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Edward F. Suicidality: Once Again, Don’t Blame the Drug Class. Epilepsy Curr 2021. [PMCID: PMC8832346 DOI: 10.1177/15357597211053193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Importance Mostantiseizure medications (ASMs) carry a US Food and Drug Administration–mandated class label warning of increased suicidality risk, based on a meta-analysis comparing suicidality between individuals treated with medications vs placebo in randomized clinical trials done before 2008. ASMs approved since then carry this warning although they were not similarly studied. Objective To review all placebo-controlled phase 2 and 3 studies of 10 ASMs approved since 2008 to evaluate the risk of suicidality of these drugs compared with placebo. Data Sources Primary publications and secondary safety analyses in PubMed of all phase 2 and 3 randomized placebo-controlled epilepsy trials of ASMs approved since 2008, using keywords epilepsy, antiepileptic drugs, seizures, suicidality, suicidal ideation, and the names of individual drugs. Study Selection All phase 2 and 3 randomized clinical trials of adjunctive treatment of drug-resistant epilepsy and their secondary safety analyses. Data Extraction and Synthesis Articles were reviewed for frequency of suicidality (ideation, attempts, and completed suicides). Mode of suicidality ascertainment included treatment-emergent adverse event reports, Standardized Medical Dictionary for Regulatory Activities queries for events in prespecified categories including suicidal ideation and behavior, prospective collection of suicidality data as a prespecified safety outcome using the Columbia-Suicide Severity Rating Scale, and retrospective evaluation by blinded review using the Columbia-Classification Algorithm of Suicide Assessment. A meta-analysis compared risk for drugs vs placebo of each outcome for all drugs overall and by individual drugs and trials. Main Outcomes and Measures Suicidality (total and by ideation), attempts, and completed suicides. Results Excluding studies that did not evaluate suicidality (everolimus and fenfluramine) or did not evaluate it prospectively (lacosamide, ezogabine, and clobazam), 5 drugs were analyzed: eslicarbazepine, perampanel, brivaracetam, cannabidiol, and cenobamate. Suicidality was evaluated in 17 randomized clinical trials of these drugs, involving 5996 patients, of whom 4000 patients were treated with ASMs and 1996 with placebo. There was no evidence of increased risk of suicidal ideation (drugs vs placebo overall risk ratio, .75; 95% CI, .35–1.60) or attempt (risk ratio, .75; 95% CI, .30–1.87) overall or for any individual drug. Suicidal ideation occurred in 12 of 4000 patients treated with ASMs (.30%) vs 7 of 1996 patients treated with placebo (.35%) ( P = .74). Three patients treated with ASMs and no patients treated with placebo attempted suicide ( P = .22). There were no completed suicides. Conclusions and Relevance There is no current evidence that the 5 ASMs evaluated in this study increase suicidality in epilepsy and merit a suicidality class warning
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Nestsiarovich A, Kumar P, Lauve NR, Hurwitz NG, Mazurie AJ, Cannon DC, Zhu Y, Nelson SJ, Crisanti AS, Kerner B, Tohen M, Perkins DJ, Lambert CG. Using Machine Learning Imputed Outcomes to Assess Drug-Dependent Risk of Self-Harm in Patients with Bipolar Disorder: A Comparative Effectiveness Study. JMIR Ment Health 2021; 8:e24522. [PMID: 33688834 PMCID: PMC8100888 DOI: 10.2196/24522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 02/08/2021] [Accepted: 03/09/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Incomplete suicidality coding in administrative claims data is a known obstacle for observational studies. With most of the negative outcomes missing from the data, it is challenging to assess the evidence on treatment strategies for the prevention of self-harm in bipolar disorder (BD), including pharmacotherapy and psychotherapy. There are conflicting data from studies on the drug-dependent risk of self-harm, and there is major uncertainty regarding the preventive effect of monotherapy and drug combinations. OBJECTIVE The aim of this study was to compare all commonly used BD pharmacotherapies, as well as psychotherapy for the risk of self-harm, in a large population of commercially insured individuals, using self-harm imputation to overcome the known limitations of this outcome being underrecorded within US electronic health care records. METHODS The IBM MarketScan administrative claims database was used to compare self-harm risk in patients with BD following 65 drug regimens and drug-free periods. Probable but uncoded self-harm events were imputed via machine learning, with different probability thresholds examined in a sensitivity analysis. Comparators included lithium, mood-stabilizing anticonvulsants (MSAs), second-generation antipsychotics (SGAs), first-generation antipsychotics (FGAs), and five classes of antidepressants. Cox regression models with time-varying covariates were built for individual treatment regimens and for any pharmacotherapy with or without psychosocial interventions ("psychotherapy"). RESULTS Among 529,359 patients, 1.66% (n=8813 events) had imputed and/or coded self-harm following the exposure of interest. A higher self-harm risk was observed during adolescence. After multiple testing adjustment (P≤.012), the following six regimens had higher risk of self-harm than lithium: tri/tetracyclic antidepressants + SGA, FGA + MSA, FGA, serotonin-norepinephrine reuptake inhibitor (SNRI) + SGA, lithium + MSA, and lithium + SGA (hazard ratios [HRs] 1.44-2.29), and the following nine had lower risk: lamotrigine, valproate, risperidone, aripiprazole, SNRI, selective serotonin reuptake inhibitor (SSRI), "no drug," bupropion, and bupropion + SSRI (HRs 0.28-0.74). Psychotherapy alone (without medication) had a lower self-harm risk than no treatment (HR 0.56, 95% CI 0.52-0.60; P=8.76×10-58). The sensitivity analysis showed that the direction of drug-outcome associations did not change as a function of the self-harm probability threshold. CONCLUSIONS Our data support evidence on the effectiveness of antidepressants, MSAs, and psychotherapy for self-harm prevention in BD. TRIAL REGISTRATION ClinicalTrials.gov NCT02893371; https://clinicaltrials.gov/ct2/show/NCT02893371.
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Affiliation(s)
- Anastasiya Nestsiarovich
- Center for Global Health, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Praveen Kumar
- Department of Computer Science, The University of New Mexico, Albuquerque, NM, United States
| | - Nicolas Raymond Lauve
- Department of Computer Science, The University of New Mexico, Albuquerque, NM, United States
| | | | | | | | - Yiliang Zhu
- Division of Epidemiology, Biostatistics, and Preventive Medicine, Department of Internal Medicine, The University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Stuart James Nelson
- Biomedical Informatics Center, George Washington University, Washington, DC, DC, United States
| | - Annette S Crisanti
- Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Berit Kerner
- Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Mauricio Tohen
- Department of Psychiatry & Behavioral Sciences, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Douglas J Perkins
- Center for Global Health, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - Christophe Gerard Lambert
- Center for Global Health, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, United States.,Division of Translational Informatics, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
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Georgi U, Lämmel J, Datzmann T, Schmitt J, Deckert S. Do drug-related safety warnings have the expected impact on drug therapy? A systematic review. Pharmacoepidemiol Drug Saf 2020; 29:229-251. [PMID: 32045502 DOI: 10.1002/pds.4968] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/22/2019] [Accepted: 01/28/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE The need for drug-related safety warnings is undisputed, and their impact should also be evaluated. This systematic review investigates and assesses the impact of safety warnings on drug therapy. METHODS Studies published in English between January 1998 and December 2018 were searched in EMBASE and MEDLINE, complemented by manual search. Randomised controlled trials, cohort studies with a before/after component, and case-control studies were included, selected to predefined criteria, and assessed for their reporting and methodological quality. RESULTS Out of 7454 references identified, 72 studies were included. A total of 28/72 (39%) studies described the impact of safety warnings on drug therapy as being effective, whereas 12/72 (17%) studies did not. Further, 26/72 (36%) studies described a partial implementation of the warnings (one part of the warning had an impact on drug therapy and another did not). Unintended effects were investigated in 6/72 (8%) studies. While 34 (47%) studies examined safety warnings on psychotropic drugs using an interrupted time series (ITS) design (53%), a before/after (26%), and a time series design (21%), 38 (53%) studied other substances using an ITS design (34%), a before/after (40%), and a time series design (26%). The proportion of an effective impact on drug therapy was lower in the "psychotropic drugs" group (23%) than in the "others" group (53%). CONCLUSION Drug-related safety warnings induce intended and unintended effects. The included studies are of broadly varying methodological quality. To better compare their effectiveness, studies should be conducted using standardised procedures.
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Affiliation(s)
- Ulrike Georgi
- Pharmacy Service of Clinical Center, Chemnitz, Germany.,Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Julia Lämmel
- Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany.,Pharmacy Service, Medical Center of the Carl Gustav Carus Technical University, Dresden, Germany
| | - Thomas Datzmann
- Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany.,National Center for Tumor Diseases, Dresden, Germany
| | - Jochen Schmitt
- Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Stefanie Deckert
- Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany
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Jordan S, Logan PA, Panes G, Vaismoradi M, Hughes D. Adverse Drug Reactions, Power, Harm Reduction, Regulation and the ADRe Profiles. PHARMACY 2018; 6:E102. [PMID: 30231573 PMCID: PMC6165166 DOI: 10.3390/pharmacy6030102] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 09/12/2018] [Accepted: 09/13/2018] [Indexed: 12/15/2022] Open
Abstract
The power and influence of healthcare systems comes largely from the ability to prescribe efficacious medicine. However, medicine can sometimes cause harm rather than bring benefits. Systematically checking patients for the adverse effects of medicines, as listed in manufacturers' literature, would protect patients from iatrogenic harm, but this is rarely undertaken. We argue for the benefits of this approach using the example of the prescription of antipsychotics to older adults. Prescribing antipsychotics to control challenging behaviours associated with dementia is a controversial matter, and regulatory intervention is under discussion. Improved regulatory systems could protect against iatrogenic harm, such as over-sedation, falls, tremor, or drug-induced Parkinsonism. However, measuring the impact and outcomes of regulatory interventions has proved difficult, not least because there are rarely systematic records of all adverse effects of medicines. We indicate how regulatory initiatives to reduce antipsychotic prescribing can be supported by systematic monitoring and documentation of patients' signs and symptoms of putative adverse drug reactions. Monitoring documentation then provides the rationale and support for professionals' responses to identified problems. Longitudinal monitoring records would improve understanding of the impact and outcomes of adverse drug reactions (ADRs) on health and wellbeing, and the many costs of ADRs.
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Affiliation(s)
- Sue Jordan
- College of Human and Health Sciences, Swansea University, Swansea SA2 8PP, UK.
| | - Patricia A Logan
- Faculty of Science, Charles Sturt University, Bathurst Campus, NSW 2795, Australia.
| | - Gerwyn Panes
- College of Human and Health Sciences, Swansea University, Swansea SA2 8PP, UK.
| | - Mojtaba Vaismoradi
- Faculty of Nursing and Health Sciences, Nord University, 8049 Bodø, Norway.
| | - David Hughes
- College of Human and Health Sciences, Swansea University, Swansea SA2 8PP, UK.
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Raju Sagiraju HK, Wang CP, Amuan ME, Van Cott AC, Altalib HH, Pugh MJV. Antiepileptic drugs and suicide-related behavior: Is it the drug or comorbidity? Neurol Clin Pract 2018; 8:331-339. [PMID: 30140585 DOI: 10.1212/cpj.0000000000000489] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/11/2018] [Indexed: 11/15/2022]
Abstract
Background We sought to compare trends of suicide-related behavior (SRB) before and after initiation of antiepileptic drug (AED) therapy among AED users (with and without epilepsy) to that of individuals without AED use controlling for sociodemographic characteristics and mental health comorbidity. Methods We used national Veterans Health Administration (VHA) data for post-9/11 veterans who received VHA care (2013-2014) without prior AED use. We conducted generalized estimation equation (GEE) analyses, stratified by epilepsy status and type of AED received, to assess the trend of SRB prevalence the year prior to and after the index date (date of first AED prescription/date of first health care encounter for non-AED users) controlling for sociodemographic factors and mental health comorbidity. Results The GEE analysis showed significant curvilinear trends of SRB prevalence over the 24-month study period among the AED users, indicating that the probability of SRB diagnoses increased over time with a peak before the index month and decreased thereafter. Similar patterns were observed among non-AED users, but significantly lower odds for SRB. Among AED users, there were no significant differences by epilepsy status; however, higher SRB prevalence and differential SRB trajectory measures were observed among those who received AEDs with mood-stabilizing action. Conclusions The peak of SRB prior to and rapid reduction in SRB after initiation of AED, and the finding that individuals eventually prescribed a mood-stabilizing AED (vs other AED or levetiracetam) had higher odds of SRB, suggests a strong possibility that the relationship of AED and SRB is one of residual confounding.
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Affiliation(s)
- Hari K Raju Sagiraju
- South Texas Veterans Health Care System (HKRS, C-PW), San Antonio; Division of General and Hospital Medicine (HKRS) and Department of Epidemiology & Biostatistics (C-PW), University of Texas Health Science Center at San Antonio; Center for Healthcare Organization and Implementation Research (MEA), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; VA Pittsburgh Health Care System (ACVC); Department of Neurology (ACVC), University of Pittsburgh, PA; VA Connecticut Health Care System (HHA), West Haven; Department of Neurology & Psychiatry (HHA), Yale School of Medicine, New Haven, CT; Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0) (MJVP), VA Salt Lake City Health Care System; and Division of Epidemiology (MJVP), University of Utah Health Science Center
| | - Chen-Pin Wang
- South Texas Veterans Health Care System (HKRS, C-PW), San Antonio; Division of General and Hospital Medicine (HKRS) and Department of Epidemiology & Biostatistics (C-PW), University of Texas Health Science Center at San Antonio; Center for Healthcare Organization and Implementation Research (MEA), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; VA Pittsburgh Health Care System (ACVC); Department of Neurology (ACVC), University of Pittsburgh, PA; VA Connecticut Health Care System (HHA), West Haven; Department of Neurology & Psychiatry (HHA), Yale School of Medicine, New Haven, CT; Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0) (MJVP), VA Salt Lake City Health Care System; and Division of Epidemiology (MJVP), University of Utah Health Science Center
| | - Megan E Amuan
- South Texas Veterans Health Care System (HKRS, C-PW), San Antonio; Division of General and Hospital Medicine (HKRS) and Department of Epidemiology & Biostatistics (C-PW), University of Texas Health Science Center at San Antonio; Center for Healthcare Organization and Implementation Research (MEA), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; VA Pittsburgh Health Care System (ACVC); Department of Neurology (ACVC), University of Pittsburgh, PA; VA Connecticut Health Care System (HHA), West Haven; Department of Neurology & Psychiatry (HHA), Yale School of Medicine, New Haven, CT; Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0) (MJVP), VA Salt Lake City Health Care System; and Division of Epidemiology (MJVP), University of Utah Health Science Center
| | - Anne C Van Cott
- South Texas Veterans Health Care System (HKRS, C-PW), San Antonio; Division of General and Hospital Medicine (HKRS) and Department of Epidemiology & Biostatistics (C-PW), University of Texas Health Science Center at San Antonio; Center for Healthcare Organization and Implementation Research (MEA), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; VA Pittsburgh Health Care System (ACVC); Department of Neurology (ACVC), University of Pittsburgh, PA; VA Connecticut Health Care System (HHA), West Haven; Department of Neurology & Psychiatry (HHA), Yale School of Medicine, New Haven, CT; Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0) (MJVP), VA Salt Lake City Health Care System; and Division of Epidemiology (MJVP), University of Utah Health Science Center
| | - Hamada H Altalib
- South Texas Veterans Health Care System (HKRS, C-PW), San Antonio; Division of General and Hospital Medicine (HKRS) and Department of Epidemiology & Biostatistics (C-PW), University of Texas Health Science Center at San Antonio; Center for Healthcare Organization and Implementation Research (MEA), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; VA Pittsburgh Health Care System (ACVC); Department of Neurology (ACVC), University of Pittsburgh, PA; VA Connecticut Health Care System (HHA), West Haven; Department of Neurology & Psychiatry (HHA), Yale School of Medicine, New Haven, CT; Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0) (MJVP), VA Salt Lake City Health Care System; and Division of Epidemiology (MJVP), University of Utah Health Science Center
| | - Mary Jo V Pugh
- South Texas Veterans Health Care System (HKRS, C-PW), San Antonio; Division of General and Hospital Medicine (HKRS) and Department of Epidemiology & Biostatistics (C-PW), University of Texas Health Science Center at San Antonio; Center for Healthcare Organization and Implementation Research (MEA), Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; VA Pittsburgh Health Care System (ACVC); Department of Neurology (ACVC), University of Pittsburgh, PA; VA Connecticut Health Care System (HHA), West Haven; Department of Neurology & Psychiatry (HHA), Yale School of Medicine, New Haven, CT; Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0) (MJVP), VA Salt Lake City Health Care System; and Division of Epidemiology (MJVP), University of Utah Health Science Center
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Goedecke T, Morales DR, Pacurariu A, Kurz X. Measuring the impact of medicines regulatory interventions - Systematic review and methodological considerations. Br J Clin Pharmacol 2018; 84:419-433. [PMID: 29105853 PMCID: PMC5809349 DOI: 10.1111/bcp.13469] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/24/2017] [Accepted: 10/31/2017] [Indexed: 12/20/2022] Open
Abstract
AIMS Evaluating the public health impact of regulatory interventions is important but there is currently no common methodological approach to guide this evaluation. This systematic review provides a descriptive overview of the analytical methods for impact research. METHODS We searched MEDLINE and EMBASE for articles with an empirical analysis evaluating the impact of European Union or non-European Union regulatory actions to safeguard public health published until March 2017. References from systematic reviews and articles from other known sources were added. Regulatory interventions, data sources, outcomes of interest, methodology and key findings were extracted. RESULTS From 1246 screened articles, 229 were eligible for full-text review and 153 articles in English language were included in the descriptive analysis. Over a third of articles studied analgesics and antidepressants. Interventions most frequently evaluated are regulatory safety communications (28.8%), black box warnings (23.5%) and direct healthcare professional communications (10.5%); 55% of studies measured changes in drug utilization patterns, 27% evaluated health outcomes, and 18% targeted knowledge, behaviour or changes in clinical practice. Unintended consequences like switching therapies or spill-over effects were rarely evaluated. Two-thirds used before-after time series and 15.7% before-after cross-sectional study designs. Various analytical approaches were applied including interrupted time series regression (31.4%), simple descriptive analysis (28.8%) and descriptive analysis with significance tests (23.5%). CONCLUSION Whilst impact evaluation of pharmacovigilance and product-specific regulatory interventions is increasing, the marked heterogeneity in study conduct and reporting highlights the need for scientific guidance to ensure robust methodologies are applied and systematic dissemination of results occurs.
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Affiliation(s)
- Thomas Goedecke
- Pharmacovigilance and Epidemiology Department, Inspections Human Medicines Pharmacovigilance and Committees DivisionEuropean Medicines Agency (EMA)LondonE14 5EUUK
| | - Daniel R. Morales
- Pharmacovigilance and Epidemiology Department, Inspections Human Medicines Pharmacovigilance and Committees DivisionEuropean Medicines Agency (EMA)LondonE14 5EUUK
- Division of Population Health SciencesUniversity of DundeeDundeeDD2 4BFUK
| | - Alexandra Pacurariu
- Pharmacovigilance and Epidemiology Department, Inspections Human Medicines Pharmacovigilance and Committees DivisionEuropean Medicines Agency (EMA)LondonE14 5EUUK
- Dutch Medicines Evaluation Board3531AHUtrechtThe Netherlands
| | - Xavier Kurz
- Pharmacovigilance and Epidemiology Department, Inspections Human Medicines Pharmacovigilance and Committees DivisionEuropean Medicines Agency (EMA)LondonE14 5EUUK
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Thibault DP, Mendizabal A, Abend NS, Davis KA, Crispo J, Willis AW. Hospital care for mental health and substance abuse in children with epilepsy. Epilepsy Behav 2016; 57:161-166. [PMID: 26963820 PMCID: PMC5347535 DOI: 10.1016/j.yebeh.2016.01.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 01/18/2016] [Accepted: 01/30/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Reducing the burden of pediatric mental illness requires greater knowledge of mental health and substance abuse (MHSA) outcomes in children who are at an increased risk of primary psychiatric illness. National data on hospital care for psychiatric illness in children with epilepsy are limited. METHODS We used the Kids' Inpatient Database (KID), the Healthcare Cost and Utilization Project (HCUP), and the Agency for Healthcare Research and Quality from 2003 to 2009 to examine MHSA hospitalization patterns in children with comorbid epilepsy. Nonparametric and regression analyses determined the association of comorbid epilepsy with specific MHSA diagnoses and examined the impact of epilepsy on length of stay (LOS) for such MHSA diagnoses while controlling for demographic, payer, and hospital characteristics. RESULTS We observed 353,319 weighted MHSA hospitalizations of children ages 6-20; 3280 of these involved a child with epilepsy. Depression was the most common MHSA diagnosis in the general population (39.5%) whereas bipolar disorder was the most common MHSA diagnosis among children with epilepsy (36.2%). Multivariate logistic regression models revealed that children with comorbid epilepsy had greater adjusted odds of bipolar disorder (AOR: 1.17, 1.04-1.30), psychosis (AOR: 1.78, 1.51-2.09), sleep disorder (AOR: 5.90, 1.90-18.34), and suicide attempt/ideation (AOR: 3.20, 1.46-6.99) compared to the general MHSA inpatient population. Epilepsy was associated with a greater LOS and a higher adjusted incidence rate ratio (IRR) for prolonged LOS (IRR: 1.12, 1.09-1.17), particularly for suicide attempt/ideation (IRR: 3.74, 1.68-8.34). CONCLUSIONS Children with epilepsy have distinct patterns of hospital care for mental illness and substance abuse and experience prolonged hospitalization for MHSA conditions. Strategies to reduce psychiatric hospitalizations in this population may require disease-specific approaches and should measure disease-relevant outcomes. Hospitals caring for large numbers of children with neurological disease (such as academic centers) may have inaccurate measurements of mental health-care quality unless the impact of key comorbid conditions such as epilepsy is considered.
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Affiliation(s)
- Dylan P Thibault
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, United States; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, United States
| | | | - Nicholas S Abend
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, United States; The Children's Hospital of Philadelphia, United States
| | - Kathryn A Davis
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, United States; Penn Epilepsy Center, United States
| | - James Crispo
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, United States; McLaughlin Centre for Population Health Risk Assessment, University of Ottawa, Ottawa, Canada
| | - Allison W Willis
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, United States; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, United States; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, United States
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8
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Strzelczyk A, Zschebek G, Bauer S, Baumgartner C, Grond M, Hermsen A, Kieslich M, Krämer G, Kurlemann G, May TW, Mayer T, Neubauer BA, Pfäfflin M, Plecko B, Ryvlin P, Schubert-Bast S, Stefan H, Trinka E, Knake S, Seifart C, Rosenow F. Predictors of and attitudes toward counseling about SUDEP and other epilepsy risk factors among Austrian, German, and Swiss neurologists and neuropediatricians. Epilepsia 2016; 57:612-20. [PMID: 26899504 DOI: 10.1111/epi.13337] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine the attitudes toward counseling about sudden unexpected death in epilepsy (SUDEP) and other epilepsy risk factors among Austrian, German, and Swiss neurologists and neuropediatricians, and to determine factors associated with not discussing SUDEP. METHODS Questionnaires were sent to approximately 5,000 neurologists and neuropediatricians in 2014 regarding respondents' demographics, their working environments, and how often they discussed SUDEP, suicidal ideations on anticonvulsive medication, driving restrictions, and risks in daily life activities. RESULTS In total, 519 surveys were completed (respondents' mean age: 45.5 years, 41.6% female, 66.9% adult neurologists, 31.0% neuropediatricians). A minority of 2.7% reported that they counseled all of their patients on SUDEP, 8.7% counseled most of the time (50-90%), 20.8% sometimes (10-49%), 44.5% rarely (1-9%), and 23.3% reported not counseling about SUDEP at all. In contrast, 92.9% reported that they counseled all patients about driving restrictions and 81.5% about risks in daily life activities. Suicidal ideations were discussed in 59.0% for some and in 3.3% for all patients, whereas 35.1% of respondents reported never discussing suicidal ideations. Independent predictors of not discussing SUDEP were no additional epilepsy training, no or uncertain SUDEP cases in the past, <10 years in practice, <25 epilepsy patients seen per quarter, and the opinion of a lack of consequences in SUDEP prevention. The opinion that SUDEP is a risk factor in particular patient groups and the attitude that all risks should be discussed predicted counseling on SUDEP. SIGNIFICANCE Our findings show a discrepancy between guidelines and practice regarding the discussion of premature mortality due to SUDEP or suicidality. Both are not discussed at all by a substantial proportion of neurologists and neuropediatricians. This is in contrast to ubiquitous education about driving restrictions. Dissemination of knowledge among physicians about potential preventive strategies might increase the likelihood of discussion. Clinical practice guidelines are welcomed by the majority of physicians in this process.
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Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Hessen, Philipps-University, Marburg, Germany.,Epilepsy Center Frankfurt Rhine-Main, Goethe University, Frankfurt, Germany
| | - Gerda Zschebek
- Epilepsy Center Hessen, Philipps-University, Marburg, Germany.,Institutional Review Board, Medical Faculty, Philipps-University, Marburg, Germany
| | - Sebastian Bauer
- Epilepsy Center Hessen, Philipps-University, Marburg, Germany.,Epilepsy Center Frankfurt Rhine-Main, Goethe University, Frankfurt, Germany
| | - Christoph Baumgartner
- Karl Landsteiner Institute for Clinical Epileptology and Cognitive Neurology, General Hospital Hietzing with Neurological Center Rosenhuegel, Vienna, Austria
| | - Martin Grond
- Department of Neurology, Kreisklinikum, Siegen, Germany
| | - Anke Hermsen
- Epilepsy Center Hessen, Philipps-University, Marburg, Germany.,Epilepsy Center Frankfurt Rhine-Main, Goethe University, Frankfurt, Germany
| | - Matthias Kieslich
- Department of Neuropediatrics, Goethe University, Frankfurt, Germany
| | | | - Gerhard Kurlemann
- Department of Neuropediatrics, University Hospital, Münster, Germany
| | | | | | - Bernd A Neubauer
- Department of Neuropediatrics, Epilepsy Center Hessen, Justus-Liebig-University, Giessen, Germany
| | | | - Barbara Plecko
- Department of Neuropediatrics, University of Zürich, Zürich, Switzerland
| | - Philippe Ryvlin
- Department of Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main, Goethe University, Frankfurt, Germany.,Department of Neuropediatrics, Goethe University, Frankfurt, Germany.,Department of Neuropediatrics, Ruprecht-Karls-University, Heidelberg, Germany
| | - Hermann Stefan
- Epilepsy Center Erlangen, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University and Center for Cognitive Neuroscience, Salzburg, Austria
| | - Susanne Knake
- Epilepsy Center Hessen, Philipps-University, Marburg, Germany
| | - Carola Seifart
- Institutional Review Board, Medical Faculty, Philipps-University, Marburg, Germany
| | - Felix Rosenow
- Epilepsy Center Hessen, Philipps-University, Marburg, Germany.,Epilepsy Center Frankfurt Rhine-Main, Goethe University, Frankfurt, Germany
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Mittal M, Harrison DL, Thompson DM, Miller MJ, Farmer KC, Ng YT. An evaluation of three statistical estimation methods for assessing health policy effects on prescription drug claims. Res Social Adm Pharm 2016; 12:29-40. [DOI: 10.1016/j.sapharm.2015.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 03/25/2015] [Indexed: 11/28/2022]
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Key issues in addressing the comorbidity of depression and pediatric epilepsy. Epilepsy Behav 2015; 46:12-8. [PMID: 25863941 DOI: 10.1016/j.yebeh.2015.02.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 02/24/2015] [Accepted: 02/25/2015] [Indexed: 12/14/2022]
Abstract
Depression is a common comorbidity associated with epilepsy. However, the etiology of depression is difficult to establish given the heterogeneity in both epilepsy and depression. Nevertheless, the co-occurrence is so common that a bidirectional relationship between depression and epilepsy has been theorized. Persons with temporal lobe seizure foci and partial-onset epilepsy may be more vulnerable to the development of depression. In pediatrics, depression differs but may be readily identified by understanding nuances of mood states and variability of neurovegetative symptom presentation. Although no clear treatment guidance exists in the context of epilepsy, antidepressants have been relatively well studied in pediatrics and are effective and well tolerated. Anticonvulsant drugs may also improve depressive symptoms though clinical research is lacking in pediatrics. Treatment of depression may independently improve outcome for epilepsy and for quality of life. Future studies will clarify etiologies of depression in the context of epilepsy and improve the evidence base for treatment outcomes.
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