Antidepressant drug prescribing among elderly subjects: a population-based study

Childhood intelligence and risk of depression in later-life: A longitudinal data-linkage study

Background

Lower childhood intelligence test scores are reported in some studies to be associated with higher risk of depression in adulthood. The reasons for the association are unclear. This longitudinal data-linkage study explored the relationship between childhood intelligence (at age ∼11) and risk of depression in later-life (up to age ∼85), and whether childhood family structure and adulthood socio-economic and geographical factors accounted for some of this association.

Methods

Intelligence test scores collected in the Scottish Mental Survey 1947 were linked to electronic health records (hospital admissions and prescribing data) between 1980 and 2020 (n = 53,037), to identify diagnoses of depression. Mixed-effect Cox regression models were used to explore the relationship between childhood intelligence test scores and risk of depression in later-life. Analyses were also adjusted for childhood family structure (size of family) and adulthood socio-economic and geographical factors (Carstairs index, urban/rural).

Results

Twenty-seven percent of participants were diagnosed with depression during follow-up (n = 14,063/53,037). Greater childhood intelligence test scores were associated with a reduced risk of depression in an unadjusted analysis (HR = 0.95, 95% CI = 0.93 to 0.97, P < 0.001), and after adjustment for factors experienced in childhood and adulthood (HR = 0.95, 95% CI = 0.91 to 1.00, P = 0.032). When identifying depression using only hospital admissions data, greater childhood intelligence test scores were associated with a reduced risk of depression following unadjusted analysis (HR = 0.86, 95% CI = 0.82 to 0.90, P < 0.001), and after adjusting for risk factors in childhood and adulthood (HR = 0.94, 95% CI = 0.89 to 0.99, P = 0.026). There was no association between childhood cognitive test scores and depression when identifying cases of depression using only prescribed drugs data.

Conclusions

This study provides additional evidence suggesting that higher childhood intelligence predicts reduced risk of later-life depression only when depression is assessed based on hospital admission records. Childhood family structure and adulthood socio-economic and geographical factors did not seem to be substantial confounders.

Stakeholders' views on the use of psychotropic medication in older people: a systematic review

Background

psychotropic medication use has been shown to increase with age and has been associated with increased risk of falls, strokes and mortality. Various guidelines, regulations and tools have been developed to reduce inappropriate prescribing, but this remains high. In order to understand the reasons for this, we aimed to systematically review healthcare professionals’, patients’ and family caregivers’ attitudes towards the use of psychotropic medication in older people.

Methods

a systematic literature search was carried out from inception to September 2020 using PUBMED, EMBASE, PsycINFO and CINAHL and hand-searching of reference lists. Included studies investigated stakeholder views on psychotropic in adults over the age of 65. Findings were thematically synthesised.

Results

overall, there was an acceptance of long-term psychotropic medication for older people both living in the community and in residential care. While healthcare professionals were aware of guidelines for the use of benzodiazepines and psychotropic medicines, they identified barriers to following them on individual, team and organisational levels. Alternative non-pharmacological approaches were not always available or accepted by patients.

Conclusion

psychotropic medicine use in older adults remains a complex issue, which needs to be addressed on a broad level. Attitudes of older people and healthcare professionals encourage long-term use. Meanwhile, various internal and external factors act as barriers to the use of non-drug alternatives in this population. In order to reduce overprescribing of psychotropics, there is a need to increase the acceptability and accessibility of alternative interventions in both care homes and the community.

Why we need to evaluate long-term antidepressant use in older patients with depression

In this commentary, we address current clinical practice of long-term antidepressant use in older adults with depression, and recommend improvements. Compared with younger adults, older adults more frequently use antidepressants in the long term, although they may not always benefit from them, and in spite of an increased risk for adverse events. Unfortunately, evaluations of long-term antidepressant use are sparse, especially in older age groups. To prevent and reduce inappropriate long-term use and adverse events, antidepressant use in older age groups should be regularly evaluated.

Antidepressant use and associated factors among the elderly: the Bambuí Project

This study examined the factors associated with antidepressant use among community-dwelling elderly individuals. Data collected from the Bambuí Project, a population-based study on aging and health with a cohort of 1,606 elderly individuals, were used. Gender, age, education, marital status, household income and cohabitation status were the sociodemographic characteristics investigated. Health conditions included self-reported health, number of chronic diseases, depressive symptoms, cognitive impairment and functional disability. Poisson regression with robust variance was used to test associations and to estimate prevalence ratios with 95% confidence intervals. The prevalence of antidepressant use was 8.4%. After multivariate analysis, antidepressant use was associated with the female gender (PR = 2.96; 95%CI 1.82-4.81), being single or divorced (PR = 0.48; 95%CI 0.25-0.91), cognitive impairment (PR = 0.44; 95%CI 0.24-0.84) and worse self-reported health (poor/very poor) (PR=1.86; 95%CI 1.11-3.10). The results are similar to those observed in several other studies conducted in higher-income countries and suggest that self-reported health in the elderly population of Bambuí is a key factor in the decision to use antidepressants.

Trends in patterns of antidepressant use in older general population between 2006 and 2012 following publication of practice guidelines

OBJECTIVE

The French regulatory agency published in 2006 practice guidelines related to the management of depressive and anxiety disorders. The main objective of the study was to assess their impact regarding use and monitoring of antidepressant drug treatment in older patients. The secondary objective was to identify factors associated with compliance with practice guidelines.

METHODS

A historical fixed cohort study with dynamic follow-up time was conducted in 16,144 subjects aged 65 years and over, initiating antidepressant treatment and registered in the National Health Insurance Database between 2006 and 2012. Compliance with guidelines was assessed from year to year using segmented regression analysis. Multiple logistic regressions were used to identify factors associated with compliance with guidelines.

RESULTS

Duration of antidepressant treatment was compliant with guidelines in 13.0% of patients aged 65-74 years and 18.5% of patients aged 75 years and over. Biological monitoring was performed in 12.6% of patients aged 65-74 years and 18.5% of patients aged 75 years and over. No significant change of rate of compliance with guidelines was observed over the study period. Compliance of prescriptions with guidelines was associated with patient's age, specialty of the prescriber, presence of chronic disease, year of treatment initiation, and presence of a university hospital in the area of residence.

CONCLUSION

While treatment duration and biological monitoring were often inadequate in older patients, the publication of guidelines by the French health regulatory authorities did not lead to any significant and sustained improvement in their patterns of antidepressant use. Copyright © 2016 John Wiley & Sons, Ltd.

Continuation and maintenance treatments for depression in older people

BACKGROUND

Depressive illness is common in old age. Prevalence in the community of case level depression is around 15% and milder forms of depression are more common. It causes significant distress and disability. The number of people over the age of 60 years is expected to double by 2050 and so interventions for this often long-term and recurrent condition are increasingly important. The causes of late-life depression differ from depression in younger adults and so it is appropriate to study it separately.This is an update of a Cochrane review first published in 2012.

OBJECTIVES

To examine the efficacy of antidepressants and psychological therapies in preventing the relapse and recurrence of depression in older people.

SEARCH METHODS

We performed a search of the Cochrane Common Mental Disorders Group's specialised register (the CCMDCTR) to 13 July 2015. The CCMDCTR includes relevant randomised controlled trials (RCTs) from the following bibliographic databases: The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). We also conducted a cited reference search on 13 July 2015 of the Web of Science for citations of primary reports of included studies.

SELECTION CRITERIA

Both review authors independently selected studies. We included RCTs involving people aged 60 years and over successfully treated for an episode of depression and randomised to receive continuation and maintenance treatment with antidepressants, psychological therapies, or a combination.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. The primary outcome for benefit was recurrence rate of depression (reaching a cut-off on any depression rating scale) at 12 months and the primary outcome for harm was drop-outs at 12 months. Secondary outcomes included relapse/recurrence rates at other time points, global impression of change, social functioning, and deaths. We performed meta-analysis using risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, with 95% confidence intervals (CI).

MAIN RESULTS

This update identified no further trials. Seven studies from the previous review met the inclusion criteria (803 participants). Six compared antidepressant medication with placebo; two involved psychological therapies. There was marked heterogeneity between the studies.Comparing antidepressants with placebo on the primary outcome for benefit, there was a statistically significant difference favouring antidepressants in reducing recurrence compared with placebo at 12 months with a GRADE rating of low for quality of evidence (three RCTs, n = 247, RR 0.67, 95% CI 0.54 to 0.82; number needed to treat for an additional beneficial outcome (NNTB) 5). Comparing antidepressants with placebo on the primary outcome for harms, there was no difference in drop-out rates at 12 months' follow-up, with a GRADE rating of low.There was no significant difference between psychological treatment and antidepressant in recurrence rates at 12 months (one RCT, n = 53) or between combination treatment and antidepressant alone at 12 months.

AUTHORS' CONCLUSIONS

This updated Cochrane review supports the findings of the original 2012 review. The long-term benefits and harm of continuing antidepressant medication in the prevention of recurrence of depression in older people are not clear and no firm treatment recommendations can be made on the basis of this review. Continuing antidepressant medication for 12 months appears to be helpful with no increased harms; however, this was based on only three small studies, relatively few participants, use of a range of antidepressant classes, and clinically heterogeneous populations. Comparisons at other time points did not reach statistical significance.Data on psychological therapies and combined treatments were too limited to draw any conclusions on benefits and harms.The quality of the evidence used in reaching these conclusions was low and the review does not, therefore, offer clear guidance to clinicians and patients on best practice and matching interventions to particular patient characteristics.Of note, we identified no new studies that evaluated pharmacological or psychological interventions in the continuation and maintenance treatment of depression in older people. We are aware of studies conducted since the previous review that included both older people and adults under the age of 65 years, but these fall outside of the remit of this review. We believe that there remains a need for studies solely recruiting older people, particularly the 'older old' with comorbid medical problems. However, these studies are likely to be challenging to conduct and may not, so far, have been prioritised by funders.

Aging in Italy: The Need for New Welfare Strategies in an Old Country

Italy, a Southern European country with 60.8 million inhabitants, has the largest proportion of elderly citizens (aged ≥65) in Europe of 21.4%. The aging of the population is due to a number of reasons, such as baby boomers growing old, an increase in longevity, and low birth rate. Although international migration has increased in recent years, the addition of a foreign segment of the population has neither compensated for nor significantly curtailed the aging phenomenon. The impact of aging on the economic sustainability concerns the progressive reduction of the workforce, high incidence of pension spending in the overall resources allocated to welfare, recent reform of the pension system, and the growing issue of "non-self-sufficiency" in the elderly. Despite limited financial measures dedicated to research, Italy is conducting important studies on aging, both at the national and international level. Physicians and researchers in the field of geriatrics and gerontology are not only promoting quality of life in the elderly, and healthy-active aging, but also contributing to economic stability and social organization. Finally, nutritional and lifestyle habits-and their role in preventing chronic diseases-are the focus of the current international event EXPO 2015, with many sections dedicated to the elderly.

Trends, correlates, and disease patterns of antidepressant use among elderly persons in Taiwan

PURPOSE

The population-based National Health Insurance database was used to investigate the trends, correlates, and disease patterns for elderly people in Taiwan who use antidepressants.

METHODS

The National Health Research Institute provided a database of 1000,000 random subjects for study. We created a sample of subjects who were older than 65 years from 1997 to 2005. Trends, prevalence, and associated factors of antidepressant use were detected. We also examined the proportion of antidepressant use for psychiatric and medical disorders.

RESULTS

The one-year prevalence of antidepressant use in elderly persons increased from 5.8 % in 1997 to 9.8 % in 2005. The one-year prevalence rates of tricyclic antidepressant (TCA), selective serotonin reuptake inhibitor (SSRI), serotonin-norepinephrine reuptake inhibitor (SNRI), serotonin modulator, and other antidepressant use in 2005 were 5.3, 2.6, 0.4, 2.9, and 0.6 %, respectively. Overall antidepressant use was higher for those in the 75- to 84-year-old age group, females, and those with higher Charlson Comorbidity Index scores. Among subjects using TCAs, 77.6 % users did not have a psychiatric diagnosis. Psychiatric disorders were commonly found in most SSRI and SNRI users (85.1 and 90.1 %, respectively). Subjects using SSRIs and SNRIs had higher proportions of psychiatric disorders such as neurotic depression, major depression, senile and presenile organic psychotic conditions, and anxiety.

CONCLUSION

The prevalence of antidepressant use among elderly persons increased greatly from 1997 to 2005. SSRIs, SNRIs, and other antidepressants were used mostly by subjects with psychiatric disorders, whereas TCAs were used mostly by subjects with nonpsychiatric disorders.

Regional variation in prescribing for chronic conditions among an elderly population using a pharmacy claims database

BACKGROUND

Age, gender and geographical regions are recognised factors in inequalities in prescribing for chronic diseases in the elderly.

AIM

To compare the health board regional distribution of chronic disease among the elderly and to examine variation in quality prescribing across age, gender and regions.

METHODS

Population based study of prescribing for chronic disease using a national pharmacy claims database. All individuals aged 70 years and over (n = 271,518) were eligible.

RESULTS

Over 60% of the elderly in all regions received cardiovascular related medication. The South Eastern, North Western and Western Health Boards had below average prescribing for many chronic conditions. Logistic regression identified age, gender and regional variations in prescribing of preventative therapies for CVD and diabetes.

CONCLUSION

There is a high prevalence of prescribing for chronic conditions in the elderly in Ireland, and there is evidence of gender, age and residing health board inequalities in prescribing.

Continuation and maintenance treatments for depression in older people

BACKGROUND

Depressive illness in older people causes significant suffering and health service utilisation. Relapse and recurrence rates are high.

OBJECTIVES

To examine the efficacy of antidepressants and psychological therapies in preventing the relapse and recurrence of depression in older people.

SEARCH METHODS

Search of the Cochrane Depression, Anxiety and Neurosis Review Group's specialized register (the CCDANCTR) up to 22 June 2012. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE, (1974 to date) MEDLINE (1950 to date) and PsycINFO (1967 to date). We handsearched relevant journals, contacted experts in the field and examined reference lists, conference proceedings and bibliographies.

SELECTION CRITERIA

Both review authors independently selected studies. We included randomised controlled trials (RCTs) involving people aged 60 and over successfully treated for an episode of depression and randomised to receive continuation and maintenance treatment with antidepressants, psychological therapies, or combination.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by the two authors.The primary outcome was relapse/recurrence rate of depression (reaching a cut-off on any depression rating scale) at six-monthly intervals. Secondary outcomes included global impression of change, social functioning, and deaths. Meta-analysis was performed using risk ratio for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals.

MAIN RESULTS

Seven studies met the inclusion criteria (803 participants). Six compared antidepressant medication with placebo; two involved psychological therapies. There was marked heterogeneity between the studies.Comparing antidepressants with placebo, at six months follow-up there was no significant difference. At 12 months follow-up there was a statistically significant difference favouring antidepressants in reducing recurrence compared with placebo (three RCTs, N = 247, RR = 0.67, 95% CI 0.55 to 0.82; NNTB = five). At 24 months there was no significant difference for antidepressants overall, however, for the subgroup of tricyclic antidepressants there was significant benefit (three RCTs, N = 169, RR = 0.70, 95% CI 0.50 to 0.99; NNTB = five). At 36 months there was no significant difference for antidepressants overall. There was no difference in treatment acceptability or death rates between antidepressant and placebo.There was no significant difference between psychological treatment and antidepressant in recurrence rates at 12, 24, and 36 months (one RCT, N = 53) or between combination and antidepressant alone.Overall, the included studies were at low risk of bias.

AUTHORS' CONCLUSIONS

The long-term benefits of continuing antidepressant medication in the prevention of recurrence of depression in older people are not clear and no firm treatment recommendations can be made on the basis of this review. Continuing antidepressant medication for 12 months appears to be helpful but this is based on only three small studies with relatively few participants using differing classes of antidepressants in clinically heterogeneous populations. Comparisons at other time points did not reach statistical significance. Data on psychological therapies and combined treatments are too limited to draw any conclusions.

Subthreshold depression in older subjects: an unmet therapeutic need

Major depression, defined according to DSM IV TR criteria, is less common in older subjects, while other types of depression are two to three times more prevalent. This heterogeneous group of disturbances has received different names: depression not otherwise specified, minor depression, subthreshold or subsyndromal depression. Moreover, each condition has been defined using heterogeneous criteria by different authors. The term of subthreshold depression will be adopted in this position statement. Subthreshold depression has been associated with the same negative consequences of major depression, including reduced well being and quality of life, worsening health status, greater disability, increased morbidity and mortality. Nevertheless, there is a dearth of clinical trials in this area, and therefore older patients with subthreshold depression are either not treated or they are treated with the same non pharmacological and pharmacological therapies used for major depression, despite the lack of supporting scientific evidence. There is an urgent need to reach a consensus concerning the diagnostic criteria for subthreshold depression as well as to perform clinical trials to identify effective and safe therapies in this too long neglected patient group.

Persistence with pharmacological treatment in the specialist mental healthcare of patients with severe mental disorders

PURPOSE

The aim of this study was to measure persistence with pharmacological treatment in the specialist mental healthcare of patients with schizophrenia, bipolar disorder, and unipolar depression in Lombardy, a region of 10 million inhabitants located in the northernmost part of Italy.

METHODS

The data concerning psychiatric care used in this study were retrieved from the regional Psychiatric Information System, while information on drug treatment was retrieved from the regional administrative database. Time to lack of persistence with initial pharmacological treatment was the outcome measure.

RESULTS

A total of 11,797 patients, followed in the specialist mental healthcare system, started a new pharmacological treatment for depression, schizophrenia, or bipolar disorder during 2007. Overall, 8,500 patients (72.1%) discontinued treatment during the 12 month follow-up, with a median duration of 101 days. Very similar discontinuation rates were observed in patients with unipolar depression, schizophrenia, and bipolar disorder. In the multivariate analysis, operational definitions of continuity and intensity of care were the most robust determinants of persistence with drug treatment in each of the three cohorts of psychiatric diagnoses.

CONCLUSIONS

High rates of treatment discontinuation were found in a population of patients with severe mental disorders followed in the specialist mental healthcare system of an Italian region, with no differences among patients with unipolar major depression, schizophrenia, and bipolar disorder. These findings corroborate the notion that the problem of treatment discontinuation in psychiatric disorders is a factor related to the capacity of the mental health system to assure and maintain continuity and intensity of care.

Antidepressant and antipsychotic drug prescribing in Lombardy

Background – The patterns of antidepressant and antipsychotìc drag prescribing have rarely been studied in large and geographically defined catchment areas. In the present study we examined the prevalence and distribution of antidepressant and antipsychotic prescribing in Lombardy, a northern Italy region of nine million inhabitants. Methods – This study used the Regional Administrative Database of Lombardy. This database includes all prescriptions reimbursed by the National Health System in the population living in this region. All antidepressant and antipsychotic prescriptions dispensed from the 1st January to the 31st December 2001 were extracted and prevalence data calculated by dividing antidepressant and antipsychotic users by the total number of male and female residents in each age group. In addition, from the Regional database of hospital admissions we extracted all patients aged 65 or above with cerebrovascular-related outcomes for the year 2002. The two databases were linked anonymously with the aim of investigating the relationship between exposure to psychotropics and occurrence of cerebrovascular accidents in the elderly. Results – During the study period 404, 238 individuals were dispensed antidepressants, yielding a prevalence of use of 2.85 (95% CI 2.84, 2.87) per 100 males and 5.92 (95% CI 5.90, 5.94) per 100 females. The prevalence of use progressively rose with age in both sexes, with the highest rates in old and very old individuals. The majority of individuals received a pharmacological treatment with selective-serotonin reuptake inhibitors only, slightly more than 12% received a treatment with tricyclic antidepressants. A total of 86, 187 subjects were dispensed antipsychotic agents, yielding a prevalence of use of 0.87 (95% CI 0.86, 0.88) per 100 males and 1.01 (95% CI 1.00, 1.02) per 100 females. The prevalence of use progressively rose with age in both sexes, with the highest rates in old and very old subjects. Concerning the relationship between exposure to second-generation antipsychotics (SGAs) and occurrence of cerebrovascular (CBV) accidents, the analysis showed a significantly increased risk of CBV events in elderly subjects exposed to SGAs in comparison with those exposed to first-generation antipsychotics (FGAs) (3, 31%, 95% CI 2, 95–3, 69 vs. 2, 37%, 95% CI 2, 19–2, 57). Finally the analysis indicated no differences in the proportion of cerebrovascular events in elderly subjects exposed to TCAs and SSRIs. Conclusions – The very high rates of antidepressant and antipsychotic drug prescribing detected in late life suggest the need of characterising these individuals in terms of medical and psychiatric characteristics, needs and quality of life. It also suggests the need for pragmatic clinical trials, carried out in the general practice, with the aim of assessing whether antidepressants are effective in these conditions. The data provide preliminary epidemiological evidence that exposure to SGAs, in comparison with exposure to FGAs, significantly increased the risk of cerebrovascular accidents in the elderly.

Declaration of Interest: none.

Antidepressants utilization among elderly in Lombardy from 2000 to 2007: dispensing trends and appropriateness

PURPOSE

To investigate the prevalence and incidence of antidepressant (AD) use in the elderly during an 8-year period and to evaluate AD treatment appropriateness.

METHODS

A population-based dispensation study on community-dwelling elderly of a large area in Lombardy was performed. Data were drawn from the regional administrative database and from a general practice registry. For each year, prevalence of AD use (i.e., at least one recorded dispensation) and AD treatment (i.e., at least four recorded dispensations) was compared.

RESULTS

The prevalence of AD use and treatment doubled and tripled, respectively. The greatest shift occurred between 2000 and 2002 and was entirely due to SSRIs. The most pronounced increase was seen in females who accounted for 72% of all dispensations. The increase in prevalence was not mirrored by incident use, which slightly decreased (OR: 0.98; 95% CI: 0.98-0.98). The proportion of those who received a minimally adequate AD treatment grew over the years (OR: 1.63; 95% CI: 1.59-1.68). The increase in prevalence of AD treatment was most pronounced among older age groups (ORs between 1.02 and 1.06 for age classes ≥75 years relative to the 65-69 age class; P < 0.001) and was proportional to that of depressive disorders.

CONCLUSIONS

A dramatic rise in dispensations was observed. The increasing prevalence of minimally adequately treated subjects and a possible decrease in untreated depression may reflect an improvement in the pharmacological treatment of depression. The increase in prevalence and not in the incidence of dispensations could be related to an inappropriate prolongation of treatment duration.

Increase in the duration of antidepressant treatment from 1994 to 2003: a nationwide population-based study from Finland

OBJECTIVE

We examined the length and continuity of antidepressant treatment and factors associated with long-term of treatment among adults.

METHODS

Nationwide data from all reimbursed antidepressant prescriptions in 1994-2003 were linked with patients' data retrieved from Statistics Finland and the Finnish Hospital Discharge Register. Logistic regression models were used to analyse long term use of antidepressants.

RESULTS

The annual prevalence of antidepressant use increased from 3.6% in 1994 to 7.3% in 2003. Short-term use (<3 months) decreased from 58% in 1995 to 51% in 2000 and long-term treatment (≥12 months) increased from 18 to 21%. In 2000, 31% of treatment periods lasted ≥6 months and 24% ≥9 months. Long-term treatment correlated to the purchase of other psychotropics, in-patient psychiatric care, and prescription by a psychiatrist.

CONCLUSIONS

Treatment periods with antidepressants have become longer over time. Clinical factors related to mental disorder severity predict long-term use. Only a quarter had the treatment duration recommended by clinical guidelines for depression.

Long-term prescribing of antidepressants in the older population: a qualitative study

BACKGROUND

High rates of long-term antidepressant prescribing have been identified in the older population.

AIMS

To explore the attitudes of older patients and their GPs to taking long-term antidepressant therapy, and their accounts of the influences on long-term antidepressant use.

DESIGN OF STUDY

Qualitative study using in-depth semi-structured interviews.

SETTING

One primary care trust in North Bradford.

METHOD

Thirty-six patients aged > or =75 years and 10 GPs were interviewed. Patients were sampled to ensure diversity in age, sex, antidepressant type, and home circumstances.

RESULTS

Participants perceived significant benefits and expressed little apprehension about taking long-term antidepressants, despite being aware of the psychological and social factors involved in onset and persistence of depression. Barriers to discontinuation were identified following four themes: pessimism about the course and curability of depression; negative expectations and experiences of ageing; medicine discontinuation perceived by patients as a threat to stability; and passive (therapeutic momentum) and active (therapeutic maintenance) decisions to accept the continuing need for medication.

CONCLUSION

There is concern at a public health level about high rates of long-term antidepressant prescribing, but no evidence was found of a drive for change either from the patients or the doctors interviewed. Any apprehension was more than balanced by attitudes and behaviours supporting continuation. These findings will need to be incorporated into the planning of interventions aimed at reducing long-term antidepressant prescribing in older people.

Future Trends in the Pharmacogenomics of Brain Disorders and Dementia: Influence of APOE and CYP2D6 Variants

About 80% of functional genes in the human genome are expressed in the brain and over 1,200 different genes have been associated with the pathogenesis of CNS disorders and dementia. Pharmacogenetic studies of psychotropic drug response have focused on determining the relationship between variations in specific candidate genes and the positive and adverse effects of drug treatment. Approximately, 18% of neuroleptics are substrates of CYP1A2 enzymes, 40% of CYP2D6, and 23% of CYP3A4; 24% of antidepressants are substrates of CYP1A2 enzymes, 5% of CYP2B6, 38% of CYP2C19, 85% of CYP2D6, and 38% of CYP3A4; 7% of benzodiazepines are substrates of CYP2C19 enzymes, 20% of CYP2D6, and 95% of CYP3A4. 10-20% of Western populations are defective in genes of the CYP superfamily; and the pharmacogenomic response of psychotropic drugs also depends on genetic variants associated with dementia. Prospective studies with anti-dementia drugs or with multifactorial strategies have revealed that the therapeutic response to conventional drugs in Alzheimer’s disease is genotype-specific. The disease-modifying effects (cognitive performance, biomarker modification) of therapeutic intervention are APOE-dependent, with APOE-4 carriers acting as the worst responders (APOE-3/3 > APOE-3/4 > APOE-4/4). APOE-CYP2D6 interactions also influence the therapeutic outcome in patients with dementia.

Pharmacogenomic Biomarkers in Neuropsychiatry: The Path to Personalized Medicine in Mental Disorders

Neuropsychiatric disorders and dementia represent a major cause of disability and high cost in developed societies. Most disorders of the central nervous system (CNS) share some common features, such as a genomic background in which hundreds of genes might be involved, genome-environment interactions, complex pathogenic pathways, poor therapeutic outcomes, and chronic disability.

Recent advances in genomic medicine can contribute to accelerate our understanding on the pathogenesis of CNS disorders, improve diagnostic accuracy with the introduction of novel biomarkers, and personalize therapeutics with the incorporation of pharmacogenetic and pharmacogenomic procedures to drug development and clinical practice.

The pharmacological treatment of CNS disorders, in general, accounts for 10–20% of direct costs, and less than 30–40% of the patients are moderate responders to conventional drugs, some of which may cause important adverse drugs reactions (ADRs). Pharmacogenetic and pharmacogenomic factors may account for 60–90% of drug variability in drug disposition and pharmacodynamics. Approximately 60–80% of CNS drugs are metabolized via enzymes of the CYP gene superfamily; 18% of neuroleptics are major substrates of CYP1A2 enzymes, 40% of CYP2D6, and 23% of CYP3A4; 24% of antidepressants are major substrates of CYP1A2 enzymes, 5% of CYP2B6, 38% of CYP2C19, 85% of CYP2D6, and 38% of CYP3A4; 7% of benzodiazepines are major substrates of CYP2C19 enzymes, 20% of CYP2D6, and 95% of

CYP3A4. About 10–20% of Caucasians are carriers of defective CYP2D6 polymorphic variants that alter the metabolism of many psychotropic agents. Other 100 genes participate in the efficacy and safety of psychotropic drugs. The incorporation of pharmacogenetic/ pharmacogenomic protocols to CNS research and clinical practice can foster therapeutics optimization by helping to develop cost-effective pharmaceuticals and improving drug efficacy and safety. To achieve this goal several measures have to be taken, including: (a) educate physicians and the public on the use of genetic/ genomic screening in the daily clinical practice; (b) standardize genetic testing for major categories of drugs; (c) validate pharmacogenetic and pharmacogenomic procedures according to drug category and pathology; (d) regulate ethical, social, and economic issues; and (e) incorporate pharmacogenetic and pharmacogenomic procedures to both drugs in development and drugs in the market to optimize therapeutics.

Medication use and nonadherence to psychoactive medication for mental health problems by community-living Canadian seniors with depression

OBJECTIVES

To determine the relation between level of depression and psychoactive medication use and nonadherence in Canadian seniors, given that late-life depression is a common, serious mental health problem in Canada.

METHODS

Canadian Community Health Survey-Mental Health and Well-Being respondents aged 65 years and older (n = 7,736) comprised the study sample. Using the Composite International Diagnostic Interview to assess depressive symptoms, we created 4 depression levels to capture a spectrum of depressive disorders and (or) symptoms: major depression, comorbid major depression, depressive symptoms, and no depressive symptoms. Psychoactive medications assessed included sleep aids, anxiolytics, and mood stabilizers and (or) antidepressants (AD). Nonadherence was defined as either not taking medication as recommended or taking medication at a lower dosage than prescribed.

RESULTS

In total, 22.5% of respondents took psychoactive medication for a mental health problem in the previous 12 months. Psychoactive medication use was 46.8% for major depression, 43.1% for comorbid major depression, 34.0% for depressive symptoms, and 17.6% for no depressive symptoms. Rates of psychoactive medication use ranged from 46.5% of those with major depression, to 17.6% of those with no depressive symptoms. Overall, the rate of nonadherence to psychoactive medication was 31%; rates were highest among those with depressive symptoms (37.4%) and lowest among those with no depressive symptoms (27.4%). All 3 depressive categories were associated with greater odds of use and nonadherence.

CONCLUSION

All 3 depression categories were associated with increased use of and nonadherence to psychoactive medication; however, rates of AD and (or) mood stabilizer use for clinically significant depression were low.

Factors associated with antidepressant use in depressed and non-depressed community-dwelling elderly: the three-city study

OBJECTIVES

The aim of this study was to identify factors associated with antidepressant use in non-depressed and depressed elderly persons, assuming that they varied according to clinical status.

METHODS

We studied 7,868 French community-dwelling subjects aged 65 years and over. The Center for Epidemiological Studies-Depression scale and the Mini International Neuropsychiatric Interview were used to define three groups: non-depressed, high depressive symptoms and current major depressive disorder. Separate analyses were performed to identify the factors which were associated with antidepressant use in each group.

RESULTS

Antidepressant use (55% selective serotonin re-uptake inhibitors, 25% tricyclic antidepressants, 20% other types) increased from 4.9% in non-depressed subjects to 17.3% in subjects with high depressive symptoms (HDS) and 33.6% of in those with current major depressive disorder (MDD). The factors associated with antidepressant use varied according to depression status. In particular, men with current MDD were more often treated with antidepressants than women whereas, in both the HDS and the non-depressed groups, antidepressant use was, as has been observed elsewhere, more frequent in women. Gender also had a strong modifying effect on the relationship between antidepressant use and history of major depression. Finally, the direction of the association between antidepressant use and cognitive performance varied according to depression status.

CONCLUSIONS

This study showed that the direction and strength of the association between antidepressant use and demographic and health-related factors varied according to the severity of depression symptoms. Further studies are needed to clarify the relationship between gender and cognition and antidepressant use.

Pharmacogenomics in Alzheimer's disease

Pharmacological treatment in Alzheimer's disease (AD) accounts for 10-20% of direct costs, and fewer than 20% of AD patients are moderate responders to conventional drugs (donepezil, rivastigmine, galantamine, memantine), with doubtful cost-effectiveness. Both AD pathogenesis and drug metabolism are genetically regulated complex traits in which hundreds of genes cooperatively participate. Structural genomics studies demonstrated that more than 200 genes might be involved in AD pathogenesis regulating dysfunctional genetic networks leading to premature neuronal death. The AD population exhibits a higher genetic variation rate than the control population, with absolute and relative genetic variations of 40-60% and 0.85-1.89%, respectively. AD patients also differ in their genomic architecture from patients with other forms of dementia. Functional genomics studies in AD revealed that age of onset, brain atrophy, cerebrovascular hemodynamics, brain bioelectrical activity, cognitive decline, apoptosis, immune function, lipid metabolism dyshomeostasis, and amyloid deposition are associated with AD-related genes. Pioneering pharmacogenomics studies also demonstrated that the therapeutic response in AD is genotype-specific, with apolipoprotein E (APOE) 4/4 carriers the worst responders to conventional treatments. About 10-20% of Caucasians are carriers of defective cytochrome P450 (CYP) 2D6 polymorphic variants that alter the metabolism and effects of AD drugs and many psychotropic agents currently administered to patients with dementia. There is a moderate accumulation of AD-related genetic variants of risk in CYP2D6 poor metabolizers (PMs) and ultrarapid metabolizers (UMs), who are the worst responders to conventional drugs. The association of the APOE-4 allele with specific genetic variants of other genes (e.g., CYP2D6, angiotensin-converting enzyme [ACE]) negatively modulates the therapeutic response to multifactorial treatments affecting cognition, mood, and behavior. Pharmacogenetic and pharmacogenomic factors may account for 60-90% of drug variability in drug disposition and pharmacodynamics. The incorporation of pharmacogenetic/pharmacogenomic protocols to AD research and clinical practice can foster therapeutics optimization by helping to develop cost-effective pharmaceuticals and improving drug efficacy and safety.

Antidepressant drugs: prevalence, incidence and indication of use in general practice of Southern Italy during the years 2003-2004

PURPOSE

To estimate 1-year prevalence, 1-year incidence and indication of use of antidepressant (AD) drug treatment in general practice of Southern Italy during the years 2003-2004.

METHODS

Among 142,346 individuals registered in the lists of 119 general practitioners of Southern Italy, we identified users of different AD types: tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs) and other antidepressants. Annual prevalence of AD use was measured as the number of individuals receiving at least one AD prescription in the years 2003-2004, divided by the number of patients registered in the general practitioner (GP) lists. One-year incidence of AD treatment was calculated as the number of new users of AD, divided by the number of total patients free from AD prescriptions in the previous year.

RESULTS

Overall, 1-year prevalence of AD use was 5.08 (95% confidence interval (CI): 4.97-5.20) per 100 inhabitants in the year 2003, with a 20% increase in 2004 (6.00, 5.88-6.13). Prevalence of SSRI use markedly increased from 3.80 (3.73-3.90) in 2003 to 4.51 (4.40-4.61) in 2004. The incidence rates of SSRI, TCA and other antidepressant use were 2.11 (2.03-2.19), 0.38 (0.35-0.41) and 0.53 (0.49-0.57) respectively. Depressive disorders were the main indication of use of any AD user (mostly for SSRI users), followed by anxious disturbances.

CONCLUSIONS

SSRIs, particularly those recently marketed, have been increasingly used during the last years, mainly to treat affective disorders.

Prevalence, incidence and persistence of antipsychotic drug prescribing in the Italian general population: retrospective database analysis, 1999-2002

PURPOSE

To investigate the prevalence, incidence and persistence with antipsychotic drug therapy in a large and geographically defined catchment area of Italian general population.

METHODS

All antipsychotic drug prescriptions dispensed during 1999, 2000, 2001 and 2002 were extracted from an administrative prescription database covering a population of 2 640 379 individuals. Antipsychotic drug users were defined as patients who had at least one recorded prescription in the current year. New users were defined as patients receiving a first prescription without any recorded antipsychotic drug treatment in the previous 12 months. Prevalence data were calculated by dividing users by the total number of male and female residents in each age group. Incidence data were calculated as the number of new users divided by the person-time free from antipsychotic drugs in the current year. The cumulative persistence of each medication was calculated by dividing the total prescribed amount of antipsychotic drug by the recommended daily dose, according to each agent's defined daily dose (DDD).

RESULTS

A progressive rise in prevalence and incidence rates was observed during the 4-year period. In each census year, the prevalence and incidence of prescribing was higher in females than males, and progressively rose with age, with the highest rates in old and very old subjects. The analysis of persistence with therapy revealed that 3176 individuals (78.5%) were occasional antipsychotic drug users, and that occasional use was more frequent among individuals receiving conventional antipsychotic drugs than among individuals receiving novel antipsychotic drugs. This difference was not explained by differences in the occurrence of neurologic adverse reactions, as shown by the concurrent prescribing of anticholinergic drugs, which was fairly similar between the two groups of new drug users. Additionally, we found that conventioal antipsychotic drugs were more often used in older individuals, where occasional use is very frequent, while novel antipsychotic drugs were more often prescribed in young and adult individuals, where regular use is more frequent.

CONCLUSIONS

An epidemiologically relevant proportion of everyday individuals is annually exposed to antipsychotic drugs. The distribution of prevalence and incidence rates by age highlighted an emerging public health issue related to the adverse and beneficial consequences of antipsychotic drug exposure in the elderly. The finding that persistence with therapy was longer in new users of novel antipsychotic drugs compared with new users of conventional agents might be explained by the different demographic and clinical characteristics of individuals receiving these two drug classes and not by the different tolerability profile of these two drug classes.

Generating psychotropic drug exposure data from computer-based medical records

PURPOSE

To develop a methodology for extracting psychotropic drug exposure data from computer-based medical records and for generating drug exposure variables suitable for secondary use.

METHODS

In South-Verona, Italy, a registry including every patient receiving psychotropic medications is operating since 2004. The basic structure of the registry is the medication record. Each record stores data on a specific prescription, and patients with more than one prescription have more than one record.

RESULTS

The longitudinal history of drug use was described identifying consecutive prescriptions of a specific drug, concomitant prescriptions of a specific drug and distinct prescriptions of a specific drug. Consecutive prescriptions implies that the beginning of the second prescription coincides with the end of the first prescription, concomitant prescriptions implies that the beginning of the second prescription precedes the end of the first prescription, distinct prescriptions implies that a gap of at least 1 day exists between prescriptions. Using this framework of drug representation, we identified episodes of drug therapy, where each episode is constituted of consecutive and/or concomitant prescriptions. Within each episode, prescriptions were categorised into theoretical phases, where the beginning of the new phase always coincides with the end of the previous phase. On the basis of this data representation, a module operating in Access and using Visual Basic for Applications was developed for creating episodes and phases on a routine basis (available from authors). A graphical representation of this conceptual model is presented.

CONCLUSION

The development of a simple methodology for extracting and generating drug exposure data suitable for secondary use will allow a better understanding of the beneficial and adverse consequences of psychotropic drug use in ordinary practice.

Epidemiological impact of antidepressant and antipsychotic drugs on the general population

PURPOSE OF REVIEW

To analyse the prevalence of and sex and age distribution associated with antidepressant and antipsychotic drug exposure in the general population and to highlight recent epidemiological findings concerning specific adverse outcomes associated with drug exposure.

RECENT FINDINGS

Epidemiological studies indicate high rates of second-generation antidepressant and antipsychotic drug use in the general population. The use is more prevalent among women than among men, and in older rather than in younger age groups. A new pattern of adverse outcomes has been described in individuals exposed to newer agents, including a possible risk of suicidal acts in adults receiving second-generation antidepressants, the risk of cerebrovascular events in older individuals receiving second-generation antipsychotics and the risk of metabolic disturbances in individuals exposed to specific second-generation antipsychotics.

SUMMARY

The assessment of, and attention to, the development of specific adverse reactions in individuals exposed to second-generation psychotropic drugs may improve treatment outcomes.

Pharmacologic response to a diagnosis of late-life depression: A population study in Quebec

OBJECTIVE

To identify predictors of receiving psychoactive medication and receiving recommended first-line pharmacotherapy in individuals with newly diagnosed late-life depression.

METHODS

We undertook a retrospective database cohort study of 5258 beneficiaries of the Quebec provincial health insurance plan between 1999 and 2002. Subjects were aged 65 to 84 years and diagnosed with depression by primary care physicians or psychiatrists between October 2000 and March 2001; they had no depression diagnosis in the previous year. We defined receipt of psychoactive medication as having a pharmacy claim in the year following the depression diagnosis. We determined receipt of recommended first-line pharmacotherapy from the first psychoactive medication dispensed following diagnosis and defined it accordingly; we defined first-line pharmacotherapy according to the 2001 Canadian Psychiatric Association guidelines. We used multivariate generalized estimating equations models to identify the determinants of the 2 outcomes.

RESULTS

A total of 4421 (84.1%) patients received psychoactive medication following diagnosis; 2623 (59.3%) patients had not received antidepressants in the previous year. Of these, 1310 (49.9%) received recommended first-line pharmacotherapy. Independent predictors of receiving psychoactive medication were female sex, depression not otherwise specified (NOS), increasing comorbidity, and living in rural areas. Independent predictors of receiving recommended first-line pharmacotherapy were male sex, depression NOS, receiving medication in the month following diagnosis, and having the same physician diagnosing and treating the patient.

CONCLUSION

Male sex and continuity of care predicted that patients had the recommended medication dispensed.

Pharmacogenomics, nutrigenomics and therapeutic optimization in Alzheimer’s disease

The molecular neuropharmacology of Alzheimer’s disease (AD) is still at an early stage. During the past 20 years, only five drugs, four cholinesterase inhibitors (tacrine, donepezil, rivastigmine and galantamine) and one NMDA receptor partial antagonist (memantine), with poor cost-effectiveness, have been approved for the treatment of AD. Patients with dementia receive many different drugs daily to palliate cognitive and noncognitive symptoms, as well as for the treatment of concomitant disorders present in the elderly population. Polypharmacy, drug–drug interactions and adverse events may combine to deteriorate the frail condition of AD patients. In recent times, the partial elucidation of the pathogenic mechanisms underlying AD-related neurodegeneration, in which many different genes are involved, has helped to foster the development of novel drugs and pharmacogenomics studies. Functional genomics studies have revealed the association of specific mutations in primary loci (APP,PS1, PS2) and/or apolipoprotein (APO)-E-related polymorphic variants with the phenotypic expression of biological traits (e.g., age at onset, brain atrophy, cognitive decline rate, β-amyloid deposition, lipid metabolism dysfunction, immunologic dysregulation or therapeutic outcome). In most pharmacogenomics studies, patients harboring the APOE-4 allele (especially homozygotes) are the worst responders. Genetic clusters integrating 3–4 AD-related genes, representing 25–30% of the AD population, have allowed the identification of selective genotype clusters of good responders. Furthermore, approximately 15% of the European population with AD show mutant CYP2D6 alleles (poor and ultrarapid metabolizers) potentially responsible for efficacy and safety problems with cholinesterase inhibitors and psychotropic drugs. Nutritional factors may also contribute to the deterioration of cognition and brain function in dementia. Novel nutraceutical products obtained from marine sources with biotechnologic procedures have demonstrated atheroprotective properties and lipid-lowering effects and are devoid of hepatotoxic activity. Some of these nutraceuticals exhibit a genotype-dependent therapeutic effect, reflecting a nutrigenomic profile. Nutrigenetics/nutrigenomics- and pharmacogenetics/pharmacogenomics-associated factors may represent major determinants of drug efficacy and safety and therapeutics optimization in dementia and other CNS disorders.