Predictors of chronic benzodiazepine use in a health maintenance organization sample

Risk of long-term benzodiazepine and Z-drug use following the first prescription among community-dwelling adults with anxiety/mood and sleep disorders: a retrospective cohort study

OBJECTIVE

To measure the incidence of long-term benzodiazepine receptor agonist (BZRA) use among individuals with anxiety, mood and/or sleep disorders. To identify factors associated with long-term use following the first prescription.

METHODS

This was a population-based retrospective cohort study using administrative databases in Manitoba, Canada. Individuals with anxiety/mood or sleep disorder who received their first BZRA between 1 April 2001 and 31 March 2015 were included. Long-term use was defined as ≥180 days. Logistic regression modelling was used to examine predictors of long-term use.

RESULTS

Among 206 933 individuals included, long-term BZRA use in the first episode of use was 4.5% (≥180 days) following their first prescription. Factors associated with ≥180 days of use included male sex (adjusted OR (aOR) 1.33, 95% CI 1.27 to 1.39), age ≥65 (aOR 5.15, 95% CI 4.81 to 5.52), income assistance (aOR 1.68, 95% CI 1.55 to 1.81), previous non-BZRA psychotropic (aOR 1.93, 95% CI 1.83 to 2.02) or opioid use (aOR 1.16, 95% CI 1.11 to 1.22), high comorbidity (aOR 1.43, 95% CI 1.32 to 1.55), high healthcare use (aOR 1.46, 95% CI 1.33 to 1.60) and psychiatrist prescriber (aOR 2.11, 95% CI 1.93 to 2.32).

CONCLUSIONS

Less than 1 in 20 patients use BZRAs ≥180 days in their first treatment episode. Several factors were associated with long-term use following the first prescription and further investigation into whether these factors need to be considered at the point of prescribing is warranted. In light of these findings, future research should examine the predictors of cumulative repeat episodes of BZRA exposure.

Discontinuation of Chronic Benzodiazepine Use Among Adults in the United States

BACKGROUND

Guidelines recommend most benzodiazepine (BZD) treatment be short-term, though chronic BZD use is increasing.

OBJECTIVE

Determine the rate of BZD discontinuation among chronic users and identify patient- and provider-level factors associated with discontinuation.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study using nationwide insurance claims data from 2014 to 2016 of US adults ≥ 18 years old with chronic BZD use (i.e., > 120 days) during the baseline year.

MAIN OUTCOMES AND MEASURES

The primary outcome was BZD discontinuation among chronic users after 1 year of follow-up. A series of multilevel logistic regression models examined the association of BZD discontinuation with patient and provider characteristics. Covariates included patient sociodemographics, medical and psychiatric comorbidity, co-prescribed opioids and other psychotropics, and characteristics of the prescribed BZD.

KEY RESULTS

Of 141,008 chronic BZD users, 13.4% discontinued use after 1 year. Females had lower odds of discontinuation (AOR 0.83, 99% CI 0.79-0.87), while African-American patients had higher odds (AOR 1.12, 99% CI 1.03-1.22). Those prescribed a high-potency BZD had lower odds of discontinuation (AOR 0.51, 99% CI 0.47-0.54), as did those prescribed an opioid (AOR 0.94, 99% CI 0.89-0.99). After adjusting for patient- and provider-level factors, differences between providers accounted for 5.8% of variation in BZD discontinuation (p < 0.001). The median odds ratio for provider was 1.54, an association with discontinuation larger than almost all patient-level clinical variables.

CONCLUSIONS

A small minority of patients prescribed chronic BZD in a given year are no longer prescribed BZDs 1 year later. There is significant variation in the likelihood of discontinuation accounted for by non-clinical factors such as race, geography, and a patient's provider, which had a stronger association with the odds of discontinuation than almost every other patient-level variable. Provider-facing elements of interventions to reduce BZD prescribing may be critical.

Factors associated with long-term prescription of benzodiazepine: a retrospective cohort study using a health insurance database in Japan

OBJECTIVES

Current clinical guidelines discourage long-term prescription of benzodiazepines and Z-drugs (BZD); however, the practice continues to exist. The aim of this study was to investigate the proportion of long-term BZD prescriptions and its risk factors.

DESIGN

Retrospective cohort study using a health insurance database.

SETTING

Japan.

PARTICIPANTS

A total of 86 909 patients were identified as outpatients aged 18 to 65 years who started BZD between 1 October 2012 and 1 April 2015. After excluding patients who underwent surgery on the day of first BZD prescription (n=762) and patients without 8 months follow-up (n=12 103), 74 044 outpatients were analysed.

MAIN OUTCOME MEASURES

We investigated the proportion of long-term prescriptions for ≥8 months among new BZD users. We assessed patient demographics, diagnoses, characteristics of the initial BZD prescription and prescribers as potential predictors of the long-term BZD prescription. Multivariable logistic regression was performed to assess the association between long-term prescription and potential predictors.

RESULTS

Of the new BZD users, 6687 (9.0%) were consecutively prescribed BZD for ≥8 months. The long-term prescription was significantly associated with mood and neurotic disorder, cancer, prescription by psychiatrists, multiple prescriptions, hypnotics and medium half-life BZD in the initial prescription.

CONCLUSION

Despite the recent clinical guidelines, 9% of new BZD users were given prescriptions for more than 8 months. Physicians should be aware of risk factors when prescribing BZDs for the first time.

Frequent attenders in general medical practice in Italy: a preliminary report on clinical variables related to low functioning

BACKGROUND

Frequent attenders (FAs), defined as patients reporting a disproportionate number of visits to general practitioners (GPs), may represent up to one-third of GP patients responsible for a high burden of care not always justified by the severity of the medical condition. The aim of this study was to explore sociodemographic and clinical characteristics of FAs of GP in Italy with particular attention to functional impairment.

METHODS

A total sample of 75 FAs (defined as individuals who had consulted GPs 15 times or more during 2015) of GPs of three primary care centers (Pisa, Livorno, and Lucca) in Italy were enrolled and assessed by sociodemographic scale, Structured Clinical Interview for DSM-5 (SCID-5), global functioning (Global Assessment of Functioning [GAF]), illness behavior and perceived health (Illness Behavior Inventory), and somatic comorbidity (Cumulative Illness Rating Scale).

RESULTS

Most of the sample were females, middle aged, married, or cohabiting, with low levels of education. One-third of FAs was low functioning (LF; GAF score <70), with no differences in the sociodemographic variables. Approximately 70.3% of the patients reported a current SCID diagnosis, in particular, major depressive disorder, somatic symptom disorders, and panic disorder, all being more frequent in LF patients. Half of the patients were taking a psychopharmacological therapy, mostly benzodiazepines (BDZs).

CONCLUSION

Most FAs were female with current medical disorders, and LF. All claimed to be worried about their own health and perceived themselves as more impaired also regarding the health perception and social role. LF patients were, or had been more likely to be under psychopharmacological treatment. FAs seem to constitute a special population that should be carefully evaluated for mental disorders and appropriate treatment.

County and Physician Variation in Benzodiazepine Prescribing to Medicare Beneficiaries by Primary Care Physicians in the USA

BACKGROUND

Physicians widely prescribe benzodiazepines (BZD) despite well-recognized harms.

OBJECTIVE

To determine county and provider characteristics that predict high-intensity BZD prescribing by primary care physicians (PCPs) to Medicare beneficiaries.

DESIGN

Cross-sectional analysis of the 2015 Medicare Part D Public Use Files (PUF).

SUBJECTS

n = 122,054 PCPs who prescribed 37.3 billion medication days.

MAIN MEASURES

Primary outcome was intensity of BZD prescribing (days prescribed/total medication days) at the county- and physician levels. PCP and county characteristics were derived from the Part D PUF, Area Health Resources Files, and County Health Rankings. Logistic regression determined the characteristics associated with high-intensity (top quartile) BZD prescribing.

KEY RESULTS

Beneficiaries were prescribed over 1.2 billion days of BZD in 2015, accounting for 2.3% of all medication days prescribed in Part D. Top quartile counties had 3.1 times higher BZD prescribing than the lowest (3.4% vs. 1.1%; F = 3293.8, df = 3, p < 0.001). Adjusting for county-level demographics and health care system characteristics (including supply of mental health providers), counties with more adults with at least some college had lower odds of high-intensity prescribing (per 5% increase, adjusted odds ratio [AOR] 0.80, 99% confidence interval (CI) 0.73-0.87, p < 0.001), as did higher income counties (per US$1000 increase, AOR 0.93, CI 0.91-0.95, p < 0.001). Top quartile PCPs prescribed at 6.5 times the rate of the bottom (3.9% vs. 0.6%; F = 63,910.2, df = 3, p < 0.001). High-intensity opioid prescribing (AOR 4.18, CI 3.90-4.48, p < 0.001) was the characteristic most strongly associated with BZD prescribing.

CONCLUSIONS

BZD prescribing appears to vary across counties and providers and is related to non-patient characteristics. Further work is needed to understand how such non-clinical factors drive variation.

What can predict and prevent the long-term use of benzodiazepines?

Although benzodiazepines (BZDs) are commonly prescribed for insomnia or anxiety, long-term use of BZDs causes serious adverse effects such as daytime drowsiness and cognitive decline. In the current study, we evaluated the predictors and preventers of long-term usage of BZDs from a retrospective survey by utilizing the 12-year prescription record of a university hospital. From the prescription data of 92,005 people, users of BZDs (n = 3,470, male = 39.2%, mean age = 60 ± 17.5) were analyzed. During this period, both the number of prescriptions (2722 in 2004 to 1019 in 2016) and the number of BZDs (1.73 in 2004 to 1.36 in 2016) gradually decreased, although more than half of the patients continued to take BZDs for over three years. High risk factors for long-term use of BZDs include elderly patients (>65 years old), high dosage (>5 mg diazepam per day), psychiatrist-prescribers, and users with polytherapy. Discontinuation is significantly found in users of hypnotic BZDs and alternative psychotropic medical drugs (including antipsychotics, serotonergic drugs, or newer types of sleep medicine). Future studies should focus on elucidating interventions that are more effective against long-term usage of BZDs.

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.

Benzodiazepine use in patients with chronic pain in an interdisciplinary pain rehabilitation program

Objectives

In the context of widespread opioid use, increased emphasis has been placed on the potentially deleterious effects of concurrent benzodiazepine (BZD) and opioid use. Although use of opioids in chronic pain has been a major focus, BZD use is equally concerning. Thus, the primary aim of this study was to determine the associations between BZD and opioid use in adults with chronic pain upon admission to an outpatient interdisciplinary pain rehabilitation (IPR) program.

Methods

The study cohort involved 847 consecutive patients admitted to a 3-week outpatient IPR program from January 2013 through December 2014. Study variables included baseline demographic and clinical characteristics, Center for Epidemiologic Studies-Depression Scale, Pain Catastrophizing Scale, and the pain severity subscale of the Multidimensional Pain Inventory.

Results

Upon admission, 248 (29%) patients were taking BZDs. Patients using BZDs were significantly more likely to use opioids and to be female. Additionally, patients using BZDs had significantly greater depression, pain catastrophizing, and pain severity scores. In univariable logistic regression analysis, opioid use, female sex, and greater scores of depression, pain catastrophizing, and pain severity were significantly associated with BZD use. In multivariable logistic regression analysis adjusted for age, sex, pain duration, opioid use, depression, pain catastrophizing, and pain severity, only female sex and greater depression scores were significantly associated with BZD use.

Discussion

Among patients participating in an outpatient IPR program, female sex and greater depression scores were associated with BZD use. Results identify a high prevalence of BZD use in patients with chronic pain and reinforce the need to weigh the risks versus benefits when prescribing in this patient population.

No End in Sight: Benzodiazepine Use in Older Adults in the United States

OBJECTIVES

To establish the rate of new and continuation of benzodiazepine use in older adults seen by nonpsychiatrist physicians and to identify subpopulations at risk of new and continuation benzodiazepine use.

DESIGN

Cross-sectional analysis.

SETTING

National Ambulatory Medical Care Survey (2007-10).

PARTICIPANTS

Adults visiting office-based nonpsychiatrist physicians (n = 98,818) who were prescribed a benzodiazepine (new or continuation).

MEASUREMENTS

Percentage of benzodiazepine visits of all outpatient encounters according to patient age and corresponding annual visit rate per 1,000 population. Analysis was then limited to adults aged 65 and older, demographic, clinical, and visits characteristics were used to compare visits of benzodiazepine users with those of nonusers and visits of continuation users with those of new users.

RESULTS

The overall proportion of benzodiazepine visits ranged from 3.2% (95% confidence interval (CI) = 2.7-3.7) of those aged 18 to 34 to 6.6% (95% CI = 5.8-7.6) of those aged 80 and older, and the proportion of continuation visits increased with age, rising to 90.2% (95% CI = 86.2-93.1) of those aged 80 and older. The population-based visit rate ranged from 61.7 (95% CI = 50.7-72.7) per 1,000 persons in the youngest adults to 463.7 (95% CI = 385.4-542.0) in those aged 80 and older. Only 16.0% (95% CI = 13.5-18.8) of continuation users had any mental health diagnosis. Of all benzodiazepine users, fewer than 1% (95% CI = .4-1.8) were provided or referred to psychotherapy, and 10.0% (95% CI = 7. 2-13.3) were also prescribed an opioid.

CONCLUSION

In the United States, few older adult benzodiazepine users receive a clinical mental health diagnosis, and almost none are provided or referred to psychotherapy. Prescribing to older adults continues despite decades of evidence documenting safety concerns, effective alternative treatments, and effective methods for tapering even chronic users.

Preteen Attitudes about Smoking and Parental Factors Associated with Favorable Attitudes

Purpose.

To describe youth smoking-related attitudes and evaluate the effects of parental factors on child adoption of positive attitudes about smoking.

Design.

This study used baseline and 20-month data from a family-based smoking-prevention study (82.9% completed both surveys).

Setting.

Telephone recruitment from two health maintenance organizations.

Subjects.

Children aged 10 to 12 years and one parent of each child (n = 418 families) were randomly assigned to a frequent assessment cohort (12.5% of participants).

Intervention.

Families received a mailed smoking-prevention packet (parent handbook, videotape about youth smoking, comic book, pen, and stickers), outreach telephone counselor calls to the parent, a newsletter, and medical record prompts for providers to deliver smoking-prevention messages to parents and children.

Measures.

Demographics, tobacco status, attitudes about smoking (Teenage Attitudes and Practices Survey), family discussions about tobacco, family cohesiveness (family support and togetherness), parent involvement, parent monitoring, and parenting confidence.

Results.

One-third of the children endorsed beliefs that they could smoke without becoming addicted, and 8% to 10% endorsed beliefs on the benefits of smoking. Children's positive attitudes about smoking were associated with lower family cohesiveness (p = .01). Parental use of tobacco was the only significant predictor of children's positive attitudes about tobacco at 20 months (p = .03).

Conclusions.

Children as young as 10 years underestimate addictive properties of smoking, which may place them at risk for future smoking. Parental use of tobacco and family cohesiveness are important factors in the formulation of preteen attitudes about smoking.

Continuation and discontinuation of benzodiazepine prescriptions: A cohort study based on a large claims database in Japan

Although benzodiazepines (BZDs) are often prescribed to treat a wide range of psychiatric and neurological conditions, they are also associated with various harms and risks including dependence. However the frequency of its continued use in the real world has not been well studied, especially at longer follow-ups. The aim of this study was to clarify the frequency of long-term BZD use among new BZD users over longer follow-ups and to identify its predictors. We conducted a cohort study to examine how frequently new BZD users became chronic users, based on a large claims database in Japan from January 2005 to June 2014. We used Cox proportional hazards models to identify potential predictors. A total 84,412 patients with new BZD prescriptions were included in our cohort. Among them, 35.8% continued to use BZD for three months, 15.2% for one year and 4.9% for eight years without ever attaining three months of no BZD prescription. The confirmed predictors for long-term BZD use were older age, psychiatrist-prescriber, regular use, high dose of BZD, and concomitant prescription of psychotropic drugs. When we consider BZD use, we have to keep in mind these figures and avoid these predictors as much as possible.

Long-term use of benzodiazepines: Definitions, prevalence and usage patterns – a systematic review of register-based studies

Background

Numerous treatment guidelines recommend that long-term use of benzodiazepines (BZD) should be avoided primarily due to development of tolerance and a risk for BZD dependence. Despite this, long-term BZD use remains a controversial subject in clinical patient care with “for and against” debates. However, there is no explicit understanding of what is meant by long-term BZD use in real world. The aim of this study was to assess different definitions, usage patterns, prevalence and other characteristics of long-term BZD use based on published register-based studies. Synthesis of these characteristics is essential to derive a meaningful definition of long-term BZD.

Methods

Systematic review of register-based studies on long-term BZD use published in 1994–2014.

Results

Fourty-one studies met our predetermined inclusion criteria. The length of BZD use defined as “long-term” varied in these studies ranging from one month to several years. The most common definition was six months or longer during a year. The prevalence of long-term BZD use in the general population was estimated to be about 3%. The relative proportion of long-term BZD users (all definitions) in adult BZD users ranged from 6% to 76% (mean 24%; 95% CL 13–36%). The estimates were higher in studies only on the elderly (47%; 95% CL 31–64%). Long-term use involved typically steady treatment with low BZD doses. However, in elderly patients long-term BZD use and exceeding recommended doses was relatively common. Several characteristics associated with long-term use were found.

Conclusions

Long-term BZD use is common and a clinical reality. Uniform definitions for “long-term”, which is in line with population-based evidence, is needed to have more comparable results between studies. Our systematic review suggests that duration of BZD treatment over six months, the most common definition for long-term BZD use in the included studies. As also recommended previously, it is a useful starting point for further analyses on disadvantages but also potential advantages associated with long-term BZD use.

Chronic opioid use emerging after bariatric surgery

PURPOSE

Little is known about opioid use after bariatric surgery among patients who did not use opioids chronically before surgery. Our purpose was to determine opioid use the year after bariatric surgery among patients who did not use opioids chronically pre-surgery and to identify pre-surgery characteristics associated with chronic opioid use after surgery.

METHODS

This retrospective cohort study across nine US health systems included 10 643 patients aged 21 years or older who underwent bariatric surgery and who were not chronic opioid users pre-surgery. The main outcome was chronic opioid use the post-surgery year (excluding 30 post-operative days) defined as ≥10 dispensings over ≥90 days or ≥120 total days' supply.

RESULTS

Overall, 4.0% (n = 421) of patients became chronic opioid users the post-surgery year. Pre-surgery opioid total days' supply was strongly associated with chronic use post-surgery (1-29 days adjusted odds ratio [OR] 1.89 [95%CI, 1.24-2.88]; 90-119 days OR, 14.29 [95%CI, 6.94-29.42] compared with no days). Other factors associated with increased likelihood of post-surgery chronic use included pre-surgery use of non-narcotic analgesics (OR, 2.22 [95%CI, 1.39-3.54]), antianxiety agents (OR, 1.67 [95%CI, 1.12-2.50]), and tobacco (OR, 1.44 [95%CI, 1.03-2.02]). Older age (OR, 0.84 [95%CI, 0.73-0.97] each decade) and a laparoscopic band procedure (OR, 0.42 [95%CI, 0.25-0.70] vs. laparoscopic bypass) were associated with decreased likelihood of chronic opioid use post-surgery.

CONCLUSIONS

Most patients who became chronic opioid users the year after bariatric surgery used opioids intermittently before surgery.

Clearance of meperidine and its metabolite normeperidine in hemodialysis patients with chronic noncancer pain

CONTEXT

Normeperidine accumulates in patients with impaired renal function and may cause central neurotoxicity. However, some uremic patients still undergo meperidine treatment for chronic pain.

OBJECTIVES

To prevent normeperidine side effects and complications, we investigated the clearance rate and extraction ratio of meperidine and normeperidine in hemodialysis patients with chronic pain.

METHODS

Three hemodialysis patients, with diagnoses of chronic pancreatitis, chronic back pain, and intractable intra-abdominal pain, received long-term (more than six months) administration of meperidine for chronic noncancer pain. During regular hemodialysis, 72 blood samples in total were collected from the afferent port, efferent port, and ultradiafiltrate port at eight time points. The plasma concentrations of meperidine and normeperidine were determined by high-performance liquid chromatography.

RESULTS

The prehemodialysis plasma concentrations of meperidine and normeperidine were 2963 ± 315 and 2369 ± 1974 ng/mL, which declined to 591 ± 109 and 853 ± 765 ng/mL, with 80% and 65% reduction, respectively. The plasma clearance and extraction ratios of meperidine were 22.7 ± 9.8 mL/minute and 10.1 ± 5.6% and for normeperidine 26.0 ± 11.4 mL/minute and 10.8 ± 2.5%, respectively.

CONCLUSION

Hemodialysis can efficiently remove meperidine and its active metabolite, normeperidine, in uremic patients receiving long-term meperidine therapy for chronic noncancer pain.

The effect of the Medicare Part D benzodiazepine exclusion on the utilization patterns of benzodiazepines and substitute medications

BACKGROUND

Although the benzodiazepine exclusion policy in the U.S. Medicare Part D drug coverage program has been studied, little information is available on individual use and switching patterns between benzodiazepines and substitute medications. Patients voluntarily were continuing or stopping benzodiazepines or switching to substitute medications. These individual-level outcomes can provide information beneficial to providers and policymakers to better understand the intended and unintended consequences of exclusion policies.

OBJECTIVE

The objective was to determine the effect of the Medicare Part D benzodiazepine exclusion on the utilization patterns of benzodiazepines and substitute medications by a select group of Medicare beneficiaries for a year following implementation of the exclusion. This research focused on the examination of the within-person patterns of benzodiazepine use and factors associated with these patterns.

METHODS

A quasi-experimental, comparative study was used to analyze prescription patterns and multinomial regression models were applied to investigate factors predicting different benzodiazepine use patterns. Pharmacy dispensing data for continuously eligible Medicare beneficiaries with at least one benzodiazepine fill in 2005 were reduced to a comparison group of 216 individuals with continual coverage and an intervention group of 250 individuals who lost coverage for benzodiazepines. Four individual patients' drug use patterns, continuation, switch, fluid movement, and cessation were identified by sorting and arraying pharmacy dispensing data to apply systematic drug file review. Multinomial regression models were used to examine the impact of coverage, demographic, medical, economic, and pharmaceutical factors.

RESULTS

Significantly more Medicare seniors who lost benzodiazepine coverage switched to potential substitute medications than those who continued to have coverage. Interestingly, 12 percent of affected seniors and 6 percent of unaffected seniors switched from and back to benzodiazepines (fluid movement). Zolpidem was the most popular substitute agent despite being an expensive brand-name drug. Regression models revealed that affected individuals had nearly two times the odds of engaging in switch-related patterns than those who had continuous coverage. Also, women were twice as likely to discontinue benzodiazepines as men.

CONCLUSIONS

More seniors who lost benzodiazepine coverage engaged in medication switching, and women were more likely to stop benzodiazepines after the implementation of the exclusion policy.

The effect of eszopiclone in patients with insomnia and coexisting rheumatoid arthritis: a pilot study

OBJECTIVE

To evaluate the efficacy and safety of eszopiclone 3 mg, a nonbenzodiazepine medication/hypnotic indicated for the treatment of insomnia with comorbid rheumatoid arthritis (RA).

METHOD

This multicenter, double-blind, placebo-controlled pilot study was conducted in 153 patients aged 25-64 years with American College of Rheumatology-defined RA who met DSM-IV criteria for insomnia. The data were collected from February to November of 2004. Patients were randomly assigned to either eszopiclone or placebo nightly for 4 weeks, followed by a 2-week placebo run out. Efficacy was evaluated using patient reports of sleep (wake time after sleep onset [WASO], sleep latency [SL], and total sleep time [TST]), daytime function, pain, and RA assessments. Insomnia severity was evaluated using the Insomnia Severity Index. Safety was also evaluated.

RESULTS

Eszopiclone significantly improved all patient-reported sleep measures (WASO, SL, and TST), sleep quality, depth of sleep, and daytime function (P < .05 vs placebo). At week 4, 48% of eszopiclone-treated patients had no clinically meaningful insomnia as assessed by ISI score (versus 30% of placebo-treated patients, P = .03). Eszopiclone was significantly better than placebo on some RA-associated pain measures: (1) overall (P = .05), pain (P = .006), and pain and other symptoms (P = .02) scores of the Arthritis Self-Efficacy Scale, (2) tender joint counts (P = .03) and pain severity scores (P = .023), (3) the activities domain of the Health Assessment Questionnaire-Disability Index (P = .04), and (4) the role physical (P = .03) and bodily pain (P = .01) scales of the 36-item Medical Outcomes Study Short-Form General Health Survey. The most commonly reported adverse events with eszopiclone were unpleasant taste and transient increases in RA symptoms.

CONCLUSIONS

In this pilot study of patients with insomnia comorbid with RA, eszopiclone 3 mg improved all assessed sleep and daytime function measures over the treatment period, as well as some measures of RA-associated pain, disability, and quality of life.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00367965.

Determinants of initiated and continued benzodiazepine use in the Netherlands study of depression and anxiety

BACKGROUND

Longitudinal research on determinants of initiated and continued benzodiazepine (BZD) use is inconsistent and has identified many possible determinants. It is unclear which of those are most important in the prediction of BZD use. We aimed to identify the most important predictors of initiated and continued BZD use. Therefore, we analyzed the most consistently identified determinants from previous research plus some new determinants.

METHODS

We identified baseline and 2-year longitudinal predictors of initiated BZD use (vs nonuse) among 2205 baseline BZD nonusers and of continued use (vs discontinued use) among 369 baseline BZD users in the Netherlands Study of Depression and Anxiety using logistic regression analyses.

RESULTS

During follow-up, BZD use was initiated by 4.9% of BZD nonusers at baseline. Initiated use was predicted by insomnia (odds ratio [OR], 1.60), enduring anxiety symptoms (OR, 2.02), entering secondary care during follow-up (OR, 2.85), and past BZD use (OR, 3.57). Positive life events during follow-up reduced the likelihood of BZD initiation (OR, 0.76). Of BZD users at baseline, 54.2% continued use during the entire follow-up period. Continuation of BZD use was predicted by higher age (OR, 1.03), severe anxiety (OR, 1.85), and a long duration of BZD use (OR, 1.54). Leaving secondary care was associated with less continued BZD use (OR, 0.29).

CONCLUSION

Insomnia and anxiety were the main risk factors of initiated use, whereas advanced age and anxiety severity were the main risk factors of continued use. Sex, education, pain, and physical health seemed to be less important.

Adjunctive benzodiazepine treatment of hospitalized schizophrenia patients in Asia from 2001 to 2008

Benzodiazepines are commonly prescribed to patients with schizophrenia in many countries, but as little is known about such treatment in Asia, we evaluated their adjunctive use for 6761 in-patients diagnosed with schizophrenia in nine Asian countries using a cross-sectional study design in 2001, 2004 and 2008. Multivariate logistic regression and multivariate linear regression analyses were performed to assess predictors of benzodiazepine use and dose, respectively. Overall, 54% of the patients received adjunctive benzodiazepines at an average daily dose equivalent to 30.3 mg diazepam, with minor changes over the years sampled. Benzodiazepine use was highest in Taiwan and Japan, lowest in Thailand and China, and was associated with fewer years ill, presence of delusions (OR 1.24), hallucinations (OR 1.22), disorganized speech (OR 1.17), social or occupational dysfunction (OR 1.16), and use of mood stabilizers (OR 3.15), antiparkinsonian (OR 1.79) or antidepressant drugs (OR 1.33), and lower doses of antipsychotics (all p=0.016 to <0.001). Benzodiazepine doses were highest in Taiwan and China, lowest in Korea and Singapore; higher doses were associated with being young, male, physically aggressive, receiving mood stabilizers, and having electroconvulsive treatment (all p=0.019 to <0.001). Benzodiazepine use was associated with neurological and systemic adverse effects. In conclusion, benzodiazepine use was common in Asian patients with schizophrenia. Predictors of benzodiazepine use and dose differed in this population. Critical clinical guidelines should be developed specifically for Asian countries to address sound practices in regard to use of benzodiazepines for psychotic disorders.

Racial differences in primary care opioid risk reduction strategies

PURPOSE

Racial disparities in treating pain with opioids are widely reported; however, differences in use of recommended strategies to reduce the risk of opioid misuse by race/ethnicity have not been evaluated.

METHODS

In a retrospective cohort of black and white patients with chronic noncancer pain prescribed opioid analgesics for at least 3 months, we assessed physicians' use of 3 opioid risk reduction strategies: (1) urine drug testing, (2) regular office visits (at least 1 visit per 6 months on opioids and within 30 days of an opioid change), and (3) restricted early opioid refills (receipt of a refill >1 week early less than twice). Nonlinear mixed effect regression models accounted for clustering within physician and adjusted additively for demographics, substance abuse, mental health and medical comorbidities, health care factors, and practice site.

RESULTS

Of the 1,612 patients studied, 62.1% were black. Black patients were more likely than white patients to receive urine drug testing (10.4% vs 4.1%), regular office visits (56.4% vs 39.0%), and restricted early refills (79.4% vs 72.0%) (P <.001 for each). In fully adjusted models, black patients had significantly higher odds than their white counterparts of receiving regular office visits (odds ratio = 1.51; 95% confidence interval, 1.06-2.14) and restricted early refills (odds ratio = 1.55; 95% confidence interval, 1.03-2.32), but not urine drug testing (odds ratio = 1.41; 95% confidence interval, 0.78-2.54).

CONCLUSIONS

In this cohort of primary care patients receiving opioid analgesics on a long-term basis, use of risk reduction strategies was very limited overall; however, black patients were more likely than white patients to receive 2 of 3 guideline-recommended strategies. These data raise questions about lax monitoring, especially for white patients taking opioids long term.

Benzodiazepine prescription among patients with severe mental illness and co-occurring alcohol abuse/dependence in Taiwan

OBJECTIVE

Because benzodiazepines (BZDs) may be abused, prescribing them is debatable. The purpose of this study was to investigate the prescription of BZDs to explore the current status of BZD use at discharge and at 4 months after discharge.

METHODS

From 1 January 2006 to 31 December 2006, prescribed doses for BZDs at discharge and at 4 months after discharge were recorded for all discharged inpatients with schizophrenia, bipolar I disorder, and major depressive disorder. Two‐way analysis of variance was used to analyze the effects of severe mental illness and co‐occurring alcohol abuse/dependence on BZD doses at discharge and at 4 months after discharge.

RESULTS

Patients with severe mental illness prescribed with significantly higher rates and higher doses of BZDs at discharge and at 4 months after discharge are more likely to have major depressive disorder and to have co‐occurring alcohol abuse/dependence problems. No significant interactions were found between severe mental illness and co‐occurring alcohol abuse/dependence.

CONCLUSIONS

These findings suggest that caution should be applied in prescribing BZDs to patients with severe mental illness, particularly those with major depressive disorder and co‐occurring alcohol abuse/dependence. Future studies require being conducted in many different mental health‐care systems in Taiwan to generalize the findings.

Correlates of (inappropriate) benzodiazepine use: the Netherlands Study of Depression and Anxiety (NESDA)

AIM

Results on determinants of benzodiazepine (BZD) use in general and inappropriate use were inconsistent and mostly univariate. The relative importance of sociodemographic, psychological and physical determinants has never been investigated in a comprehensive, multivariate model.

METHODS

We included 429 BZD users and 2423 non-users from the Netherlands Study of Depression and Anxiety (NESDA) in order to investigate sociodemographic, psychological and physical determinants of BZD use and inappropriate use by logistic and linear regression analyses.

RESULTS

BZDs were used by a considerable proportion of the 2852 NESDA participants (15.0%). BZD use was independently associated with older age, singleness, unemployment, treatment in secondary care, higher medical consumption (more severe) anxiety, depression (OR [95% CI]=1.95 [1.29, 2.93]), comorbidity, insomnia, SSRI (OR [95% CI]=2.05 [1.55, 2.70]), TCA and other antidepressant (OR [95% CI]=2.44 [1.64, 3.62]) use. Overall, BZD use was rarely in accordance with all guidelines, mainly because most users (82.5%) exceeded the recommended duration of safe use. Inappropriate use was independently associated with older age (β=0.130) and chronic illnesses (β=0.120). Higher scores on agreeableness were associated with less inappropriate use.

CONCLUSIONS

Mentally or physically vulnerable subjects were most likely to use BZDs. The most vulnerable (i.e. the old and physically ill) BZD users were at highest risk of inappropriate BZD use. Without further evidence of the effectiveness of BZDs in long-term use, caution in initiating BZD prescriptions is recommended, particularly when patients are chronically ill and old, as those are most likely to display inappropriate use.

The association between obesity, depression, and educational attainment in women: the mediating role of body image dissatisfaction

OBJECTIVE

We examine the mediating role of body image dissatisfaction (BID) on the association between obesity and depression and the variation of this association as a function of years of education among a population-based sample of women aged 40-65 years.

METHODS

A series of sample-weighted logistic regression models were used to estimate the associations between obesity, BID, and depression, stratified by educational attainment. Data were obtained from a structured telephone interview of 4543 female health plan enrollees, including self-reported height and weight, the Patient Health Questionnaire assessment of depression, and a single-item measure of BID.

RESULTS

Among those with <16 years of education, in both the unadjusted and adjusted models, obesity and BID were significantly associated with depression. Similarly, among those with ≥ 16 years of education, obesity and BID were significantly associated with depression in the unadjusted models. However, in the adjusted model, only BID was associated with depression. A formal test for mediation suggests that the association between obesity and depression was mediated by BID regardless of level of education.

CONCLUSIONS

Our data suggest that BID-mediated the obesity-depression association. In addition, obesity and BID may be salient risk factors for depression among middle-aged women as a function of the level of education.

Elderly and drugs: risks and necessity of rational use

In recent decades, the world has undergone a demographic transformation with a rapid growth of the elderly population, resulting in an increased demand for funds to maintain their health and drug consumption. Pharmacokinetic and pharmacodynamic changes occurring in the elderly can interfere directly in the adverse effects of drugs and increase the risk of intoxication. In addition, there are external factors interfering with the pharmacotherapy of the elderly, such as inappropriate use and the lack of access to information. Many therapeutic classes of drugs should be used with caution or avoided in the elderly population, such as anti-inflammatory and some anti-hypertensive drugs, diuretics and digitalis. If not managed carefully, these medicines can affect the safety and quality of life in the elderly. Thus, the aim of this review was to identify drugs that should be used with caution in elderly patients in order to avoid intoxication and/or adverse drug events.

Use of benzodiazepines, hypnotics, and anxiolytics in major depressive disorder: association with chronic pain diseases

We examined the use of benzodiazepines (BZD), hypnotics, and anxiolytics and their associations with chronic pain diseases (CPD) in patients with major depressive disorder (MDD). A retrospective analysis of 153,913 MDD patients (18-64 years) in a large administrative insured claims database during the year 2006 was performed. Results showed that during the study year, 33.1% of the patients had been prescribed BZD; 16.9%, hypnotics; and 6.1%, anxiolytics. The use of BZD and hypnotics increased with age. Patients with CPD were more likely than those without CPD to use BZD (41.2% vs. 27.0%, p < 0.001), hypnotics (21.7% vs. 13.3%, p < 0.001), and anxiolytics (7.8% vs. 4.8%, p < 0.01). After adjustment for demographics and comorbidities, CPD was still significantly associated with increased use of BZD (OR = 1.62), hypnotics (OR = 1.49), and anxiolytics (OR = 1.51). Further research is needed to examine the long-term benefits and risks of BZD and hypnotics in the treatment of MDD and CPD.

Facteurs associés à la consommation de courte et de longue durée des benzodiazépines chez les personnes âgées du Québec

In Quebec, benzodiazepines are some of the most extensively used drugs by the elderly. The goal of this study was to identify factors associated with short- and long-term benzodiazepine use among 2,039 elderly persons having participated in the Quebec Health Survey conducted in 1998. Results of the multivariate, multinomial logistic regression showed that a higher number of chronic health problems, a higher number of physicians visited and general practitioners consulted were associated with short- and long-term use of benzodiazepines. Factors specifically associated with long-term use were female gender (OR=1.84) and the presence of benzodiazepine users in the household (OR=1.90). In this study, we were unable to show a difference between the two groups of users with regards to the risk factors studied. This result leads us to conclude that prevention of long-term use must be aimed at all new benzodiazepine users.

Treatment of major depressive disorder in the Finnish general population

BACKGROUND

Few general population studies of the treatment of major depressive disorder (MDD) have included the whole spectrum of treatments. We estimated the rates of different treatments and the effect of individual and disorder characteristics plus provider type on treatment received.

METHODS

In the Health 2000 Study, a representative sample (n=6,005) from the adult Finnish population (> or =30 years) were interviewed (CIDI) in 2000-2001 for the presence of DSM-IV mental disorders during the past 12 months. Logistic regression models were used to examine factors influencing the type of treatment: either pharmacotherapies (antidepressants, anxiolytics, sedatives/hypnotics, antipsychotics) or psychological treatment.

RESULTS

Of the individuals with MDD (n=288), currently 24% used antidepressants, 11% anxiolytics, 16% sedatives/hypnotics, 5% antipsychotics, and 17% reported having received psychological treatment. Overall, 31% received antidepressants or psychological treatment or both; 18% received minimally adequate treatment. Of those 33% (n=94) using health care services for mental reasons, 76% received antidepressants or psychological treatment or both; 54% received minimal adequate treatment. In logistic regression models, the use of antidepressants was associated with female sex, being single, severe MDD, perceived disability, and comorbid dysthymic disorder; psychological treatment with being divorced, perceived disability, and comorbid anxiety disorder.

CONCLUSIONS

Due to the low use of health services for mental reasons, only one-third of subjects with MDD use antidepressants, and less than one-fifth receives psychological treatment. The treatments provided are determined mostly by clinical factors such as severity and comorbidity, in part by sex and marital status, but not education or income.

Does the association between depression and smoking vary by body mass index (BMI) category?

OBJECTIVE

The purpose of this study was to explore how weight might influence the relationship between depression and smoking.

METHODS

Data were obtained from a cross-sectional survey representative of women age 40-65 enrolled in Group Health Cooperative, a health plan serving members in Washington and northern Idaho (n=4640). We examined the relationships between depression and smoking in normal weight, overweight, and obese women using weighted multiple logistic regression with both minimal and full adjustment.

RESULTS

Current depression was significantly associated with current smoking in obese women (adjusted odds ratio=2.48, 95% confidence interval=1.26-4.88) but not in underweight/normal or overweight women. Among ever smokers, obese women, but not other groups, were significantly less likely to have quit smoking in the past.

CONCLUSIONS

In our preliminary study, the association between smoking and depression in middle-aged women appears to be limited to the obese subset and may stem from a lesser likelihood of obese ever smokers to have quit. This population represents an important target for preventive medicine efforts.

Predictors of the incidence and discontinuation of long-term use of benzodiazepines: a population-based study

Long-term use of benzodiazepines (BZDs) has been linked with an array of negative health consequences and increased medical costs and social burden. In this study, we sought to investigate the factors accounting for differential risks in the process from incident BZD use to long-term use and discontinuation in the general population. On the basis of a random sample of 187,413 people enrolled in Taiwan's National Health Insurance program on January 1, 2000, data of 2000-2002 healthcare and pharmacological services utilization were retrieved. Long-term use (LTU) was defined by having received BZD prescriptions for 180 or more days within any given calendar year. Multivariate logistic regression analyses were carried out to assess the strength of associations while adjusting for the effects of individual sociodemographics, service providers, and pharmacological agents simultaneously. Results indicated that males, elderly, and those with physical or mental disorders were more likely to become long-term users of BZDs. Having received BZD prescriptions in multiple pharmacological agents, short-acting or mixed-type agents, and hypnotic indication were associated with a roughly 2- to 5-fold increased risk of BZD LTU soon after prescription initiation. With respect to discontinuation, the effects of pharmacological characteristics seem more salient as compared to those of individual and service-provider factors. Future strategies targeting individual factors and modifying service-provider prescription behaviors may be considered to reduce possible negative consequences of BZD LTU.

Benzodiazepine use in the elderly: an indicator for inappropriately treated geriatric depression?

OBJECTIVE

To measure the prevalence of benzodiazepine (BZD) use and to explore associated demographic and clinical variables of BZD use within a cohort of 75-year- old inhabitants of an urban district of Vienna.

METHODS

This is a prospective, interdisciplinary cohort study on aging. Our investigation is based on the first consecutive 500 subjects that completed the study protocol. Demographic and clinical characteristics, benzodiazepine and antidepressant use were documented using a standardized questionnaire. Affective status was assessed using the Hamilton Depression Rating Scale (HAMD), the Geriatric Depression Scale (GDS), and the Spielberger State-and Trait Anxiety Inventory subscales (STAI).

RESULTS

Prevalence of BZD use was 13.8%. Compared to non-users, BZD users had significantly higher mean scores at the HAMD (p = 0.001), the GDS (p = 0.026), and the Spielberger State-and Trait Anxiety Inventory subscales (p = 0.003; p = 0.001). Depression was found in 12.0% (HAMD) and 17.8% when using a self-rating instrument (GDS). Less than one-third of depressed subjects were receiving antidepressants. Statistically equal numbers were using benzodiazepines.

CONCLUSIONS

Inappropriate prescription of BZD is frequent in old age, probably indicating untreated depression in many cases. The implications of maltreated geriatric depression and the risks associated with benzodiazepine use highlight the medical and socioeconomic consequences of inappropriate BZD prescription.

Associations of child sexual and physical abuse with obesity and depression in middle-aged women

OBJECTIVE

Examine whether (1) childhood maltreatment is associated with subsequent obesity and depression in middle-age; (2) maltreatment explains the associations between obesity and depression; and (3) binge eating or body dissatisfaction mediate associations between childhood maltreatment and subsequent obesity.

METHODS

Data were obtained through a population-based survey of 4641 women (mean age=52 years) enrolled in a large health plan in the Pacific Northwest. A telephone survey assessed child sexual and physical abuse, obesity (BMI>or=30), depressive symptoms, binge eating, and body dissatisfaction. Data were analyzed using logistic regression models incorporating sampling weights.

RESULTS

Both child sexual and physical abuse were associated with a doubling of the odds of both obesity and depression, although child physical abuse was not associated with depression for the African American/Hispanic/American Indian subgroup. The association between obesity and depression (unadjusted OR=2.82; 95% CI=2.20-3.62) was reduced somewhat after controlling for sexual abuse (adjusted OR=2.54; 1.96-3.29) and for physical abuse (adjusted OR=2.63; 2.03-3.42). Controlling for potential mediators failed to substantially attenuate associations between childhood maltreatment and obesity.

CONCLUSIONS

This study is the first to our knowledge that compares associations of child abuse with both depression and obesity in adults. Although the study is limited by its cross-sectional design and brief assessments, the fact that child abuse predicted two debilitating conditions in middle-aged women indicates the potential long-term consequences of these experiences.

Characteristics associated with benzodiazepine usage in elderly outpatients in Taiwan

OBJECTIVE

To investigate benzodiazepine usage and the characteristics associated with usage among elderly outpatients in Taiwan.

METHODS

This was an observational study of subjects who were enrolled in the National Health Insurance program and aged at least 65 in 2002. They were grouped according to treatment period and mean dosage. An ordered logit regression model was used to evaluate associations of characteristics with benzodiazepine usage.

RESULTS

Of the 4,267 elderly people included, 1,826 had received at least one prescription for benzodiazepines. The 1-year prevalence of benzodiazepine usage by elderly outpatients was approximately 43%. Characteristics associated with receiving benzodiazepine therapy included female gender, displaying comorbid insomnia, anxiety, depression, other mental diseases, cardiovascular disease, cancer, chronic obstructive pulmonary disease, arthritis, and previous use of benzodiazepines. Individuals older than 75 years, with comorbid insomnia, anxiety, depression, other mental diseases, cardiovascular disease, cancer, being in previous receipt of benzodiazepines, or high prescription-overlap ratio were more likely to receive longer treatment. Individuals with insomnia, anxiety, depression, and previous use of higher cumulative dosage of benzodiazepine were more likely to receive higher-dosage therapy.

CONCLUSIONS

Mental disorders and previous exposure to higher cumulative dosages of benzodiazepines are associated with an increased likelihood of receiving benzodiazepine therapy, longer treatment, and a higher mean dosage. Older individuals, less likely to receive higher dosage benzodiazepine therapy, are more likely to receive more prolonged therapy. Women are more likely to receive benzodiazepine therapy, but both men and women have comparable benzodiazepine usage patterns.

Determinants of coprescription of anxiolytics with antidepressants in general practice

OBJECTIVES

Anxiolytics are the most frequently prescribed psychotropic drugs in France. General practitioners (GPs) tend to prescribe anxiolytics and other benzodiazepines to patients with major depressive disorders (MDD). However, the extent to and reasons for which they prescribe these medications together are not well documented. This article assesses how often and why GPs coprescribe an anxiolytic when starting patients on antidepressant (AD) treatment, and which patient- and GP-related factors are associated with this coprescription.

METHODS

We used a survey of 131 GPs practising in southeastern France and of patients seen consecutively during June to October 2004 to whom they prescribed an AD. Data were collected from GPs (consultation-questionnaires focusing on their prescription, diagnosis, and symptom detection) and patients (self-administered questionnaires, including the Hospital Anxiety and Depression scale, and social and demographic characteristics). Factors associated with anxiolytic coprescription were analyzed with a multilevel logistic regression.

RESULTS

GPs completed 438 consultation-questionnaires for patients; 258 patients (58.9%) returned their questionnaires. Sixty percent of the patients received anxiolytics with ADs. Anxiolytics were prescribed more frequently by male GPs who reported feeling ill at ease treating MDD, or detected suicidal ideation or anxiety in their patients, and finally to patients with stable jobs.

CONCLUSIONS

Although some practice guidelines and authors acknowledge that there might be some justification for coprescribing anxiolytics with ADs at the beginning of MDD treatment in specific situations, the high percentage of coprescriptions for anxiolytics observed in our study suggests that training and knowledge of GPs about MDD treatment are not optimal.

Association between obesity and depression in middle-aged women

OBJECTIVE

Evaluate the association between obesity and depression among middle-aged women.

METHODS

A total of 4641 female health plan enrollees aged 40-65 years completed a structured telephone interview including self-reported height and weight, the Patient Health Questionnaire (PHQ) assessment of depression; a brief measure of rate was 62%.

RESULTS

Prevalence of moderate or severe depression increased from 6.5% among those with body mass index (BMI) under 25 to 25.9% among those with BMI over 35. Prevalence of obesity increased from 25.4% among those with no depressive symptoms to 57.8% among those with moderate to severe depression. Independent of obesity, depression was associated with significant reductions in frequency of moderate (4.6 vs. 5.4 times per week) or vigorous (2.8 vs. 3.7 times per week) physical activity. Depression was associated with significantly higher daily caloric intake (1831 vs. 1543) among those with BMI over 30.

CONCLUSIONS

Among middle-aged women, depression is strongly and consistently associated with obesity, lower physical activity and (among the obese) higher caloric intake. Public health approaches to reducing the burden of obesity or depression must consider the strong association between these two common conditions.

Determinants of chronic benzodiazepine use in the elderly: a longitudinal study

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

* The risk of adverse events due to chronic benzodiazepine use is high in the elderly. * Cross-sectional studies have shown that increasing age, female gender and poor physical and mental health are associated with benzodiazepine use. * When users were re-examined some years later, chronic somatic disease, pain and stress seemed to contribute to the continuation of benzodiazepine use.

WHAT THIS STUDY ADDS

* This is the first longitudinal study that analyzed the determinants of new-onset chronic benzodiazepine use in community-dwelling elderly. * Symptoms of depression, hypertension, pain related joint complaints and the perception of poor physical health predicted new-onset chronic use. Living alone was found to decrease the risk of chronic use.

AIMS

The risk of adverse events due to chronic benzodiazepine use is high in the elderly. Clinicians need to be able to identify those persons who are at risk of chronic benzodiazepine use, but little is known about the determinants. This study determined social and health related factors that predict new-onset chronic benzodiazepine use in community-dwelling elderly.

METHODS

This study was embedded in an ongoing cohort study among 5364 persons aged >or=57 years. Drug-dispensing medication records were available for the period between 1991 and 2003. We defined chronic benzodiazepine use as use during at least 180 days in a period of 365 consecutive days. The association of various social, psychiatric and somatic variables with new-onset chronic benzodiazepine use was studied with a Cox proportional hazards analysis.

RESULTS

Symptoms of depression, hypertension, pain related joint complaints and the perception of poor physical health predicted new-onset chronic use. In the subsample of participants who had filled at least one prescription in the follow-up period, of these variables only pain related joint complaints increased the risk of new-onset chronic use. Living alone protected against chronic benzodiazepine use.

CONCLUSIONS

The elderly with poor mental and physical health are at an increased risk of chronic benzodiazepine use. Living alone was found to decrease the risk of chronic use, which suggests that social factors may determine drug usage patterns. Very few characteristics predicted chronic benzodiazepine use once patients had received their first prescription. For clinicians, identification of patients at high risk is therefore not straightforward.

General Practitioners reduced benzodiazepine prescriptions in an intervention study: a multilevel application

OBJECTIVE

This study investigated the effects of general practitioner, patient, and prescription characteristics on the reduction of long-term benzodiazepine prescribing by sending a letter to chronic users. The data were analyzed with a method respecting the hierarchical data structure.

STUDY DESIGN AND SETTING

Data were obtained from 8,170 chronic users nested in 147 general practices. One thousand two hundred fifty-six chronic users in 19 general practices received a letter with the advice to reduce or stop the use of benzodiazepines after the general practitioners had attended a course on benzodiazepine use. In a three-level random intercept multilevel regression model, long-term prescribing of benzodiazepines was the dependent variable.

RESULTS

The reduction in benzodiazepine prescribing was significantly larger in the intervention than in the control group: 16% after 6 months and 14% after 12 months, respectively. The age of the patient, gender, and the interaction between age and gender were significant. The combination of the duration (long acting or short acting) with the type of benzodiazepine (anxiolytic or hypnotic) was an important pharmacological baseline covariate.

CONCLUSIONS

The reduction of benzodiazepine prescribing was mainly explained by the letter intervention and individual patient characteristics. Multilevel analysis was a worthwhile method for application in this study with its unbalanced design.

Risk of suicide attempt and suicide death in patients treated for bipolar disorder

OBJECTIVES

To evaluate demographic and clinical predictors of suicide attempt and suicide death in a population-based sample of people treated for bipolar disorder (BD).

METHODS

Computerized records were used to identify 32,360 individuals treated for BD at two large prepaid health plans. Suicide attempts were identified using computerized records of outpatient visit diagnoses and hospital discharge diagnoses. Suicide deaths were identified using state death certificate data.

RESULTS

Overall event rates were 1.06 per 1,000 person-years for suicide death, 5.6 per 1,000 person-years for suicide attempt leading to hospitalization, and 13.9 per 1,000 person-years for suicide attempt not leading to hospitalization. Men had a significantly lower rate of suicide attempt [hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.56-0.83] but a higher rate of suicide death (HR 2.70, 95% CI 1.69-4.31). Suicide attempts were significantly more frequent among younger patients, but suicide deaths did not vary significantly by age. Substance use comorbidity was significantly related to risk of suicide attempt (HR 2.53, 95% CI 2.07-3.09) but not to risk of suicide death (HR 1.02, 95% CI 0.54-1.93). Comorbid anxiety disorder was associated with significantly higher risk of both suicide attempt (HR 1.40, 95% CI 1.14-1.72) and suicide death (HR 1.81, 95% CI 1.09-2.99).

CONCLUSIONS

Among people treated for BD, risk of suicide death is significantly related to male sex and comorbid anxiety disorder. The predictors of suicide death differ markedly from predictors of suicide attempt.

Relation of body mass index to depression and weighing frequency in overweight women

OBJECTIVE

Research suggests that overweight and obesity are associated with depressive symptoms, particularly among women. Evidence from weight control trials suggests that higher weighing frequency is associated with greater weight loss or less weight gain. As limited data exist on the effects of self-weighing on body mass index (BMI) among overweight adults with or without depression, this study seeks to examine this issue using data from a population-based epidemiologic survey.

METHODS

Data from a large population-based survey of 4655 women ages 40-65 in the greater Seattle area, surveyed from November 2003 to February 2005, were used to examine associations of depression and weight self-monitoring with BMI. Sample-weighted regression models were used to examine associations of depression, self-weighing frequency, and BMI, with demographic factors (race/ethnicity, employment status, smoking status, age, martial status, educational attainment) entered as covariates.

RESULTS

Regression models indicated that higher self-weighing frequency and negative depression status were independently associated with lower BMI, with no interaction observed between depression and self-weighing.

CONCLUSION

Frequent self-weighing appears to be associated with lower BMI in both depressed and non-depressed overweight women.

The Long-Term Prescription of Benzodiazepines, Psychotropic Agents, to the Elderly at a University Hospital in Japan

Benzodiazepines are useful and effective psychotropic agents used worldwide. However, the long term use of the drugs can lead to serious adverse health effects such as psychomotor and cognitive impairment, especially in the elderly. In Japan, there are very few reports concerning long-term use of benzodiazepines, and no countermeasures have been instituted. Thus, this study assessed the characteristics of long-term prescription of benzodiazepines at a university hospital in Japan. A cross-sectional study using the database of a computer ordering system examined 4,239 adult outpatients who were prescribed benzodiazepines at a university teaching hospital between July 2002 and June 2003. The patients were divided into two groups: those with long-term (> or = 3 months) and short-term (< or = 2 months) prescriptions. A logistic regression model was used to analyze the effect of patient age on long-term benzodiazepine prescription. Adjusting for patient gender, pharmacological half-life of the drug, and department group, a logistic regression model showed that long-term benzodiazepine prescription occurred more frequently in older patients (p < 0.0001 in trend tests) and varied according to the physician's specialty (p < 0.0001). Benzodiazepines were more frequently prescribed for long term in the elderly by internal medicine group (p = 0.003). Of the patients older than 71 years (n = 1,105), 86% were assigned to the long-term group and were more likely to have been prescribed benzodiazepines by an internist than a surgeon (p < 0.0001). The appropriate prescription of benzodiazepines in the elderly should be included in the educational programs at teaching hospitals, and rational prescribing needs to be monitored carefully.

[Appropriate use of benzodiazepines zolpidem and zopiclone in diseases attended in primary care]

OBJECTIVES

To estimate the proportion of benzodiazepine prescriptions that comply with the guidelines for appropriate prescription. To identify the variables associated with appropriate prescription.

DESIGN

Observational, cross-sectional study.

SETTING

Monóvar Health Centre in Area IV, Madrid, Spain.

SUBJECTS

Random sample of 270 active benzodiazepine prescriptions in adult patients from the prescriptions record of the OMI-AP V. 5.0 computer system.

MEASUREMENTS

The chosen dimensions for appropriate prescription were: a) correct diagnostic indication; b) absence of benzodiazepines with long half-life in the elderly; c) existence of support or monitoring visits; d) overall appropriateness or coexistence of correct diagnostic indications and monitoring visits. Independent variables were recorded in relation to patient, person prescribing and prescription.

RESULTS

Diagnostic indication, 75.6%; absence of benzodiazepines with long half-life in the elderly, 79.8%; existence of support visits, 63.3%; overall appropriateness, 53%. Main diagnoses: pure anxiety, 29%; anxiety related to other illness, 18.6%; insomnia, 14.8%; cardiovascular illness, 14.8%; alcohol and drug abuse, 4.5%; osteo-muscular illness, 4.4%; schizophrenia, 4.4%. Most prescribed substances: lorazepam, 27.8%; bromazepam, 23.7%. Average life of prescriptions: 18.58 months. Origins: health centre, 68.5%; out-patient psychiatry, 10%; hospital, 10%. The variable that is most closely associated with overall appropriateness, fitted with the rest of the variables, is out-patient psychiatry prescription (OR, 6.67; 95% CI, 1.92-23.18).

CONCLUSIONS

The mean duration of the prescriptions infringes all standards. The overall appropriateness or correct coexistence of adequate diagnostic indication with follow-up visits is associated with out-patient Psychiatry prescription.

Outcome of new benzodiazepine prescriptions to older adults in primary care

OBJECTIVE

The objective of this study was to examine the indications for benzodiazepine use, and the baseline characteristics, duration of use and clinical outcomes of older primary care patients prescribed benzodiazepines.

METHODS

Computerized records were used to identify outpatients (n=129) aged >or=60 years who received new benzodiazepine prescriptions from primary care physicians of a group model managed care organization. A baseline telephone survey assessed indications for prescription, sleep quality (Pittsburgh Sleep Quality Index), depression (Symptom Checklist depression scale and Structured Clinical Interview for DSM-IV), alcohol use (CAGE) and functional status (SF-36). A 2-month follow-up survey assessed benzodiazepine use, sleep quality and depression.

RESULTS

The most common indications for prescription were insomnia (42%) and anxiety (36%). At baseline, participants reported moderate sleep disturbance (mean Pittsburgh Sleep Quality Index=9.3, S.D.=4.0), only 15% met criteria for current depressive episode and only 3% reported at-risk alcohol use. After 2 months, 30% of participants used benzodiazepines at least daily. Both those continuing daily use and those not continuing daily use reported significant improvements in sleep quality and depression, with no difference between groups in rates of improvement.

CONCLUSIONS

Initial benzodiazepine prescriptions to older adults are typically intended for the treatment of anxiety or insomnia, with little evidence for occult depression or alcohol abuse. A significant minority develops a pattern of long-term use, raising concerns about tolerance and dependence.

Incidence and Characteristics of Benzodiazepine Use in an Elderly Cohort: The EVA Study

OBJECTIVE

The aim of this study was to estimate the incidence of benzodiazepine use in an elderly population and to identify associated factors.

METHODS

Data were collected in four self-report questionnaires on the use of sedatives and sleeping drugs. These questionnaires were sent every 6 months, over a 2-year period, to the 1272 elderly subjects interviewed at the first follow-up examination of the EVA (Epidemiology of Vascular Aging) Study.

RESULTS

The incidence rate of benzodiazepine use was 4.7 per 1000 person-months (95% confidence interval [CI] 3.6, 5.8). In multivariable analyses (logistic regression model), incident use of benzodiazepines was significantly associated with depressive or anxious symptoms (odds ratio [OR] = 3.3; 95% CI 1.7, 6.4), high use of non-psychotropic drugs (> or = 3; OR = 1.8; 95% CI 1.1, 3.1) and female gender (OR = 1.9; 95% CI 1.1, 3.3).

CONCLUSION

Simultaneous use of benzodiazepines and other medications should be carefully assessed in elderly patients, considering the risk of adverse drug reactions and drug-drug interactions.

Le traitement cognitivo-comportemental de l’insomnie et son utilisation lors de l’arrêt des hypnotiques

L’insomnie constitue un problème de santé très répandu menant souvent à l’utilisation d’hypnotiques. Parmi les agents pharmacologiques disponibles pour traiter l’insomnie, les benzodiazépines (BZD) sont les plus prescrites. Bien qu’efficaces pour améliorer le sommeil à court terme, les BZD présentent certains effets indésirables, entraînent des risques de tolérance et de dépendance, et augmentent le risque d’accidents de la route, de chutes et de fractures chez les personnes âgées. Le traitement cognitivo-comportemental (TCC) de l’insomnie, qui met l’accent sur les facteurs psychologiques et comportementaux jouant un rôle dans le maintien des difficultés de sommeil, est efficace pour améliorer le sommeil des personnes aux prises avec un trouble d’insomnie primaire. Il peut représenter une alternative à la pharmacothérapie ou encore être un complément thérapeutique facilitant lors de l’arrêt des hypnotiques. Le TCC de l’insomnie peut inclure différentes composantes, telles que le contrôle par le stimulus, la restriction du sommeil, la relaxation, la restructuration cognitive et l’hygiène du sommeil. Chez les personnes dépendantes aux BZD ou autres hypnotiques, un sevrage supervisé, basé sur l’atteinte d’objectifs successifs, s’ajoute généralement au TCC de l’insomnie.

Correlates of benzodiazepine use in individuals with insomnia

BACKGROUND AND PURPOSE

Although benzodiazepines (BZDs) are commonly used in the treatment of insomnia, there is little information about psychological, health, and sociodemographic correlates associated with their use.

OBJECTIVE

This study examined correlates of benzodiazepine use for sleep in a clinical sample of patients seeking treatment for insomnia at a sleep disorders clinic.

PATIENTS AND METHODS

The sample consisted of 97 individuals evaluated at a sleep disorders clinic for a presenting complaint of insomnia. Two groups were formed, including one with 61 patients who had been using BZDs for sleep for an average of 56.6 months (SD=68.0), and another with 36 patients who had insomnia but were not using BZDs or any other sleep aid. Logistic regressions, adjusting for an age difference between the user and non-user groups, were performed to examine variables associated with BZD use. Independent variables included demographic, medical, insomnia-related and psychological parameters and subjective sleep-wake characteristics. Unadjusted regression analyses were performed to identify factors associated with a pattern of long-term use (>12 months) within the user group.

RESULTS

Age was a significant predictor of BZD use (OR=1.84, P = 0.0002). Significant age-adjusted predictors of BZD use included perceived insomnia severity (OR=1.17, P = 0.038), depressive symptoms, (OR=1.108, P = 0.009) and state and trait anxiety symptoms (OR=1.062, P = 0.016; OR=1.084, P = 0.005, respectively). Significant predictors of long-term use (>12 months) were age of insomnia onset (OR=0.951, P = 0.0214), more frequent BZD use (OR=3.284, P = 0.0221), and higher state-anxiety (OR=1.106, P = 0.0471).

CONCLUSIONS

Age, psychological variables and perceived sleep disturbances severity, are associated with BZD use in patients with insomnia.

Use of benzodiazepine drugs and perceived job stress in a cohort of working men and women in Belgium. Results from the BELSTRESS-study

The aim of the Belstress Study was to see whether use of benzodiazepines is associated with perceived job stress as measured by Karasek's job-strain model. This model has as its central tenet that the most adverse health outcomes are to be expected in high strain jobs characterized by high job demands and low job control. An extension of the model states that the most noxious combination is high job demands, low control and low social support at work. Sample subjects were recruited from 25 Belgian companies between 1994 and 1998, and cover a wide range of occupations. A 5.6% of 16,094 men and 9.3% of 5012 women aged 35-59 years report use of benzodiazepines during the last month. A clear association is displayed between self-reported use of benzodiazepines and a high strain job compared to a low strain job (men: OR=1.93, 99% CI=1.4-2.6; women: OR=1.66, 99% CI=1.0-2.7), after adjustment is made for socio-demographic confounders (age, level of education, occupational group, employment sector, living situation). The independent association with quartile level of job demands is a striking feature (men: OR of highest quartile compared to lowest quartile group=1.91, 99% CI=1.4-2.6; women: OR=1.99, 99% CI=1.3-3.1). In men, an inverse association with quartile level of job control is observed (OR= 0.65, 99% CI=0.5-0.9) whereas in women a clear tendency in that direction is displayed (OR=0.62, 99% CI=0.4-1.1). The association with low social support is less clear; an independent association between use of benzodiazepines and iso-strain was observed particularly in men.