in deep sleep. As the circadian mechanism in older people becomes less efficient, their sleep schedule is shifted forward. Even when they manage to obtain 7 or 8 h sleep, they wake up early, as they have gone to sleep quite early. The prevalence of sleep disorders is higher among older adults. Loud snoring, which is more common in the elderly, can be a symptom of obstructive sleep apnoea, which puts a person at risk for cardiovascular diseases, headaches, memory loss, and depression. Restless legs syndrome and periodic limb movement disorder that disrupt sleep are more prevalent in older persons. Other common medical problems of old age such as hypertension diabetes mellitus, renal failure, respiratory diseases such as asthma, immune disorders, gastroesophageal reflux disease, physical disability, dementia, pain, depression, and anxiety are all associated with sleep disturbances.

Effect of Sedative-Hypnotic Medicines on Mortality in Peritoneal Dialysis Patients with Sleep Disorders: A Retrospective Cohort Study

BACKGROUND

Sedative-hypnotic medication is widely used among continuous ambulatory peritoneal dialysis (CAPD) patients with sleep disorders; however, its effect on mortality has rarely been investigated.

METHODS

Logistic regression was employed to identify factors associated with sedative-hypnotic medication, whose effect on mortality was evaluated by Cox proportional hazards models.

RESULTS

A total of 146 CAPD patients with sleep disorders were recruited, of which 46 patients (31.5%) used either benzodiazepines or zolpidem. Sedative-hypnotic medication was more frequently used by older patients and those with longer duration of CAPD therapy and there was no significant association between sedative-hypnotic medicines and all-cause mortality after adjusting for age, gender, diabetes, cardiovascular disease, and duration of CAPD.

CONCLUSION

Sedative-hypnotic medication was more often used by older patients and patients with a longer duration of CAPD. There was no association between these agents and all-cause mortality in CAPD patients with sleep disorders.

Patterns and correlates of benzodiazepine use in nurses: A nationwide, population-based study

In the present study, we examined patterns of benzodiazepine (BZD) use in nurses, and compared the characteristics of frequent users with those of infrequent users. Data on all nurses enrolled in the study were derived from the reimbursement claim records in Taiwan's National Health Insurance Research Database for the period 2004-2008. The case group comprised 33 588 nurses with BZD use, and the control group was exactly matched to each case according to age and sex. The patterns of occasional, frequent, and daily BZD use demonstrated an increasing trend from 2004 to 2008. This trend was observed for most of the BZD with a short or intermediate half-life. Older nurses (>45 years) and those with greater experience (≥5 years) were more likely to use BZD frequently. Moreover, the risk of frequent BZD use increased significantly when nurses exhibited comorbid depression (adjusted odds ratio (aOR): 2.58), anxiety (aOR: 1.78), or sleep disorders (aOR: 2.29) compared with infrequent BZD use. The results indicated that nurses with BZD use had comorbidities of anxiety, depression, and sleep disorders. The increasing trend of patterns of BZD use and its association with sleep disorders, depression, and anxiety can be used as references for stress and sleep management in nurses.

Can clinical practice indicator relating to long-acting benzodiazepine use in the elderly be easily generated in a hospital setting?

BACKGROUND

To improve the appropriate use of long-acting benzodiazepine (la.bzd) prescriptions in the elderly, the Haute Autorité de Santé (HAS) has developed clinical practice indicators (CPI). The alert indicator (AI) evaluates the prevalence of la.bzd prescription among older people. The mastering indicator (MI) corresponds to the prevalence of elderly with a justified, i.e., appropriate, la.bzd prescription among all the elderly with la.bzd prescriptions.

OBJECTIVE

The objective of this study was to test the feasibility of routine generation of CPI regarding la.bzd prescriptions among the elderly in the hospital setting.

DESIGN

This was a retrospective study.

SETTING

The study was conducted in two university hospitals located in Paris.

SUBJECT

Eligible cases were patients aged 65 years and older who were hospitalized in acute care units from January to June 2014.

METHOD

The AI calculation was based on information extracted from medical databases from these hospitals. The appropriateness of la.bzd prescription was assessed by a physician and a pharmacist and was based on review of computerized patient records and prescriptions, using an ad hoc algorithm. The MI was then calculated. Variation in the level of indicators was explored according to the characteristics of patients and of their hospitalization using chi² test. Factors associated with a potentially inappropriate prescription (PIP) of la.bzd were studied using univariate and multivariate logistic regression.

RESULT

Among the 4167 patients included in the study, 362 had la.bzd prescriptions, i.e., the AI was 9%. Prescriptions were found to be appropriate for 83 patients, i.e., the MI was 23% and PIP was 77%. The MI varied between 13 and 31% according to characteristics of patients and of hospitalization. In multivariate analysis, factors associated with PIP were age, number of comorbidities, type of care unit, and concurrent prescription of a neuroleptic or hypnotic.

CONCLUSION

Generation of the AI was routinely possible but only for acute care units with computerized prescriptions, corresponding to 78% of patients. Production of the MI has required medical record review for all patients with a la.bzd prescription and cannot be automated. However, difficulties in generating the MI have identified areas for significant improvement. Moreover, strategies to improve the care of older people with a la.bzd prescription could be targeted using characteristics of patients and of hospitalization associated with PIP. The future deployment of a single electronic medical record in all care departments would make it easier to mine the data and make possible automated production of CPI.

Benzodiazepine Use and Cognitive Decline in Elderly With Normal Cognition

Benzodiazepine (BZD) use may be associated with dementia. However, differing opinions exist regarding the effect of BZDs on long-term changes in cognition. We evaluated the association between BZD use and cognitive decline in the elderly with normal cognition from the National Alzheimer's Disease Coordinating Center's Uniform Data Set. The study exposure, BZD use, was classified 2 ways: any-use [reported BZD use at a minimum of 1 Alzheimer's disease center (ADC) visit] and always-use (reported BZD use at all ADC visits). The reference group included participants without any declared BZD use at any Alzheimer's Disease Center (ADC) visit. The main outcome measures were Clinical Dementia Rating Sum of Boxes score and Mini-Mental State Examination score. We observed a decline in cognitive status over time in the 2 comparison groups. All participants who reported taking BZDs had poorer cognitive performance at all visits than nonusers. However, cognitive decline was statistically similar among all participants. We found no evidence of an association between BZD use and cognitive decline. The poor cognitive performance in BZD users may be due to prodromal symptoms caused by preclinical dementia processes.

The use of an electronic clinical rule to discontinue chronically used benzodiazepines and related Z drugs

PURPOSE

The chronic use of benzodiazepines and benzodiazepine-related drugs (BZ/Z) in older people is common and not without risks. The objective of this study was to evaluate whether the implementation of a clinical rule promotes the discontinuation of chronically used BZ/Z for insomnia.

METHODS

A clinical rule, generating an alert in case of chronic BZ/Z use, was created and applied to the nursing home (NH) setting. The clinical rule was a one-off intervention, and alerts did not occur over time. Reports of the generated alerts were digitally sent to NH physicians with the advice to phase out and eventually stop the BZ/Z. In cases where the advice was adopted, a follow-up period of 4 months on the use of BZ/Z was taken into account in order to determine whether the clinical rule alert led to a successful discontinuation of BZ/Z.

RESULTS

In all, 808 NH patients were screened. In 161 (19.1%) of the patients, BZ/Z use resulted in a clinical rule alert. From these, the advice to phase out and stop the BZ/Z was adopted for 27 patients (16.8%). Reasons for not following the advice consisted of an unsuccessful attempt in the past (38 patients), patients family and/or patient resistance (37 patients), the non-continuous use of BZ/Z (32 patients) and indication still present (27 patients). Of the 12 NH physicians, seven adopted the advice.

CONCLUSIONS

The success rate of a clinical rule for discontinuation of chronically used BZ/Z for insomnia was low, as reported in the present study. Actions should be taken to help caregivers, patients and family members understand the importance of limiting BZ/Z use to achieve higher discontinuation rates.

Modulating Oxidative Stress Relieves Stress-Induced Behavioral and Cognitive Impairments in Rats

Background

Persistent psychological stress often leads to anxiety disorders and depression. Benzodiazepines and selective serotonin reuptake inhibitors are popular treatment options but have limited efficacy, supporting the need for alternative treatment. Based on our recent preclinical work suggesting a causal link between neurobehavioral deficits and elevated oxidative stress, we hypothesized that interventions that mitigate oxidative stress can attenuate/overcome neurobehavioral deficits.

Methods

Here, we employed the rat social defeat model of psychological stress to determine whether increasing antioxidant levels using grape powder would prevent and/or reverse social defeat-induced behavioral and cognitive deficits. Furthermore, a hippocampal-derived HT22 cell culture model of oxidative stress was employed to identify the individual beneficial constituent(s) of grape powder and the underlying mechanism(s) of action.

Results

Grape powder treatment prevented and reversed social defeat-induced behavioral and cognitive deficits and also decreased social defeat-induced increase in plasma corticosterone and 8-isoprostane (systemic and oxidative stress markers, respectively). And grape powder treatment replenished social defeat-induced depleted pool of key antioxidant enzymes glyoxalase-1, glutathione reducatse-1, and superoxide dismutase. Grape powder constituents, quercetin and resveratrol, were most effective in preventing oxidative stress-induced decreased cellular antioxidant capacity. Grape powder protected oxidative stress-induced cell death by preventing calcium influx, mitochondrial dysfunction, and release of cytochrome c.

Conclusions

Grape powder treatment by increasing antioxidant pool and preventing cell damage and death prevented and reversed social defeat-induced behavioral and cognitive deficits in rats. Quercetin and resveratrol are the major contributors towards beneficial effects of grape powder.

Effect of a medicinal plant (Passiflora incarnata L) on sleep

INTRODUCTION

Extracts of the plant Passiflora incarnata L. (Passifloraceae) were administered intraperitoneally in order to test its effects on sleep.

METHOD

Experiments were carried out on chronically implanted male adult wistar rats to obtain cerebral (EEG), ocular (EOG) and muscular (EMG) activities throughout their states of vigilance. Polygraphic recordings were taken during 9 continuous hours before and after the extract administration (500 mg/kg).

RESULTS

Passiflora incarnata induced a significant increment in the total sleep time (p<0.05). This increment was due to an increase in the time spent by animals in slow wave sleep (SWS). Concomitantly, a significant decrement in wakefulness (W) was observed (p<0.05). In contrast, time spent in rapid eye movement (REM) sleep showed a decreasing tendency, since both its frequency and mean duration were reduced.

CONCLUSIONS

The extracts obtained from Passiflora incarnata can be considered as appropriated sleep inducers.

Executive dysfunction in patients with chronic primary insomnia treated with clonazepam

Clonazepam (CNZ) is a drug used for insomnia treatment. Our objective was to search CNZ effects on executive functions (EF) in patients with chronic primary insomnia (CPI)-CNZ treated. Ninety participants were studied divided into three groups: a group of patients with CPI only (n = 30), a group of patients with CPI-CNZ treated (n = 30) and a healthy control drug-free subjects group (n = 30). EF were examined by means of E-Prime and by the Tower of London tests. Data of the EF were compared between groups, and correlation calculations between EF and CNZ dose were performed. Patients with CPI-CNZ treated showed more deleterious effects on EF (attention, inhibition, working memory, planning, cognitive flexibility, and monitoring) than patients with CPI only. Attention and cognitive flexibility correlated with CNZ dose. In conclusion, CNZ treatment was associated with deficits in some EF in patients with CPI-CNZ treated compared to CPI only and controls. We found a dose dependency between CNZ and some EF deficits.

What Does the Community Say: Key Informant Perceptions of Rural Prescription Drug Use

This article presents data from four groups of rural Key Informants—Community leaders, educators, health care providers and justice/law enforcement officials—to understand the nonmedical use and misuse of prescription drugs. Seventy key informants were purposively selected from two counties in Appalachian Kentucky. Key informants indicated that the nonmedical use of prescription drugs is complex and has historical roots. Two pathways, or entry points, into the nonmedical use and misuse of prescription drugs were identified: physical pain and recreational use. Data show trends with regard to drug use patterns, drug use education, involvement with the criminal justice system and the role of economics in the prescription drug use problem. Key Informants underscored a common theme that the rural prescription drug problem was fueled by a cultural acceptance of drug misuse. Recommendations are presented for services and research.

Assessment of the Abuse Potential of the Orexin Receptor Antagonist, Suvorexant, Compared With Zolpidem in a Randomized Crossover Study

Suvorexant is a dual orexin receptor antagonist approved in the United States and Japan for the treatment of insomnia at a maximum dose of 20 mg. This randomized double-blind crossover study evaluated the abuse potential of suvorexant in 36 healthy recreational polydrug users with a history of sedative and psychedelic drug use. Single doses of suvorexant (40, 80, and 150 mg: 2-7.5 × maximum dose), zolpidem (15 and 30 mg: 1.5-3 × maximum dose), and placebo were administered, with a 10-day washout between treatments. Subjective and objective measures, including visual analog scales (VASs), Addiction Research Center Inventory, and cognitive/psychomotor tests, were evaluated for 24-hour postdose. Suvorexant had significantly greater peak effects on "drug liking" VAS (primary endpoint) than placebo. Although effects of suvorexant on abuse potential measures were generally similar to zolpidem, they remained constant across doses, whereas zolpidem often had greater effects at higher doses. Suvorexant (all doses) had significantly fewer effects than zolpidem 30 mg on secondary measures, such as "high" VAS, Bowdle VAS, and Addiction Research Center Inventory morphine-benzedrine group. The overall incidence of abuse-related adverse events, such as euphoric mood and hallucination, was numerically lower with suvorexant than zolpidem. In agreement with its classification as a schedule IV drug, suvorexant demonstrated abuse potential, compared with placebo. The abuse potential was similar to zolpidem using certain measures, but with a reduced incidence of abuse-related adverse events. Although this suggests that the overall abuse liability of suvorexant may be lower than zolpidem, the actual abuse rates will be assessed with the postmarketing experience.

Hypnotic Dependent Insomnia in an Older Adult with Addiction-Prone Personality

Despite the proliferation of safe, effective, and cost-effective behavioral treatments of insomnia, hypnotic medication remains the most common treatment of insomnia by primary care providers. Such treatment in many cases leads to a pattern of tolerance and dependence on sleep medication, as well as difficulty discontinuing treatment and subsequent rebound insomnia. Recent research suggests promise for behavioral interventions in the treatment of hypnotic dependent insomnia. In this article, the authors report on the treatment of a particularly challenging case: an older adult with a history of addictive behavior now dependent on hypnotics. The authors demonstrate the best possible outcome: elimination of sleep medication combined with sleep improvement.

Taking Policy Action to Reduce Benzodiazepine Use and Promote Self-Care Among Seniors

This article reviews current knowledge on the risks and benefits of benzodiazepine use for seniors and addresses potential policies that could be made to reduce use and support sentors' mental health. Although seniors are only 12% to 15% of the population, they consume between 35% and 52% of all benzodiazepines prescribed in Canada and the United States. Despite significant long-term use among seniors, relatively few studies demonstrate the efficacy of more than short-term use for anxiety and insomnia. There is significant data to suggest that use is associated with increased potential for injury, cognitive and memory deficits, and a dependency syndrome. This article argues that the current controversy rests not so much in the scientific data but in the willingness of clinicians to interpret and act on that information. As internationally developed guidelines for practice suggest that benzodiazepine treatment for anxiety and insomnia may not be without risks, other first-line treatments should be developed.

Benzodiazepine prescription for patients in treatment for drug use disorders: a nationwide cohort study in Denmark, 2000-2010

BACKGROUND

Benzodiazepines are frequently prescribed to patients with drug use disorders. However, it has previously been difficult to distinguish whether this frequent prescribing was due to underlying psychiatric disorders or inappropriate prescribing. In a nationwide cohort study, we investigated the prescribing of benzodiazepines to patients with drug use disorders in connection with treatment admission.

METHODS

Benzodiazepine prescriptions to patients (N = 33203) aged 18 to 67 years admitting for outpatient treatment for drug use disorders in Denmark, 2000 to 2010, were studied by using linked data from nationwide health registries. Factors associated with increasing amounts of benzodiazepine use within the first year after admission were assessed by multinomial logistic regression. Proportions of very long-term benzodiazepine prescription were calculated.

RESULTS

During the first year after admission to treatment, 26.2 % of patients were prescribed benzodiazepines. Of these, 35.5 % were prescribed benzodiazepines at dose levels that might indicate inappropriate use (>365 Defined Daily Dose per year), and 34.6 % were prescribed more than one type of benzodiazepines. Diazepam was the most commonly prescribed type. Among patients with opioid use, 43.2 % were prescribed benzodiazepines which were three times higher than for patients with cannabis (12.2 %) or central stimulating drugs (13.8 %) as their primary drug use. Admitting to treatment for a drug use disorder did not increase the specialized psychiatric treatment coverage of this patient group, disregarding use of prescribed benzodiazepines. 29.5 % were new users of prescribed benzodiazepines, and of these, 27.5 % continued into very long-term use (≥4 years after admission) during the study period.

CONCLUSIONS

Benzodiazepines were commonly prescribed to patients admitting to treatment for drug use disorders, and included prescription of multiple and non-optimal types, high doses, and very long-term prescriptions. These findings point towards inappropriate prescribing of benzodiazepines in many cases more than treatment for psychiatric disorders.

Benzodiazepines: Sedation and Agitation

Dental anxiety is common and frequently poses a barrier to necessary dental treatment. The increasing availability of conscious sedation in dental practice has made treatment much more accessible for anxious patients. At present, benzodiazepines are the most commonly used drugs in sedation practice and provide a pleasant experience for most, but not all, patients. An understanding of the mechanism of action of benzodiazepines should inform our practice and deepen our understanding of why and how sedation may fail. CPD/CLINICAL RELEVANCE: As an increasing number of dentists provide sedation for their patients an update on benzodiazepines is timely.

High-Dose Benzodiazepine Dependence: A Qualitative Study of Patients' Perceptions on Initiation, Reasons for Use, and Obtainment

Background

High-dose benzodiazepine (BZD) dependence is associated with a wide variety of negative health consequences. Affected individuals are reported to suffer from severe mental disorders and are often unable to achieve long-term abstinence via recommended discontinuation strategies. Although it is increasingly understood that treatment interventions should take subjective experiences and beliefs into account, the perceptions of this group of individuals remain under-investigated.

Methods

We conducted an exploratory qualitative study with 41 adult subjects meeting criteria for (high-dose) BZD-dependence, as defined by ICD-10. One-on-one in-depth interviews allowed for an exploration of this group’s views on the reasons behind their initial and then continued use of BZDs, as well as their procurement strategies. Mayring’s qualitative content analysis was used to evaluate our data.

Results

In this sample, all participants had developed explanatory models for why they began using BZDs. We identified a multitude of reasons that we grouped into four broad categories, as explaining continued BZD use: (1) to cope with symptoms of psychological distress or mental disorder other than substance use, (2) to manage symptoms of physical or psychological discomfort associated with somatic disorder, (3) to alleviate symptoms of substance-related disorders, and (4) for recreational purposes, that is, sensation-seeking and other social reasons. Subjects often considered BZDs less dangerous than other substances and associated their use more often with harm reduction than as recreational. Specific obtainment strategies varied widely: the majority of participants oscillated between legal and illegal methods, often relying on the black market when faced with treatment termination.

Conclusions

Irrespective of comorbidity, participants expressed a clear preference for medically related explanatory models for their BZD use. We therefore suggest that clinicians consider patients’ motives for long-term, high-dose BZD use when formulating treatment plans for this patient group, especially since it is known that individuals are more compliant with approaches they perceive to be manageable, tolerable, and effective.

Pediatric Sleep Pharmacology: A Primer

"What will you give my child to help him sleep?" is a common question parents ask and some health care providers abhor hearing. Entire families may suffer when one member does not sleep well. Poor sleep may complicate the management of other comorbid conditions. Health care providers may have received only limited education on sleep disorders and are frequently forced to choose between treatment options that are poorly studied in children. Fortunately, when addressed correctly, many children with chronic sleep disorders may improve their sleep and daytime behavior in a relatively short time. This review provides a framework to help understand the causes of poor sleep in children and the potential pharmacologic options.

Melatonin for pre- and postoperative anxiety in adults

BACKGROUND

Anxiety in relation to surgery is a well-known problem. Melatonin offers an atoxic alternative to benzodiazepines in ameliorating this condition in the pre- and postoperative period.

OBJECTIVES

To assess the effect of melatonin on pre- and postoperative anxiety in adults when comparing melatonin with placebo or when comparing melatonin with benzodiazepines.

SEARCH METHODS

The following databases were searched on 19 April 2013: CENTRAL, MEDLINE, EMBASE, CINAHL and Web of Science. For ongoing trials and protocols we searched clinicaltrials.gov, Current Controlled Trials and the World Health Organization (WHO) International Clinical Trials Registry Platform. We reran the search in October 2014. We will deal with any studies of interest when we update the review.

SELECTION CRITERIA

Randomized, placebo-controlled or standard treatment-controlled, or both, studies that evaluated the effect of preoperatively administered melatonin on preoperative or postoperative anxiety. We included adult patients of both genders (15 to 90 years of age) undergoing any kind of surgical procedure in which it was necessary to use general, regional or topical anaesthesia.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two review authors. Data extracted included information about study design, country of origin, number of participants and demographic details, type of surgery, type of anaesthesia, intervention and dosing regimen, preoperative anxiety outcome measures and postoperative anxiety outcome measures.

MAIN RESULTS

This systematic review identified 12 randomized controlled trials (RCTs) including 774 patients that assessed melatonin for treating preoperative anxiety, postoperative anxiety or both. Four of the 12 studies compared melatonin, placebo and midazolam, whereas the remaining eight studies compared melatonin and placebo only.The quality of the evidence for our primary outcome (melatonin versus placebo for preoperative anxiety) was high. More than half of the included studies had a low risk of selection bias and at least 75% of the included studies had a low risk of attrition, performance and detection bias. Most of the included studies had an unclear risk of reporting bias.Eight out the 10 studies that assessed the effect of melatonin on preoperative anxiety using a visual analogue scale (VAS) (ranging from 0 to 100 mm, higher scores indicate greater anxiety) showed a reduction compared to placebo. The reported estimate of effect (relative effect -13.36, 95% confidence interval (CI) -16.13 to -10.58; high quality evidence) was based on a meta-analysis of seven studies. Two studies did not show any difference between melatonin and placebo. Two studies comparing melatonin with midazolam using a VAS found no evidence of a difference in preoperative anxiety between the two groups (relative effect -1.18, 95% CI -2.59 to 0.23; low quality evidence).Eight studies assessed the effect of melatonin on postoperative anxiety. Four of these studies measuring postoperative anxiety 90 minutes postoperatively using a VAS did not find any evidence of a difference between melatonin and placebo (relative effect -3.71, 95% CI -9.26 to 1.84). Conversely, two studies showed a reduction of postoperative anxiety measured six hours after surgery using the State-Trait Anxiety Inventory (STAI) when comparing melatonin with placebo (relative effect -5.31, 95% CI -8.78 to -1.84; moderate quality evidence). Two studies comparing melatonin with midazolam using a VAS did not find any evidence of a difference between the two groups in postoperative anxiety (relative effect -2.02, 95% CI -5.82 to 1.78).

AUTHORS' CONCLUSIONS

When compared to placebo, melatonin given as premedication (tablets or sublingually) can reduce preoperative anxiety in adults (measured 50 to 100 minutes after administration). Melatonin may be equally as effective as standard treatment with midazolam in reducing preoperative anxiety in adults (measured 50 to 100 minutes after administration). The effect of melatonin on postoperative anxiety (measured 90 minutes and 6 hours after surgery) in adults is mixed but suggests an overall attenuation of the effect compared to preoperatively.

The non-benzodiazepine anxiolytic drug etifoxine causes a rapid, receptor-independent stimulation of neurosteroid biosynthesis

Neurosteroids can modulate the activity of the GABAA receptors, and thus affect anxiety-like behaviors. The non-benzodiazepine anxiolytic compound etifoxine has been shown to increase neurosteroid concentrations in brain tissue but the mode of action of etifoxine on neurosteroid formation has not yet been elucidated. In the present study, we have thus investigated the effect and the mechanism of action of etifoxine on neurosteroid biosynthesis using the frog hypothalamus as an experimental model. Exposure of frog hypothalamic explants to graded concentrations of etifoxine produced a dose-dependent increase in the biosynthesis of 17-hydroxypregnenolone, dehydroepiandrosterone, progesterone and tetrahydroprogesterone, associated with a decrease in the production of dihydroprogesterone. Time-course experiments revealed that a 15-min incubation of hypothalamic explants with etifoxine was sufficient to induce a robust increase in neurosteroid synthesis, suggesting that etifoxine activates steroidogenic enzymes at a post-translational level. Etifoxine-evoked neurosteroid biosynthesis was not affected by the central-type benzodiazepine (CBR) receptor antagonist flumazenil, the translocator protein (TSPO) antagonist PK11195 or the GABAA receptor antagonist bicuculline. In addition, the stimulatory effects of etifoxine and the triakontatetraneuropeptide TTN, a TSPO agonist, were additive, indicating that these two compounds act through distinct mechanisms. Etifoxine also induced a rapid stimulation of neurosteroid biosynthesis from frog hypothalamus homogenates, a preparation in which membrane receptor signalling is disrupted. In conclusion, the present study demonstrates that etifoxine stimulates neurosteroid production through a membrane receptor-independent mechanism.

Benzodiazepines alter nucleotide and nucleoside hydrolysis in zebrafish (Danio rerio) brain

Anxiety is characterized by unpleasant bodily sensations, such as pounding heart and intense fear. The therapy involves the administration of benzodiazepine drugs. Purinergic signaling participates in the induction of several behavioral patterns and their actions are inactivated by ectonucleotidases and adenosine deaminase (ADA). Since there is evidence about the involvement of purinergic system in the actions mediated by benzodiazepines, we evaluated the effects in vitro and in vivo of administration of diazepam and midazolam on nucleoside triphosphate diphosphohydrolases, ecto-5'-nucleotidase, and ADA activities in zebrafish brain, followed by the analysis of gene expression pattern of these enzymes and adenosine receptors (A1, A2a1, A2a2, A2b). The in vitro studies demonstrated that diazepam decreased ATP (66 % for 500 µM) and ADP hydrolysis (40-54 % for 10-500 µM, respectively). Midazolam decreased ATP (16-71 % for 10-500 µM, respectively) and ADP (48-73.5 % for 250-500 µM, respectively) hydrolysis as well as the ecto-ADA activity (26-27.5 % for 10-500 µM, respectively). AMP hydrolysis was decreased in animals treated with of 0.5 and 1 mg/L midazolam (32 and 36 %, respectively). Diazepam and midazolam decreased the ecto-ADA activity at 1.25 mg/L and 1 mg/L (31 and 33 %, respectively), but only 0.1 mg/L midazolam induced an increase (40 %) in cytosolic ADA. The gene expression analysis demonstrated changes on ecto-5'-nucleotidase, A1, A2a1, A2a2, and A2b mRNA transcript levels after acute treatment with benzodiazepines. These findings demonstrated that benzodiazepine exposure induces a modulation of extracellular nucleotide and nucleoside metabolism, suggesting the purinergic signaling may be, at least in part, related to benzodiazepine effects.

The impact of chronic benzodiazepine use on cognitive evolution in nursing home residents

OBJECTIVE

Chronic use of benzodiazepines and Z-drugs (BZD/Zs) has been linked to cognitive decline. In this one-year prospective cohort study, we explored the impact of chronic BZD/Z use on cognitive decline compared to nonusers.

METHODS

In cognitively capable BZD/Z users and nonusers in 10 Belgian nursing homes, we investigated cognition with the MiniMentalStateExamination(MMSE) at baseline and one year. A decrease of ≥ 4 points on the MMSE (clinically relevant decrease) was used in multiple logistic regression. We collected baseline demographics, functional, psychometric and social characteristics potentially influencing cognition.

RESULTS

In both the 131 BZD/Z users and 95 nonusers, the cognition decreased significantly over time, but without significant difference between the groups. Clinically relevant decrease was present in 34% BZD/Z users and 27% nonusers (NS). Controlled for age, gender, education and BZD/Z use, the significant risk factors for clinically relevant cognitive decline were depression, hearing and functional impairment. Frequent reading was associated with less MMSE decrease. Our findings could not demonstrate with statistical significance that BZD/Z use was associated with fast cognitive decline. The risk factors for fast decline were depression, hearing and functional impairment, and the absence of a reading attitude. In addition, BZD/Z use and depression were associated, indicating a complex relationship.

Effects of pregabalin in patients with hypnotic-dependent insomnia

STUDY OBJECTIVES

Long-term use of hypnotics runs the risk of dependency, and subjects usually experience difficulties in withdrawal. The objective of this study was to investigate the success of withdrawal using pregabalin and its efficacy on sleep in patients with hypnotic-dependent insomnia.

METHODS

We enrolled patients with hypnotic-dependent insomnia who were 18 years or older. The starting dosage of pregabalin was 75 mg/day and was increased up to as much as 300 mg/day, depending on the individual patient's condition, while tapering off hypnotics. After 4 weeks of titration, the final dosage amount was maintained for at least another 4 weeks. Sleep and clinical variables were evaluated at baseline and after treatment, using the Korean versions of various sleep questionnaires as well as polysomnography.

RESULTS

Forty subjects were enrolled, with a mean age of 52.0 ± 8.5 years, of whom 28 (70.0%) were women. Twenty-one (52.5%) subjects successfully withdrew from hypnotics. The duration of withdrawal was 42.1 ± 16.0 days (range: 27.0∼84.0). The mean pregabalin dose was 121.4 ± 69.0 mg/day (range: 75.0∼300.0). After pregabalin treatment, there was a significant improvement in the total score of the Pittsburgh Sleep Quality Index (15.0 ± 2.1, 8.9 ± 3.0, p < 0.001), and insomnia severity index (20.9 ± 4.3, 9.6 ± 4.4, p < 0.001); however, most of the sleep variables of the PSG showed no differences. The main adverse effects of pregabalin were nausea and dizziness.

CONCLUSIONS

Our results showed pregabalin may be a promising candidate for withdrawal from hypnotics and improved sleep in patients with hypnotic-dependent insomnia.

Poisoning of dogs and cats by drugs intended for human use

One of the main causes of poisoning of small animals is exposure to drugs intended for human use. Poisoning may result from misuse by pet owners, off-label use of medicines or, more frequently, accidental ingestion of drugs that are improperly stored. This review focuses on classes of drugs intended for human use that are most commonly involved in the poisoning of small animals and provides an overview of poisoning episodes reported in the literature. To perform this review a comprehensive search of public databases (PubMed, Web of Science, Scopus, Google Scholar) using key search terms was conducted. Additionally, relevant textbooks and reference lists of articles pertaining to the topic were reviewed to locate additional related articles. Most published information on small animal poisoning by drugs intended for human use was from animal and human poison control centres or from single case reports. The dog was the species most frequently poisoned. The major drugs involved included analgesics (nonsteroidal anti-inflammatory drugs), antihistamines (H1-antihistamines), cardiovascular drugs (calcium channel blockers), central nervous system drugs (selective serotonin reuptake inhibitors, baclofen, benzodiazepines and zolpidem), gastrointestinal drugs (loperamide), nutritional supplements (vitamin D and iron salts) and respiratory drugs (β2-adrenergic receptor agonists).

Feasibility of discontinuing chronic benzodiazepine use in nursing home residents: a pilot study

PURPOSE

Guidelines discourage chronic benzodiazepines and related Z drugs (BZD/Zs) for sleep problems. However, prevalence among nursing home residents remains high. Discontinuing these drugs is widely recommended but seems difficult to implement. The aim of our study was to evaluate the overall feasibility in the nursing home, in terms of willingness towards discontinuation and success rate at 8 months, together with the impact on withdrawal symptoms, change in sleep quality, quality of life and medication use.

METHODS

In a convenience sample of five nursing homes (823 residents), we included cognitively competent residents with chronic BZD/Z use for insomnia. We investigated sleep quality [with Pittsburgh Sleep Quality Index (PSQI)], quality of life (EQ-5D) and withdrawal symptoms [Benzodiazepine Withdrawal Symptom Questionnaire (BWSQ)]. Success rate was analysed with survival analysis.

RESULTS

Of the 135 eligible residents, both general physician (GP) and resident were willing to initiate discontinuation in 38 residents. Reasons for refusing to initiate discontinuation among GPs was the unmotivated patient and among residents the reluctance towards change. At 8 months, 66.0% were successful discontinuers, with the subjective PSQI component evolving favourably (p = 0.013) and a decreasing number of midnight awakenings (p = 0.041). In the relapse group (n = 13), the quality of life decreased (p = 0.012), with mainly an increase of problems with activities and pain/discomfort. In both groups, the withdrawal symptoms, functionality and medication use did not change.

CONCLUSION

Discontinuation of chronic BZD/Z use is feasible in the nursing home setting without noticeable withdrawal symptoms, without a switch in medication use, without detrimental effect on quality of life and with a positive effect on the self-perceived sleep quality.

Patterns of psychotropic medication prescriptions by psychiatrists for private clinic outpatients in kerman province, iran

OBJECTIVES

The aim of this study was to assess the pattern and utilisation of psychotropic drug prescriptions by psychiatrists in Kerman Province, Iran.

METHODS

The prescriptions of 27 psychiatrists were randomly selected from two Iranian public insurance organisations and were analysed for the mean number of drugs/prescriptions, drug category and the most frequently prescribed drug in each category as well as overall.

RESULTS

A total of 6,414 prescriptions were analysed. The mean number of drugs per prescription was 2.9. Antidepressants (61.0%) were the most frequently prescribed category of psychotropic medications, followed by antipsychotics (29.5%), sedative/hypnotics or anti-anxiety drugs (27.5%) and mood stabilisers (18.5%). The combination of antidepressants with antipsychotics was the most commonly prescribed combination (18.8%). Fluoxetine (16.5%) and trifluoperazine (13.5%) were among the most frequently prescribed antidepressants and antipsychotics, respectively. Clonazepam (10.5%) was the most commonly prescribed benzodiazepine agent, followed by alprazolam (8.5%). In terms of total drug utilisation, sertraline (12.4%) was the most commonly used psychotropic medication followed by fluoxetine (9.7%), trifluoperazine (6.6%), propranolol (4.5%) and clonazepam (3.7%).

CONCLUSION

A high proportion of psychotropic prescriptions in Kerman Province were for antidepressants, followed by antipsychotics and the benzodiazepines. Further research is needed to determine the underlying correlation between prescription practice and the diagnosis and patient characteristics, as well as to investigate the use of different psychotropic medications.

Severity of alprazolam dependence and associated features among long-term alprazolam users from psychiatric outpatient clinics in Taiwan

BACKGROUND/PURPOSE

The aim of this study was to examine the correlations between the severity of alprazolam dependence and socio-demographic characteristics, the characteristics of alprazolam use, psychiatric comorbidity, and beliefs toward alprazolam use among long-term alprazolam users in Taiwan.

METHODS

A total of 148 long-term alprazolam users participated in this study. The Chinese version of the Severity of Dependence Scale was used to assess participants' severity of alprazolam dependence in the preceding month. Their socio-demographic characteristics, family function characteristics, dosage of prescribed alprazolam, duration of alprazolam use, alcohol use pattern, pain reliever and cigarette use pattern, severity of depressive symptoms, psychiatric diagnosis, and belief toward alprazolam use were investigated.

RESULTS

The results of multiple regression analysis indicated that a longer duration of alprazolam use, severe depressive symptoms, a high level of belief in the necessity of alprazolam treatment, and a high level of concern about the potential adverse consequences of alprazolam use were significantly associated with more severe alprazolam dependence.

CONCLUSION

Doctors should closely monitor the severity of alprazolam dependence among long-term users, especially patients' levels of depression, beliefs in the necessity of alprazolam treatment, and their concerns over the adverse consequences of continued treatment with alprazolam.

Distribution of Fos-immunoreactive cells in rat forebrain and midbrain following social defeat stress and diazepam treatment

The anxiolytic diazepam selectively inhibits psychological stress-induced autonomic and behavioral responses without causing noticeable suppression of other central performances. This pharmacological property of diazepam led us to the idea that neurons that exhibit diazepam-sensitive, psychological stress-induced activation are potentially those recruited for stress responses. To obtain neuroanatomical clues for the central stress circuitries, we examined the effects of diazepam on psychological stress-induced neuronal activation in broad brain regions. Rats were exposed to a social defeat stress, which caused an abrupt increase in body temperature by up to 2°C. Pretreatment with diazepam (4mg/kg, i.p.) attenuated the stress-induced hyperthermia, confirming an inhibitory physiological effect of diazepam on the autonomic stress response. Subsequently, the distribution of cells expressing Fos, a marker of neuronal activation, was examined in 113 forebrain and midbrain regions of these rats after the stress exposure and diazepam treatment. The stress following vehicle treatment markedly increased Fos-immunoreactive (IR) cells in most regions of the cerebral cortex, limbic system, thalamus, hypothalamus and midbrain, which included parts of the autonomic, neuroendocrine, emotional and arousal systems. The diazepam treatment significantly reduced the stress-induced Fos expression in many brain regions including the prefrontal, sensory and motor cortices, septum, medial amygdaloid nucleus, medial and lateral preoptic areas, parvicellular paraventricular hypothalamic nucleus, dorsomedial hypothalamus, perifornical nucleus, tuberomammillary nucleus, association, midline and intralaminar thalami, and median and dorsal raphe nuclei. In contrast, diazepam increased Fos-IR cells in the central amygdaloid nucleus, medial habenular nucleus, ventromedial hypothalamic nucleus and magnocellular lateral hypothalamus. These results provide important information for elucidating the neural circuitries that mediate the autonomic and behavioral responses to psychosocial stressors.

Retrospective population cohort study on hip fracture risk associated with zolpidem medication

STUDY OBJECTIVE

Few studies have evaluated the hip fracture risk for zolpidem users. We assessed the risk for subjects taking zolpidem.

DESIGN

Population-based retrospective cohort study using claims data of a universal insurance system.

PARTICIPANTS

We identified 6,978 patients newly prescribed for zolpidem in 2000-2001 age 18 y and older, and 27,848 nonusers frequency matched with sex, age, and date visiting a clinic.

MEASUREMENTS AND RESULTS

Both cohorts were followed up to the end of 2008 to measure the hip fracture incidence and risk, which considered factors such as sex, age, occupation, days of drug use, and osteoporosis status. The zolpidem users had a 2.23-fold higher hip fracture incidence than nonusers (3.10 versus 1.39 per 1,000 person-y). The risk increased with age for both cohorts. The elderly users had a 21-fold higher incidence than the younger users, or twofold higher than the elderly nonusers. Among 33 patients (20.4%) with hip fracture occurring during presumed medication days, which was accountable for an incidence of 1,083.0 per 1,000 person-y. Those taking the medicine for 8 days or longer had a moderately higher fracture rate than those taking it for less days (6.02 versus 4.48 per 100 person-times) with a ratio of 1.34 (95% confidence interval 0.42-4.56). Subjects with blue collar occupations were at a higher fracture risk.

CONCLUSION

The hip fracture risk of zolpidem users is higher than that of nonusers. Fracture prevention awareness should be disseminated to the users.

Carers' express positive views on the acceptability, efficacy and safety of buccal midazolam for paediatric status epilepticus

AIM

Buccal midazolam has emerged as an effective alternative to rectal diazepam in the management of paediatric status epilepticus. This study aimed to identify carers' views on the safety, efficacy and acceptability of buccal midazolam in the management of this common neurological emergency.

METHODS

Community-based, face-to-face interviews were carried out with 34 carers to evaluate the effectiveness, adverse effects and convenience of buccal midazolam as a rescue treatment for prolonged seizures. All children received 2.5 to 10 mg of Epistatus, a proprietary oral solution (10 mg/mL). We evaluated therapeutic success, time taken for seizures to cease and the need to attend the emergency department, together with the development of side effects, namely respiratory depression and sedation.

RESULTS

Most of the families (91%) found that buccal midazolam was always, or usually, effective in stopping seizures and it prevented hospital admission in 65% of cases. The majority (96%) of those who had used both buccal midazolam and rectal diazepam preferred the former as it was easier to administer, more socially acceptable and did not sedate the child as much.

CONCLUSION

Carers felt that buccal midazolam was an effective, safe and more acceptable alternative to rectal diazepam in the management of paediatric status epilepticus.

Duration of treatment and activation of α1-containing GABAA receptors variably affect the level of anxiety and seizure susceptibility after diazepam withdrawal in rats

Long-term use of benzodiazepine-type drugs may lead to physical dependence, manifested by withdrawal syndrome after abrupt cessation of treatment. The aim of the present study was to investigate the influence of duration of treatment, as well as the role of α1-containing GABAA receptors, in development of physical dependence to diazepam, assessed through the level of anxiety and susceptibility to pentylenetetrazole (PTZ)-induced seizures, 24h after withdrawal from protracted treatment in rats. Withdrawal of 2mg/kg diazepam after 28, but not after 14 or 21 days of administration led to an anxiety-like behavior in the elevated plus maze. Antagonism of the diazepam effects at α1-containing GABAA receptors, achieved by daily administration of the neutral modulator βCCt (5mg/kg), did not affect the anxiety level during withdrawal. An increased susceptibility to PTZ-induced seizures was observed during diazepam withdrawal after 21 and 28 days of treatment. Daily co-administration of βCCt further decreased the PTZ-seizure threshold after 21 days of treatment, whilst it prevented the diazepam withdrawal-elicited decrease of the PTZ threshold after 28 days of treatment. In conclusion, the current study suggests that the role of α1-containing GABAA receptors in mediating the development of physical dependence may vary based on the effect being studied and duration of protracted treatment. Moreover, the present data supports previous findings that the lack of activity at α1-containing GABAA receptors is not sufficient to eliminate physical dependence liability of ligands of the benzodiazepine type.

A drug utilization study of psychotropic drugs prescribed in the psychiatry outpatient department of a tertiary care hospital

BACKGROUND

Psychiatric disorders are one of the major causes of morbidity. Development of newer drugs like SSRIs and atypical antipsychotics has altered the treatment paradigms. Various factors like cost of drugs, local paradigms, etc. play a role in the selection of drug therapy and hence, affect the outcome. Keeping this in mind, we conducted a study to delineate the various drugs used in psychiatric disorders, to find discrepancies, if any, between the actual and the ideal prescribing pattern of psychotropic drugs and to conduct a cost analysis.

MATERIAL AND METHODS

After our institutional ethics committee approved, a retrospective cross sectional drug utilization study of 600 prescriptions was undertaken. Preparation of the protocol and conduct of the study was as per the WHO - DUS and the STROBE guidelines.

RESULTS

Drug use indicators - In 600 prescriptions, 1074 (88.25%) were psychotropic drugs. The utilization from the National and WHO EML was 100% and 90%, respectively. Average number of psychotropic drugs per prescription was 1.79 ± 1.02 (SD). 22.5% of the prescriptions contained psychotropic FDCs. 76.01% of drugs were prescribed by generic name. Percentage of psychotropic drugs prescribed from the hospital drug schedule and psychotropic drugs actually dispensed from the hospital drug store were 73.1% and 62.3%, respectively. Drug utilization pattern in different psychiatric disorders - Most commonly prescribed drugs for schizophrenia, bipolar disorders, depression and anxiety disorders were trifluoperazine + trihexiphenydyl (63.9%), carbamazepine (17.2%), amitriptyline (34.9%), and diazepam (23.8%), respectively. The least commonly prescribed drugs were levosulpiride (1.7%), lithium (1.3%), bupropion (4.7%) and clozapine (1.9%), respectively. The PDD/DDD ratio of three drugs - haloperidol, pimozide and amitriptyline - was equal to one. The cost borne by the hospital was 116, i.e., 65.2% of the total cost. The cost index of clozapine was 11.2.

CONCLUSION

Overall, the principles of rational prescribing were followed. The hospital drug schedule should include more SSRIs. The practice of using 1(st) generation/ typical anti-psychotics as the first line was as per current recommendations. Anti-cholinergics should be used only in selected cases of patients on anti-psychotics. The use of diazepam should be curtailed and it should be used for short term only.

Impact of short-term treatment with benzodiazepines and imidazopyridines on glucose metabolism in healthy subjects

AIM

In the last years there has been a progressive reduction of the average duration of sleep and an increase in the incidence of sleep disturbances. At the same time, an increase of the incidence of the metabolic syndrome has been described, partly attributable to the progressive worsening of dietary habits and the increase in sedentary lifestyle. Recent studies suggest that adequate sleep is essential to maintain good glucose metabolism and sleep disturbances may contribute to the manifestation of the metabolic syndrome. Benzodiazepines (BZ), such as brotizolam, and imidazopyridines, such as zolpidem, are frequently used as hypnotics but their potential impact on glucose metabolism has never been evaluated so far.

METHODS

In 12 healthy volunteers [age (mean ± SEM) 38.3 ± 8.1 years; body mass index (BMI) 21.9 ± 0.8 kg/m²] we studied glucose and insulin responses to oral glucose tolerance test (OGTT, 75 g) before and after 15 days treatment with brotizolam 0.25 mg/day or zolpidem 10 mg/day.

RESULTS

Brotizolam increased glucose delta area under curve response to the OGTT by 122 % (p < 0.01) and zolpidem by 86 % (p < 0.01) without significant variations of insulin levels, suggesting an impact on insulin sensitivity and/or insulin secretion.

CONCLUSIONS

This study suggests that BZ and imidazopyridines have a rapid glucometabolic effect that is detectable as early as after 15 days treatment.

Presynaptic glycine receptors as a potential therapeutic target for hyperekplexia disease

Although postsynaptic glycine receptors (GlyRs) as αβ heteromers attract considerable research attention, little is known about the role of presynaptic GlyRs, likely α homomers, in diseases. Here, we demonstrate that dehydroxylcannabidiol (DH-CBD), a nonpsychoactive cannabinoid, can rescue GlyR functional deficiency and exaggerated acoustic and tactile startle responses in mice bearing point mutations in α1 GlyRs that are responsible for a hereditary startle-hyperekplexia disease. The GlyRs expressed as α1 homomers either in HEK-293 cells or at presynaptic terminals of the calyceal synapses in the auditory brainstem are more vulnerable than heteromers to hyperekplexia mutation-induced impairment. Homomeric mutants are more sensitive to DH-CBD than are heteromers, suggesting presynaptic GlyRs as a primary target. Consistent with this idea, DH-CBD selectively rescues impaired presynaptic GlyR activity and diminished glycine release in the brainstem and spinal cord of hyperekplexic mutant mice. Thus, presynaptic α1 GlyRs emerge as a potential therapeutic target for dominant hyperekplexia disease and other diseases with GlyR deficiency.

Use of psychotropic medication groups in people with severe mental illness and stressful childhood experiences

Stressful childhood experiences (SCE) are associated with a variety of health and social problems. In people with severe mental illness (SMI) traumatic childhood experiences have been linked to more severe and treatment refractory forms of psychiatric symptoms, including psychotic symptoms. This study evaluates the use of psychotropic medication groups in a population of people with SMI and SCE, testing the association between SCE and prescription medication in an SMI population. A sample of 183 participants with SMI was divided into 2 exposure groups: high SCE (4 to 7 categories of SCE) and low SCE (0 to 3 categories of SCE). Both groups were compared in regard to prescribed dosing of psychotropic medications (antipsychotics, mood stabilizers, antidepressants, and anxiolytics/hypnotics). Participants who endorsed high SCE received higher doses of antipsychotic medications and mood stabilizers than those with low exposure. The results demonstrate that people with higher SCE categories received a higher dosing of psychotropic medication, specifically antipsychotic medication and mood stabilizers.