Frequency and predictors of the potential overprescribing of antidepressants in elderly residents of a geographically defined U.S. population

Biomarkers in the Diagnosis and Prediction of Medication Response in Depression and the Role of Nutraceuticals

Depression continues to be a significant and growing public health concern. In clinical practice, it involves a clinical diagnosis. There is currently no defined or agreed upon biomarker/s for depression that can be readily tested. A biomarker is defined as a biological indicator of normal physiological processes, pathogenic processes, or pharmacological responses to a therapeutic intervention that can be objectively measured and evaluated. Thus, as there is no such marker for depression, there is no objective measure of depression in clinical practice. The discovery of such a biomarker/s would greatly assist clinical practice and potentially lead to an earlier diagnosis of depression and therefore treatment. A biomarker for depression may also assist in determining response to medication. This is of particular importance as not all patients prescribed with medication will respond, which is referred to as medication resistance. The advent of pharmacogenomics in recent years holds promise to target treatment in depression, particularly in cases of medication resistance. The role of pharmacogenomics in routine depression management within clinical practice remains to be fully established. Equally so, the use of pharmaceutical grade nutrients known as nutraceuticals in the treatment of depression in the clinical practice setting is largely unknown, albeit frequently self-prescribed by patients. Whether nutraceuticals have a role in not only depression treatment but also in potentially modifying the biomarkers of depression has yet to be proven. The aim of this review is to highlight the potential biomarkers for the diagnosis, prediction, and medication response of depression.

Acute periapical abscesses in patients using selective serotonin reuptake inhibitors

AIMS

Depression and anxiety are severe health problems affecting millions of individuals worldwide. Consequently, the use of antidepressants has constantly been on a rise. Selective serotonin reuptake inhibitors (SSRIs) antidepressant are now commonly used due to fewer side effects as compared to other types of antidepressants. The aim of this study was to assess the prevalence of periapical abscesses (PAs)in patients using SSRIs.

METHODS AND RESULTS

Integrated data of hospital patients was used. Data from the corresponding diagnosis codes for SSRIs and acute PAs was retrieved by searching the appropriate query in the database. The different diagnoses were coded using the international coding systems ICD 10. Diagnosis was made by calibrated dentists in a hospital setting based on clinical examination and imaging data. The odds ratio (OR) for the prevalence of acute PAs and its association with the use of SSRIs were calculated and analyzed statistically. It was found that the prevalence of acute PAs was significantly higher in patients using SSRIs as compared to the other hospital patient population. The OR was 2.8 and the difference between patients using SSRIs and patients who do not was statistically significant (p < .0001).

CONCLUSION

Under the conditions of this study, it appears that the prevalence of acute PAs is higher in patients using SSRIs.

The 'discontinuity hypothesis' of depression in later life-clinical and research implications

The term depression is overused as an umbrella term for a variety of conditions, including depressed mood and various psychiatric disorders. According to psychiatric diagnostic criteria, depressive disorders impact nearly all aspects of human life and are a leading cause of disability worldwide. The widespread assumption that different types of depression lie on a continuum of severity has stimulated important research on subthreshold depression in later life. This view assumes that depressed mood is a precursor of a depressive disorder. The present narrative review argues why in later life depressed mood might either (i) lie on a continuum with depressive disorders among people vulnerable for a depressive disorder or (ii) be an ageing-related epiphenomenon of underlying physical illnesses in people who are resilient to depressive disorders ('discontinuity hypothesis'). Three arguments are discussed. First, the course of depressed mood and depressive disorders differs across the life span. Second, screening instruments for depression have low predictive value for depressive disorders in later life. Third, a dose-response relationship has not been consistently found across different types of depression and detrimental health outcomes. Using the umbrella term depression may partly explain why pharmacological treatment is less effective with increasing age, and negative health-related outcomes might be overestimated. The discontinuity hypothesis may prevent pharmacological overtreatment of milder subtypes of depression and may stimulate comprehensive multidisciplinary assessment as well as the development of separate treatment algorithms for depressed mood and depressive disorders.

Racial Differences in Antidepressant Use in Nursing Facility Residents With Moderate to Severe Cognitive Impairment

Objective To describe and compare the use of antidepressants between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment. Design This was a secondary data analysis using baseline data from the Function and Behavior Focused Care for Nursing Facility Residents with Dementia randomized control trial. Setting Participants were recruited from 10 urban and two rural nursing facilities from Maryland. Methods Participants had to be 55 years of age or older, English-speaking, reside in long-term care at time of recruitment, and score a 15 or less on the Mini Mental-State Examination. A total of 336 residents participated at baseline. Data were collected by a research evaluator through observation, proxy report from staff caring for the resident the day of testing, and patient charts. Main Outcomes A significant difference of antidepressant use between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment would be noted when controlling for depression, age, gender, functional status, agitation, and number of co-morbidities. Results In adjusted models, Black or African descent residents were less likely to be prescribed antidepressants compared with White residents. Conclusion Racial differences were noted regarding antidepressant use among nursing facility residents with moderate to severe cognitive impairment, but it is unknown if race could impact prescribing practices when indications for use are known. Further research is needed to ascertain if knowing the specific indications for use might contribute to racial disparities with antidepressant prescribing in nursing facility residents with moderate to severe cognitive impairment.

An Updated Analysis of Psychotropic Medicine Utilisation in Older People in New Zealand from 2005 to 2019

BACKGROUND

Psychotropic medicine utilisation in older adults continues to be of interest because of overuse and concerns surrounding its safety and efficacy.

OBJECTIVE

This study aimed to characterise the utilisation of psychotropic medicines in older people in New Zealand.

METHODS

We conducted a repeated cross-sectional analysis of national dispensing data from 1 January, 2005 to 31 December, 2019. We defined utilisation using the Anatomical Therapeutic Chemical classification defined daily dose system. Utilisation was measured in terms of the defined daily dose (DDD) per 1000 older people per day (TOPD).

RESULTS

Overall, the utilisation of psychotropic medicines increased marginally by 0.42% between 2005 and 2019. The utilisation increased for antidepressants (72.42 to 75.21 DDD/TOPD) and antipsychotics (6.06-19.04 DDD/TOPD). In contrast, the utilisation of hypnotics and sedatives (53.74-38.90 DDD/TOPD) and anxiolytics decreased (10.20-9.87 DDD/TOPD). The utilisation of atypical antipsychotics increased (4.06-18.72 DDD/TOPD), with the highest percentage change in DDD/TOPD contributed by olanzapine (520.6 %). In comparison, utilisation of typical antipsychotics was relatively stable (2.00-2.06 DDD/TOPD). The utilisation of venlafaxine increased remarkably by 5.7 times between 2005 and 2019. The utilisation of zopiclone was far greater than that of other hypnotics in 2019.

CONCLUSIONS

There was only a marginal increase in psychotropic medicines utilisation from 2005 to 2019 in older adults in New Zealand. There was a five-fold increase in the utilisation of antipsychotic medicines. Continued monitoring of psychotropic medicine utilisation will be of interest to understand the utilisation of antidepressants and antipsychotic medicines during the coronavirus disease 2019 pandemic year.

Long-term antidepressant use in a cohort of older people

OBJECTIVES

Depression is the most common mental health problem in older adults and untreated is associated with significant burden of illness for patients. This study aimed to examine longitudinal patterns of antidepressant use in older adults and determine which factors were associated with changes in use.

METHODS

Adults aged 50 and over, from The Irish Longitudinal Study on Ageing (TILDA), who participated at any one of the four TILDA waves (n = 8175) were included in the analysis. Repeated measures latent class analysis (RMLCA) is the model-based approach we used to identify underlying subgroups in a population.

RESULTS

We found antidepressant use ranged from 6% to 10%, over a 6-year period. RMLCA identified three distinct classes of antidepressant use. Notably, 6% of older adults were categorised in a 'long-term antidepressant use' class, with consistent use across all four waves, and 6% were categorised in an 'Intermittent/Developing Use' class. We found long-term antidepressant use to be a characteristic of older adults with chronic conditions at baseline of study and striking low uptake of psychological and psychiatric services.

CONCLUSIONS

These findings provide evidence of the complex presentations of depression with comorbidities in long-term antidepressant users. While prolonged use of antidepressants in an older cohort is often rationalised due to recurrent depression and comorbidities, this study suggests little deprescribing of antidepressants and a need for greater access and provision of psychological services tailored to later life seem necessary improve management of this condition.

Serotonin Syndrome/Serotonin Toxicity

OBJECTIVE

This review of serotonin syndrome or serotonin toxicity covers the years 2014 to 2019, including information on pathophysiology, etiology, and diagnosis, 3 criteria for diagnosing serotonin syndrome, and criteria for neuroleptic malignant syndrome.

IMPORTANCE

The review highlights the potential lethal combinations of commonly prescribed medications used to treat both veteran and nonveteran patients and includes the latest information on offending medications.

CONCLUSIONS

Prevention of serotonin toxicity includes informed clinicians, patient education, careful prescribing and monitoring, and avoidance of multidrug regimens.

First Do No Harm: Psychotropic Prescribing Principles and Guidelines for Older Adults

The drive to prescribe to alleviate symptoms and ease suffering is prevalent in health care. In psychiatry, it is no different. Although monotherapy remains the preferred approach to treating psychiatric disorders, especially when combined with nonpharmacological approaches, in practice, a focus on remission of symptoms over patient preferences and quality of life can result in higher doses than necessary and polypharmacy from the addition of drugs for augmentation or treatment of adverse effects. This is especially concerning for older adults who are likely to have comorbid medical disorders, eventually leading to prescribing cascades as different providers address different symptoms. Whereas we generally look to best practice guidelines to treat identified disorders, the approach to treating older adults with multimorbidities requires collaboration among the patient, the family (if appropriate), and the provider to re-evaluate goals based on the patient's priorities, and to examine tradeoffs, reduce medication overload, and simplify care. Fortunately, many resources are available to help the clinician in this process. [Journal of Psychosocial Nursing and Mental Health Services, 58(8), 12-16.].