Risk of suicide attempts after benzodiazepine and/or antidepressant use

Associations between treatment with melatonin and suicidal behavior: a nationwide cohort study

STUDY OBJECTIVES

Melatonin is often prescribed to patients with sleep disorders who are known to have elevated suicide risks, yet melatonin's association with suicidal behavior remains to be examined. We investigated whether individuals prescribed melatonin had higher rates of suicide and suicide attempts when compared to individuals who were not prescribed this drug, including both those with and without known mental disorders.

METHODS

A cohort design was applied to longitudinal, register data on all persons aged ≥ 10 years in Denmark during 2007-2016. Based on data from the National Prescription Registry, periods of being in treatment with melatonin were defined using information on the number of tablets and the daily defined dose. We calculated incidence rate ratios for suicide and suicide attempts, as identified in register records, comparing those in treatment with melatonin to those not in treatment.

RESULTS

Among 5,798,923 individuals, 10,577 (0.2%) were treated with melatonin (mean treatment length, 50 days) during the study period. Of those, 22 died by suicide and 134 had at least 1 suicide attempt. People in treatment with melatonin had a 4-fold higher rate of suicide (incidence rate ratio, 4.8; 95% CI, 3.0-7.5) and a 5-fold higher rate of suicide attempt (incidence rate ratio, 5.9; 95% CI, 4.4-8.0) than those not in treatment and when adjusting for sex and age group.

CONCLUSIONS

Treatment with melatonin was associated with suicide and suicide attempt. Although there are several possible explanations, attention to suicide risk is particularly warranted for people with mental comorbidity who are in treatment with melatonin.

CITATION

Høier NK, Madsen T, Spira AP, et al. Associations between treatment with melatonin and suicidal behavior: a nationwide cohort study. J Clin Sleep Med. 2022;18(10):2451-2458.

Implementing an Online Program to Change Benzodiazepine Prescription: Protocol of a Hybrid Type 1 Cluster-Randomised Trial

<b><i>Introduction:</i></b> Excessive benzodiazepine (BZD) prescription has long been considered a serious mental health concern in many countries. Many interventions using different methodologies have been implemented to change BZD prescription patterns in primary health care settings, with limited positive results. <b><i>Objectives:</i></b> The primary objective of our study was to analyse the effectiveness and implementation process of an intervention aimed at changing BZD prescription patterns in a primary health care setting in Portugal. <b><i>Methodology:</i></b> We chose as methodology an effectiveness-implementation hybrid type 1 intervention. Our intervention was based on the development of an online platform, named ePrimaPrescribe, which was delivered using a Digital Behaviour Change Intervention (DBCI), using a two-arm cluster-randomised clinical trial. <b><i>Results:</i></b> We primarily aimed to evaluate the effectiveness of our DBCI in changing BZD prescription patterns using the frequency of BZD prescriptions issued per month as an outcome measure. Secondarily, we aimed to analyse the effect of ePrimaPrescribe on antidepressant prescriptions, to study the effect of the platform on diagnosis registration associated with BZDs and antidepressant prescription, and to perform a cost analysis considering the monthly National Health Service spending on BZD co-payments. Finally, we aimed to analyse the implementation process using quantitative and qualitative methods. <b><i>Conclusion:</i></b> With this study, we expect to contribute with a cost-effective intervention to change the complex matter of excessive BZD prescriptions, and also to improve insight into the challenges to intervention implementation processes in primary health care settings. We believe that our findings are relevant not only to the specific setting where the study was implemented, but also to all countries where primary health care plays a central role in care provision.

Predicting suicide attempt or suicide death following a visit to psychiatric specialty care: A machine learning study using Swedish national registry data

BACKGROUND

Suicide is a major public health concern globally. Accurately predicting suicidal behavior remains challenging. This study aimed to use machine learning approaches to examine the potential of the Swedish national registry data for prediction of suicidal behavior.

METHODS AND FINDINGS

The study sample consisted of 541,300 inpatient and outpatient visits by 126,205 Sweden-born patients (54% female and 46% male) aged 18 to 39 (mean age at the visit: 27.3) years to psychiatric specialty care in Sweden between January 1, 2011 and December 31, 2012. The most common psychiatric diagnoses at the visit were anxiety disorders (20.0%), major depressive disorder (16.9%), and substance use disorders (13.6%). A total of 425 candidate predictors covering demographic characteristics, socioeconomic status (SES), electronic medical records, criminality, as well as family history of disease and crime were extracted from the Swedish registry data. The sample was randomly split into an 80% training set containing 433,024 visits and a 20% test set containing 108,276 visits. Models were trained separately for suicide attempt/death within 90 and 30 days following a visit using multiple machine learning algorithms. Model discrimination and calibration were both evaluated. Among all eligible visits, 3.5% (18,682) were followed by a suicide attempt/death within 90 days and 1.7% (9,099) within 30 days. The final models were based on ensemble learning that combined predictions from elastic net penalized logistic regression, random forest, gradient boosting, and a neural network. The area under the receiver operating characteristic (ROC) curves (AUCs) on the test set were 0.88 (95% confidence interval [CI] = 0.87-0.89) and 0.89 (95% CI = 0.88-0.90) for the outcome within 90 days and 30 days, respectively, both being significantly better than chance (i.e., AUC = 0.50) (p < 0.01). Sensitivity, specificity, and predictive values were reported at different risk thresholds. A limitation of our study is that our models have not yet been externally validated, and thus, the generalizability of the models to other populations remains unknown.

CONCLUSIONS

By combining the ensemble method of multiple machine learning algorithms and high-quality data solely from the Swedish registers, we developed prognostic models to predict short-term suicide attempt/death with good discrimination and calibration. Whether novel predictors can improve predictive performance requires further investigation.

Patterns of Benzodiazepine Use and Excess Risk of All-Cause Mortality in the Elderly: A Nationwide Cohort Study

INTRODUCTION

Despite the risks associated with their use, benzodiazepines remain used more widely than wisely. In this context, a better understanding of how their patterns of use can be associated with an increased risk of death appears essential. Indeed, the studies that investigated this association so far are inconsistent and question the influence of potential biases.

OBJECTIVE

The objective of this study was to investigate the association of various patterns of benzodiazepine use with all-cause mortality.

METHODS

A nationwide cohort of non-prevalent benzodiazepine users aged ≥ 65 years was identified using French healthcare insurance system claims databases. Exposure to benzodiazepines considered short-term, chronic (defined as a cumulated ≥ 6-month period over the previous 12 months), ongoing, and discontinued use. Using a Cox model, adjusted hazard ratios for all-cause mortality were estimated according to benzodiazepine patterns of use; exposure and confounders were treated as time-dependent variables.

RESULTS

In the cohort of 54,958 individuals aged ≥ 65 years, adjusted hazard ratios for all-cause mortality and benzodiazepines were 2.26 (95% confidence interval 1.96-2.61) for short-term use, 3.86 (3.04-4.90) for chronic use-discontinued, and 3.05 (2.17-4.29) for chronic use-ongoing. At age 80 years, these were 1.62 (1.48-1.79), 2.00 (1.82-2.19) and 1.13 (1.02-1.26), respectively. Adjusted hazard ratios show similar decreases with age for all patterns of benzodiazepine use.

CONCLUSIONS

These findings confirm the existence of an excess risk of mortality associated with benzodiazepine use and provide pattern- and age-specific estimates. Higher risks were observed for patients aged < 80 years, short-term use, or chronic use recently interrupted. If the two latter can relate to an indication bias, the associations found for ongoing chronic use and short-term use conversely support a potential causal hypothesis.

Understanding the effects of chronic benzodiazepine use in depression: a focus on neuropharmacology

Benzodiazepines are frequently prescribed on an ongoing basis to individuals with depression, mainly to alleviate anxiety or insomnia, despite current guideline recommendations that continuous use should not exceed 4 weeks. Currently, there are no efficacy trials published beyond 8 weeks. Several antidepressant trials demonstrate that the concomitant use of a benzodiazepine is associated with poorer depressive outcomes and functional status; however, it is unclear why this is the case. Patients with depression receiving a benzodiazepine may reflect a more ill or high anxiety group, although even within anxiety disorders, the use of a benzodiazepine is associated with poorer outcomes. The neuroadaptive consequences of long-term benzodiazepine use may be a factor underlying these findings. Chronic benzodiazepine use results in decreased gamma-aminobutyric acid and monoaminergic function, as well as interference with neurogenesis, which are all purported to play a role in antidepressant efficacy. This review will discuss the oppositional neuropharmacological interactions between chronic benzodiazepine use and antidepressant mechanism of action, which could result in reduced antidepressant efficacy and function in depression.

Association between opioid analgesic plus benzodiazepine use and death: A case-crossover study

OBJECTIVE

We aimed to investigate whether concomitant use of benzodiazepines and opioids is associated with an increased risk of death in a population-based case-crossover setting.

METHODS

We conducted a case-crossover study using the National Sample Cohort database. We introduced a 30-day hazard period before the onset of death and three consecutive previous 30-day control periods with a 30-day washout period. The use of opioids and/or benzodiazepines during the hazard period was compared with that in the three control periods. We performed the conditional logistic regression analysis to estimate the adjusted odds ratios (aORs) and their 95% confidence intervals (CIs).

RESULTS

A total of 13,161 individuals who previously used benzodiazepines or opioids and died were included in the study. The risk of death was higher in patients with concomitant use of benzodiazepines and opioids (aOR, 1.86; 95% CI, 1.71-2.02) than in those who used either benzodiazepines or opioids only. In the subgroup analysis among concomitant users, the mortality risks were highest in patients aged less than 20 years (aOR, 3.85; 95% CI, 1.65-8.99), male patients (aOR, 2.20; 95% CI, 1.93-2.51), and patients with renal disease (aOR, 2.42; 95% CI, 1.57-3.74).

CONCLUSION

In this study, concomitant use of benzodiazepines and opioids was associated with a higher risk of death compared with use of a single drug. The risks and benefits of co-prescribing of benzodiazepines and opioids must be weighed carefully.

Self-reported sleep disturbance in ambulance attendances for suicidal ideation and attempted suicide between 2012 and 2017

BACKGROUND

Sleep disturbances are among the top-ten warning signs for suicide, however there has been limited investigation of the relationship between these variables in acute presentations, particularly community settings. We examined ambulance attendances for suicide ideation and attempt to explore the role of sleep and co-morbid factors (mental health symptoms, attendance time, and alcohol and benzodiazepine use).

METHODS

Coded clinical records from Ambulance Victoria for the period 1 January 2012 to 30 June 2017 were analysed.

RESULTS

Paramedics attended 97,198 cases of suicidal ideation or suicide attempt during the study period. Just over half (56.4%) of these were for suicidal ideation, and 43.6% were for attempted suicide. Depression symptomology-related attendances were more common than those for anxiety and despite a lower proportion of both sleep and current anxiety-related symptoms, benzodiazepine use was significantly more common in attendances for suicide attempts (25.9%) than for ideation (2.2%). Co-morbid benzodiazepine use was associated with attempted suicide (OR: 10.37 (10.04-10.72), in a hierarchical regression model.

LIMITATIONS

Data represent self-report/paramedic observation only, and do include validated measures of sleep or drug use. Sleep disturbance is likely under recorded in ambulance attendances given the primary role of paramedics is to stabilise patients, and minimise risk of harm during transport.

CONCLUSION

This study reports internationally unique data, and provides the first examination of ambulance coded clinical records for suicide ideation and attempt. Sleep disturbances had a unique role in these attendances, over and above common co-occurring factors including drug use and mental health diagnoses.

Concurrent use of benzodiazepines, antidepressants, and opioid analgesics with zolpidem and risk for suicide: a case-control and case-crossover study

PURPOSE

To evaluate whether the concurrent use of benzodiazepines, antidepressants, and opioid analgesics with zolpidem increases the risk of suicide or triggers suicide compared with the use of zolpidem alone.

METHODS

We conducted a case-control and case-crossover study using the Korean National Health Insurance Service-National Sample Cohort database. Cases were older than 20 years with a suicide record (International Codes of Disease 10th Revision codes: X-60-X84 and Y87.0 intentional self-harm) between January 1, 2004, and December 31, 2013. For case-control design, ten controls were matched to each case by age, sex, index year, region, income, and health insurance type. For case-crossover analysis, we set hazard period to 60 days and assigned five corresponding sets of control periods of equal length. Exposure was assessed during 60 days before suicide for combinations of benzodiazepines, antidepressants, opioid analgesics with zolpidem against zolpidem alone. We conducted a conditional logistic regression to estimate odds ratios (ORs) and their 95% confidence intervals (CIs).

RESULTS

In the case-control study, the risk of suicide was 2.80-fold higher in cases taking benzodiazepines and antidepressants with zolpidem than in those taking zolpidem alone (adjusted OR [aOR], 2.80; 95% CI, 1.38-5.70). However, in the case-crossover study, suicide risk showed no significant difference (crude OR [cOR], 0.92; 95% CI, 0.55-1.52) and was underpowered.

CONCLUSIONS

The results of the traditional case-control study confirmed that the concurrent use of benzodiazepines and antidepressants with zolpidem was associated with an increased risk of suicide compared with the use of zolpidem alone. However, there was no significant difference in the magnitude of risk in the within-person comparison design.

Association between benzodiazepines and suicide risk: a matched case-control study

BACKGROUND

It is unclear whether benzodiazepines increase the risk of suicide. The aim of this study was to test the hypothesis that benzodiazepines are associated with an increased risk of suicide, by comparing psychopharmacological interventions between psychiatric patients who committed suicide and a group of matched controls.

METHODS

The case group comprised 154 psychiatric patients (101 men, 53 women; age range: 13-96 years) who had committed suicide in Örebro County, Sweden. Control psychiatric patients matched by age, sex, and main psychiatric diagnosis were selected for each case. Binary logistic regression was used to calculate odds ratios in unadjusted and adjusted models.

RESULTS

Benzodiazepine prescriptions were more common among cases than controls (65/154 [42.2%] versus 43/154 [27.9%], p = 0.009, odds ratio: 1.89 [95% CI: 1.17-3.03]). This association remained significant in a model adjusted for previous suicide attempts and somatic hospitalizations (odds ratio: 1.83 [95% CI: 1.06-3.14]). No statistically significant differences were seen between the groups in the use of any other subtype of psychopharmaceutical agent.

CONCLUSIONS

These data indicate that benzodiazepine use may increase the risk of suicide. However, this study is limited by the potential for indication bias.

Risks of Benzodiazepines in Chronic Obstructive Pulmonary Disease with Comorbid Posttraumatic Stress Disorder

RATIONALE

Benzodiazepines are associated with mortality and poor outcomes among patients with chronic obstructive pulmonary disease (COPD), but use of benzodiazepines for dyspnea among patients with end-stage disease may confound this relationship.

OBJECTIVES

Assess the mortality risks of long-term benzodiazepine exposure among patients with COPD and comorbid post-traumatic stress disorder (PTSD), patients with chronic nonrespiratory indications for benzodiazepines.

METHODS

We identified all patients with COPD and PTSD within the Veteran's Health Administration between 2010 and 2012. We calculated propensity scores for benzodiazepine use and compared overall and cause-specific mortality of patients with long-term (≥90 d) benzodiazepine use relative to matched patients without use. Secondary analyses assessed propensity-adjusted survival by characteristics of benzodiazepine exposure.

RESULTS

Among 44,555 eligible patients with COPD and PTSD, 23.6% received benzodiazepines long term. In the matched sample of 19,552 patients, we observed no mortality difference (hazard ratio [HR] for long-term use, 1.06; 95% confidence interval [CI], 0.95-1.18) but greater risk of death by suicide among those with long-term use (HR, 2.33; 95% CI, 1.14-4.79). Among matched and unmatched patients, short-term benzodiazepine use, but not long-term use, was associated with increased mortality (short-term: HR, 1.16; 95% CI, 1.05-1.28; long-term: HR, 1.03; 95% CI, 0.94-1.13).

CONCLUSIONS

Risks for respiratory compromise related to long-term benzodiazepine use in COPD may be less than previously estimated, but short-term use of benzodiazepines could still pose a mortality risk. Suicide associated with benzodiazepine use in this population warrants further investigation.

Hypnotic Medications and Suicide: Risk, Mechanisms, Mitigation, and the FDA

OBJECTIVE

Insomnia is associated with increased risk for suicide. The Food and Drug Administration (FDA) has mandated that warnings regarding suicide be included in the prescribing information for hypnotic medications. The authors conducted a review of the evidence for and against the claim that hypnotics increase the risk of suicide.

METHOD

This review focused on modern, FDA-approved hypnotics, beginning with the introduction of benzodiazepines, limiting its findings to adults. PubMed and Web of Science were searched, crossing the terms "suicide" and "suicidal" with each of the modern FDA-approved hypnotics. The FDA web site was searched for postmarketing safety reviews, and the FDA was contacted with requests to provide detailed case reports for hypnotic-related suicide deaths reported through its Adverse Event Reporting System.

RESULTS

Epidemiological studies show that hypnotics are associated with an increased risk for suicide. However, none of these studies adequately controlled for depression or other psychiatric disorders that may be linked with insomnia. Suicide deaths have been reported from single-agent hypnotic overdoses. A separate concern is that benzodiazepine receptor agonist hypnotics can cause parasomnias, which in rare cases may lead to suicidal ideation or suicidal behavior in persons who were not known to be suicidal. On the other hand, ongoing research is testing whether treatment of insomnia may reduce suicidality in adults with depression.

CONCLUSIONS

The review findings indicate that hypnotic medications are associated with suicidal ideation. Future studies should be designed to assess whether increases in suicidality result from CNS impairments from a given hypnotic medication or whether such medication decreases suicidality because of improvements in insomnia.

Mortality associated with anxiolytic and hypnotic drugs-A systematic review and meta-analysis

BACKGROUND

Use of hypnotics or anxiolytic drugs is common and various studies have reported increased mortality with hypnotics or anxiolytic use.

OBJECTIVE

To consolidate the evidence on mortality risk associated with hypnotics or anxiolytic use

METHODS

Major databases were searched through April 2014 for studies reporting mortality risk associated with hypnotics or anxiolytics use. A pooled hazard ratio with 95% confidence interval was estimated using random-effects model.

RESULTS

After screening 2188 articles, 25 studies (24 cohort, 1 case-control) enrolling 2,350,093 patients with 59% females (age 18-102 years) were included in the meta-analysis. Hypnotics or anxiolytic users had 43% higher risk of mortality than non-users (hazard ratio, 1.43; 95% confidence interval, [1.12, 1.84]). Eight studies reported risk estimates for each gender category and pooled results from these studies showed increased risk of mortality among men (hazard ratio = 1.60, 95% confidence interval = [1.29,1.99]) and women (hazard ratio = 1.68, 95% confidence interval = [1.38, 2.04]). Pooled results from 10 studies showed higher mortality among benzodiazepine users compared to non-users (hazard ratio = 1.60, 95% confidence interval = [1.03, 2.49]), while pooled results from five studies showed an increased risk of mortality with Z-drugs use although the effect could not reach statistical significance (hazard ratio = 1.73, 95% confidence interval = [0.95, 3.16]). Significant heterogeneity was observed in the analyses and the quality of included studies was good.

CONCLUSION

This meta-analysis suggests that hypnotics or anxiolytics drugs use is associated with increased mortality and hence should be used with caution. Future studies focused on underlying mechanism of increased mortality with hypnotics or anxiolytics use are required.

Use of antiepileptic or benzodiazepine medication and suicidal ideation--The Northern Finland Birth Cohort 1966

Both antiepileptic drugs (AEDs) and benzodiazepines (BZDs) have previously been associated with an increased risk of suicidality. Our aim was to study the association between the use of conventional AEDs and BZDs and suicidal ideation in a large population-based cohort. Information on the medications used in the Northern Finland Birth Cohort 1966 was collected from the subjects at the age of 31 years, using a postal questionnaire (N=8211). The presence of suicidal ideation and other symptoms of depression and anxiety was assessed via the Hopkins Symptom Checklist - 25 questionnaire. The associations between medications and suicidal ideation were studied in different diagnostic groups and adjusted for symptoms of depression and anxiety. No difference was observed in suicidal ideation between AED users (n=54) and nonusers (n=8157). Subjects using BZDs (n=147) had greater suicidal ideation compared with nonusers (n=8064). Antiepileptic drug and benzodiazepine users more often exhibited other depression and anxiety symptoms. After adjustment for these symptoms, both AED and BZD users had less suicidal ideation compared with nonusers. In conclusion, in this population-based cohort, neither the use of AEDs nor that of BZDs was found to be associated with increased suicidal ideation when the symptoms of depression and anxiety were taken into account.

Bridging the gap between education and appropriate use of benzodiazepines in psychiatric clinical practice

More than half a century after their discovery, benzodiazepines (BDZs) still represent one of the largest and most widely prescribed groups of psychotropic compounds, not only in clinical psychiatry but also in the entire medical field. Over the last two decades, however, there has been an increased focus on the development of antidepressants and antipsychotics on the part of the pharmaceutical industry, clinicians, and researchers, with a reduced interest in BDZs, in spite of their widespread clinical use. As a consequence, many psychiatric residents, medical students, nurses, and other mental health professionals might receive poor academic teaching and training regarding these agents, and have the false impression that BDZs represent an outdated chapter in clinical psychopharmacology. However, recent advances in the field, including findings concerning epidemiology, addiction risk, and drug interactions, as well as the introduction of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition with related diagnostic changes, strongly encourage an updated appraisal of the use of BDZs in clinical practice. During a recent thematic event convened with the aim of approaching this topic in a critical manner, a group of young Italian psychiatrists attempted to highlight possible flaws in current teaching pathways, identify the main clinical pros and cons regarding current use of BDZs in clinical practice, and provide an updated overview of their use across specific clinical areas and patient populations. The main results are presented and discussed in this review.

Suicidal behaviour and cognitive problem solving therapy: theory, application and review

Suicidal behaviour is a major public health problem worldwide, both with regard to mortality and treatment of clients who have deliberately harmed themselves. It is a multifaceted problem resulting from complex interactions between social, biological and psychological factors. There is insufficient evidence on which to make firm recommendations about the most effective forms of treatment This is remarkable considering the extent of the problem worldwide, and the importance of dealing with it appropriately in order to prevent further suicides.

Comparative efficacy of two interventions to discontinue long-term benzodiazepine use: cluster randomised controlled trial in primary care

BACKGROUND

Benzodiazepines are extensively used in primary care, but their long-term use is associated with adverse health outcomes and dependence.

AIMS

To analyse the efficacy of two structured interventions in primary care to enable patients to discontinue long-term benzodiazepine use.

METHOD

A multicentre three-arm cluster randomised controlled trial was conducted, with randomisation at general practitioner level (trial registration ISRCTN13024375). A total of 532 patients taking benzodiazepines for at least 6 months participated. After all patients were included, general practitioners were randomly allocated (1:1:1) to usual care, a structured intervention with follow-up visits (SIF) or a structured intervention with written instructions (SIW). The primary end-point was the last month self-declared benzodiazepine discontinuation confirmed by prescription claims at 12 months.

RESULTS

At 12 months, 76 of 168 (45%) patients in the SIW group and 86 of 191 (45%) in the SIF group had discontinued benzodiazepine use compared with 26 of 173 (15%) in the control group. After adjusting by cluster, the relative risks for benzodiazepine discontinuation were 3.01 (95% CI 2.03-4.46, P<0.0001) in the SIW and 3.00 (95% CI 2.04-4.40, P<0.0001) in the SIF group. The most frequently reported withdrawal symptoms were insomnia, anxiety and irritability.

CONCLUSIONS

Both interventions led to significant reductions in long-term benzodiazepine use in patients without severe comorbidity. A structured intervention with a written individualised stepped-dose reduction is less time-consuming and as effective in primary care as a more complex intervention involving follow-up visits.

Risk factors for suicidal behaviour in individuals on disability pension due to common mental disorders - a nationwide register-based prospective cohort study in Sweden

BACKGROUND

Common mental disorders (CMD) have become one of the leading causes for disability pension (DP). Studies on predictors of adverse health outcome following DP are sparse. This study aimed to examine the association of different socio-demographic factors and health care consumption with subsequent suicidal behaviour among individuals on DP due to CMD.

METHOD

This is a population-based prospective cohort study based on register data. All individuals aged 18-64 years, living in Sweden on 31-Dec-2004 who in 2005 were on DP due to CMD (N = 46 745) were followed regarding suicide attempt and suicide (2006-10). Univariate and multivariate hazard ratios (HR) and 95% confidence intervals (CI) for suicidal behaviour were estimated by Cox regression.

RESULTS

During the five-year follow-up, 1 046 (2.2%) and 210 (0.4%) individuals attempted and committed suicide, respectively. Multivariate analyses showed that young age (18-24 years) and low education predicted suicide attempt, while living alone was associated with both higher suicide attempt and suicide (range of HRs 1.23 to 1.68). Combined prescription of antidepressants with anxiolytics during 2005 and inpatient care due to mental diagnoses or suicide attempt (2001-05) were strongly associated with suicide attempt and suicide (range of HRs 1.3 to 4.9), while inpatient care due to somatic diagnoses and specialized outpatient care due to mental diagnoses during 2001-05 only predicted suicide attempt (HR 1.45; 95% CI: 1.3-1.7; HR 1.30; 95% CI: 1.1-1.7).

CONCLUSIONS

Along with socio-demographic factors, it is very important to consider type of previous healthcare use and medication history when designing further research or intervention aiming at individuals on DP due to CMD. Further research is warranted to investigate both characteristics of disability pension due to CMD, like duration, diagnoses and grade as well as mechanisms to subsequent suicidal behavior, taking potential gender differences into consideration.

Benzodiazepine therapy in psychiatric outpatients is associated with deliberate self-poisoning events at emergency departments-a population-based nested case-control study

RATIONALE

Deliberate self-poisoning (DSP), the most common form of deliberate self-harm, is closely associated with suicide. Identifying risk factors of DSP is necessary for implementing prevention strategies.

OBJECTIVES

This study aimed to evaluate the relationship between benzodiazepine (BZD) treatment in psychiatric outpatients and DSP cases at emergency departments (EDs).

METHODS

We performed a retrospective nested case-control study of psychiatric patients receiving BZD therapy to evaluate the relationship between BZD use and the diagnosis of DSP at EDs using data from the nationwide Taiwan National Health Insurance Research Database.

RESULTS

Regression analysis yielded an odds ratio (OR) and 95 % confidence interval (95 % CI) indicating that the use of BZDs in psychiatric outpatients was significantly associated with DSP cases at EDs (OR = 4.46, 95 % CI = 3.59-5.53). Having a history of DSP, sleep disorders, anxiety disorders, schizophrenia, depression, or bipolar disorder was associated with a DSP diagnosis at EDs (OR = 13.27, 95 % CI = 8.28-21.29; OR = 5.04, 95 % CI = 4.25-5.98; OR = 3.95, 95 % CI = 3.32-4.70; OR = 7.80, 95 % CI = 5.28-11.52; OR = 15.20, 95 % CI = 12.22-18.91; and OR = 18.48, 95 % CI = 10.13-33.7, respectively). After adjusting for potential confounders, BZD use remained significantly associated with a subsequent DSP diagnosis (adjusted OR = 2.47, 95 % CI = 1.93-3.17). Patients taking higher average cumulative BZD doses were at greater risk of DSP.

CONCLUSION

Vigilant evaluation of the psychiatric status of patients prescribed with BZD therapy is critical for the prevention of DSP events at EDs.

Suicidal ideation in a European Huntington's disease population

BACKGROUND

Previous studies indicate increased prevalences of suicidal ideation, suicide attempts, and completed suicide in Huntington's disease (HD) compared with the general population. This study investigates correlates and predictors of suicidal ideation in HD.

METHODS

The study cohort consisted of 2106 HD mutation carriers, all participating in the REGISTRY study of the European Huntington's Disease Network. Of the 1937 participants without suicidal ideation at baseline, 945 had one or more follow-up measurements. Participants were assessed for suicidal ideation by the behavioural subscale of the Unified Huntington's Disease Rating Scale (UHDRS). Correlates of suicidal ideation were analyzed using logistic regression analysis and predictors were analyzed using Cox regression analysis.

RESULTS

At baseline, 169 (8.0%) mutation carriers endorsed suicidal ideation. Disease duration (odds ratio [OR]=0.96; 95% confidence interval [CI]: 0.9-1.0), anxiety (OR=2.14; 95%CI: 1.4-3.3), aggression (OR=2.41; 95%CI: 1.5-3.8), a previous suicide attempt (OR=3.95; 95%CI: 2.4-6.6), and a depressed mood (OR=13.71; 95%CI: 6.7-28.0) were independently correlated to suicidal ideation at baseline. The 4-year cumulative incidence of suicidal ideation was 9.9%. Longitudinally, the presence of a depressed mood (hazard ratio [HR]=2.05; 95%CI: 1.1-4.0) and use of benzodiazepines (HR=2.44; 95%CI: 1.2-5.0) at baseline were independent predictors of incident suicidal ideation, whereas a previous suicide attempt was not predictive.

LIMITATIONS

As suicidal ideation was assessed by only one item, and participants were a selection of all HD mutation carriers, the prevalence of suicidal ideation was likely underestimated.

CONCLUSIONS

Suicidal ideation in HD frequently occurs. Assessment of suicidal ideation is a priority in mutation carriers with a depressed mood and in those using benzodiazepines.

Are selective serotonin reuptake inhibitors safe for drivers? What is the evidence?

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are widely used medications to treat several psychiatric diseases and, above all, depression. They seem to be as effective as older antidepressants but have a different adverse effect profile. Despite their favorable safety profile, little is known about their influence on traffic safety.

OBJECTIVE

To conduct a literature review to summarize the current evidence on the role of SSRIs in traffic safety, particularly concerning undesirable effects that could potentially impair fitness to drive, experimental and pharmacoepidemiologic studies on driving impairment, 2 existing categorization systems for driving-impairing medications, and the European legislative procedures for assessing fitness to drive before issuing a driver's license and driving under the influence of medicines.

METHODS

The article search was performed in the following electronic databases: MEDLINE, PsycINFO, ScienceDirect, and SafetyLit. The English-language scientific literature was searched using key words such as SSRIs and psychomotor performance, car crash or traffic accident, and adverse effects. For inclusion in this review, papers had to be full-text articles, refer to possible driving-related adverse effects, and be experimental or pharmacoepidemiologic studies on SSRIs and traffic accident risks. No restrictions concerning publication year were applied.

RESULTS

Ten articles were selected as background information on driving-related adverse effects, and 15 articles were selected regarding experimental and pharmacoepidemiologic work. Regarding SSRI adverse effects, the most reported undesirable effects referring to driving impairment were anxiety, agitation, sleep disturbances, headache, increased risk of suicidal behavior, and deliberate self-harm. Regarding the remaining issues addressed in this article, inconsistencies were found between the outcomes of the selected experimental and epidemiologic studies and between the 2 existing categorization systems under evaluation. Some pitfalls of the current legislative scenario were identified as well.

CONCLUSIONS

Based on the current evidence, it was concluded that more experimental and epidemiologic research is needed to elucidate the relationship between SSRI use and traffic safety. Furthermore, a revision of the existing categorization systems and harmonized European legislation in the field of medication use and driving were highly recommended.

Cohort study of the association of hypnotic use with mortality in postmenopausal women

OBJECTIVE

Previous studies found an association between hypnotic use and mortality risk. The prospective outcome data and the many baseline risk factors included in the Women's Health Initiative (WHI) provide an opportunity to better understand the reasons for this association.

SETTING

The WHI is a long-term national health study that focused on strategies for preventing disease in postmenopausal women. Participants were enrolled from 1993 to 1998.

DESIGN

Baseline hypnotic use was evaluated for an association with subsequent mortality or disease after adjusting for baseline risk.

SUBJECTS

148 938 postmenopausal women between the ages of 50 and 79 throughout the USA. The median follow-up was 8 years.

MAIN OUTCOME MEASURES

Mortality. Secondary outcomes included myocardial infarction, stroke, diabetes and seven types of cancer.

RESULTS

For persons who use hypnotic medications almost daily the age-adjusted hazard ratio (HR) for mortality was 1.62 (95% CI 1.50 to 1.74). Greater hypnotic use was associated with less healthy levels of physical function, general health and smoking at baseline. After adjustment for these factors the HR for almost daily hypnotic use was 1.14 (1.06 to 1.23) for mortality and 1.53 (1.18 to 1.99) for melanoma; it was not significantly associated with increased incidence of other diseases tested. Less frequent hypnotic use and several types of sleeping difficulties were not associated with mortality, but sleeping more than 10 h a night had a risk-adjusted HR for mortality of 1.28 (1.01 to 1.61).

CONCLUSIONS

The association of hypnotic use with mortality and incident disease was greatly reduced after adjusting for baseline risk factors. These findings do not support a strong independent association of hypnotic use with most health outcomes.

Road traffic accidents and psychotropic medication use in The Netherlands: a case-control study

AIM

To examine the association between the use of commonly prescribed psychotropic medications and road traffic accident risk.

METHODS

A record-linkage database was used to perform a case-control study in The Netherlands. The data came from three sources: pharmacy prescription data, police traffic accident data and driving licence data. Cases were defined as drivers, who had a traffic accident that required medical assistance between 2000 and 2007. Controls were defined as adults, who had a driving licence and had no traffic accident during the study period. Four controls were matched for each case. The following psychotropic medicine groups were examined: antipsychotics, anxiolytics, hypnotics and sedatives, and antidepressants stratified in the two groups, SSRIs and other antidepressants. Various variables, such as age, gender, medicine half-life and alcohol use, were considered for the analysis.

RESULTS

Three thousand nine hundred and sixty-three cases and 18,828 controls were included in the case-control analysis. A significant association was found between traffic accident risk and exposure to anxiolytics (OR = 1.54, 95% CI 1.11, 2.15), and SSRIs (OR = 2.03, 95% CI 1.31, 3.14). A statistically significant increased risk was also seen in chronic anxiolytic users, females and young users (18 to 29 years old), chronic SSRI users, females and middle-aged users (30 to 59 years old), and intermediate half-life hypnotic users.

CONCLUSIONS

The results of this study support previous findings and confirm that psychoactive medications can constitute a problem in traffic safety. Both health care providers and patients should be properly informed of the potential risks associated with the use of these medicines.

The role of psychopharmacology in suicide prevention

The potential role of psychopharmacology in suicide prevention is often minimised. This may to some extent reflect that few medication trials have specifically focussed on prevention of suicidal behaviour – indeed this outcome is often not reported in trials. However, there is reasonably strong evidence that lithium may reduce risk of suicide, the postulated mechanism being a specific effect on aggression. Evidence is lacking with regard to any protective effect of other mood stabilizers. Clozapine may reduce suicidal behaviour in patients with schizophrenia, with reduction of affective symptoms being a possible explanation. The role of antidepressants in relation to suicide risk is highly controversial, especially in children and adolescents. It is unclear whether minor tranquillizers or hypnotics can assist in suicide prevention, although they can reduce the anxiety symptoms that may occur during initial treatment with SSRI antidepressants. Itis also uncertain whether psychopharmacology has a role in preventing suicidal behaviour in people with personality disorders. Despite the limitations of the evidence we contend that suicide risk should be an important factor in deciding when and what to prescribe.

Declaration of Interest: We have no interests to declare.

The association between insomnia and cardiovascular diseases

Insomnia, the most common sleep complaint in the general population, is defined by difficulty initiating or maintaining sleep, or nonrestorative sleep, accompanied by some form of daytime impairment. In the current review, we present an overview of recent studies on the association between insomnia and cardiovascular disease. It can be concluded that there is growing evidence for the hypothesis that insomnia is associated with an increased risk for cardiovascular disease independently of classic coronary risk factors. Furthermore, insomnia is likely to be associated with hypertension and elevated resting heart rate, both known to lead to cardiovascular disease. However, the existing evidence is not totally consistent and most findings have not been replicated unequivocally. The major limitations of the cited studies include the failure to use state-of-the-art criteria for insomnia diagnosis, the failure to control for depression, and the use of hypnotic medication and sleep apnea as potential confounders. However, the results suggest that insomnia is associated with an increased risk for cardiovascular disease mediated by hypertension or elevated resting heart rate. Consequently, more effort should be dedicated to cope with the high prevalence of insomnia in the general population.

Risk of preterm delivery and other adverse perinatal outcomes in relation to maternal use of psychotropic medications during pregnancy

OBJECTIVE

The purpose of this study was to determine the association of maternal psychotropic medication use during pregnancy with preterm delivery and other adverse perinatal outcomes.

STUDY DESIGN

A cohort of 2793 pregnant women in Washington State was interviewed, and their medical files were abstracted. Logistic regression models were constructed to assess odds ratios for perinatal outcomes by use of psychotropic medications.

RESULTS

Maternal use of benzodiazepine during pregnancy was associated with an increased risk of preterm delivery (adjusted odds ratio, 6.79; 95% confidence interval, 4.01-11.5) and with increased risks of low birthweight, low Apgar score, neonatal intensive care unit admissions, and respiratory distress syndrome. Selective serotonin receptor inhibitors were associated with preterm deliveries only among women who started treatment after the first trimester.

CONCLUSION

Benzodiazepine was associated highly with preterm delivery and other adverse perinatal outcomes. Well-conducted cohort studies are warranted to draw conclusions about risks and benefits of psychotropic medication use during pregnancy.

Reducing diazepam prescribing for illicit drug users: A randomised control study

Illicit drug users undergoing mandatory reductions in prescribed diazepam were randomly allocated to one of two methods of delivering psychological support to help reduce their prescription: a) an enhanced intervention consisting of skills training and reinforcement, and b) a limited intervention where patients initially received skills training and thereafter only advice. Outcome measures at baseline and six-months consisted of daily diazepam dose; reported illicit drug use; Severity of Dependence Scale; Hospital Anxiety and Depression Scale (HADS); Pittsburgh Sleep Quality Index. Fifty-three of 119 eligible patients agreed to be randomly allocated to the interventions. Those in the enhanced intervention reduced their daily dose of prescribed diazepam from a mean of 27.8 mgs to 19.9 mgs at six months (5.3% per month) compared with 29.8 mgs to 17.6 mgs at six months (7.5%) among those in the limited intervention group. However, there was no statistically significant difference in the reduction rate between the intervention groups. Approximately 75% of patients in each group suspended their reduction programme. The enhanced intervention group reported a statistically and clinically greater reduction in the mean HADS depression score (10.6 at baseline and 7.7 at follow-up), compared with a rise from 8.9 to 11.2 in the limited intervention group. In conclusion, it is possible to reduce prescribed diazepam among illicit drug users but not at the rate of 10% per month set by the study. The difficulties of working with this population necessitate a flexible and possibly long-term approach to reducing prescribed benzodiazepines.

Predictors of spontaneous and systematically assessed suicidal adverse events in the treatment of SSRI-resistant depression in adolescents (TORDIA) study

OBJECTIVE

The authors sought to identify predictors of self-harm adverse events in treatment-resistant, depressed adolescents during the first 12 weeks of treatment.

METHOD

Depressed adolescents (N=334) who had not responded to a previous trial with an SSRI antidepressant were randomized to a switch to either another SSRI or venlafaxine, with or without cognitive behavior therapy. Self-harm events, i.e., suicidal and non-suicidal self-injury adverse events were assessed by spontaneous report for the first 181 participants, and by systematic weekly assessment for the last 153 participants.

RESULTS

Higher rates of suicidal (20.8% vs. 8.8%) and nonsuicidal self-injury (17.6% vs. 2.2%), but not serious adverse events (8.4% vs. 7.3%) were detected with systematic monitoring. Median time to a suicidal event was 3 weeks, predicted by high baseline suicidal ideation, family conflict, and drug and alcohol use. Median time to nonsuicidal self-injury was 2 weeks, predicted by previous history of nonsuicidal self-injury. While there were no main effects of treatment, venlafaxine treatment was associated with a higher rate of self-harm adverse events in those with higher suicidal ideation. Adjunctive use of benzodiazepines, while in a small number of participants (N=10) was associated with higher rate of both suicidal and nonsuicidal self-injury adverse events.

CONCLUSIONS

Since predictors of suicidal adverse events also predict poor response to treatment, and many of these events occurred early in treatment, improving the speed of response to depression, by targeting of family conflict, suicidal ideation, and drug use may help to reduce their incidence. The relationship of venlafaxine and of benzodiazepines to self-harm events requires further study and clinical caution.

Comorbid anxiety as a suicide risk factor among depressed veterans

BACKGROUND

Depressive disorders greatly increase suicide risk; however, little is known about the contribution of comorbid anxiety disorders or anxiety symptoms to the risk of suicide death among depressed patients. We examined whether depressed veterans with comorbid anxiety had higher risks of suicide death.

METHODS

Using VA administrative databases we identified 887,859 patients with depression. We then used univariate and multivariate logistic regression, controlling for demographics and substance use disorders, to determine the odds ratios of completed suicide associated with individual comorbid anxiety disorders, the presence of any comorbid anxiety disorder, the prescription of an antianxiety medication, or the prescription of a high dose of an antianxiety medication.

RESULTS

In multivariate analyses, the odds of completed suicide were significantly increased for patients with panic disorder (OR 1.26, 95% CI: 1.04-1.53), generalized anxiety disorder (OR 1.27, 95% CI: 1.09-1.47), and anxiety disorder, not otherwise specified (OR 1.25, 95% CI: 1.12-1.38). The odds of completed suicide were also greater among patients who received any antianxiety medication (OR 1.71, 95% CI: 1.55-1.88), and were further increased among those who received high dose treatment (OR 2.26, 95% CI: 1.98-2.57). Odds of completed suicide were decreased among patients with comorbid posttraumatic stress disorder (OR 0.87, 95% CI: 0.77-0.97), and there was no statistically significant relationship between social phobia, obsessive-compulsive disorder, and all other anxiety disorders and suicide.

CONCLUSIONS

These findings emphasize the importance of comorbid anxiety disorders and symptoms in increasing suicide risk among depressed patients and may inform suicide prevention efforts among these patients.

[Antidepressants and their onset of action: a major clinical, methodological and pronostical issue]

Although antidepressant medications are effective in about 50-70% of patients with major depressive disorder (MDD), they have a delayed onset of therapeutic effect. This latency is one of the current major limitations of these medications, in that it prolongs the impairments associated with depression, leaves patients vulnerable to an increased risk of suicide, increases the likelihood that a patient will prematurely discontinue therapy, and increases medical costs associated with severe depression. It is becoming increasingly clear that differences may exist between antidepressants and some evidence suggests that some antidepressant agents may begin to work faster than others. Escitalopram, duloxetine, venlafaxine, and mirtazapine have shown statistically significant differences in some measures of antidepressant action within the first two weeks of treatment, both in placebo-controlled trials and in head-to-head comparisons with other antidepressants. Results of the current review should be regarded with certain important limitations in mind. First, differences in times to onset of antidepressant response have been shown in clinical efficacy studies not specifically designed to detect differences in onset of action (post-hoc analysis). Second, results observed in 'pure' clinical trial samples should not be directly generalized to the real clinical practice since it has been proven in clinical settings that less than one in seven depressed patients would be eligible to participate in antidepressant clinical trials. For instance, depressed patients who are suicidal or who score higher than 30 on the 17-item HAM-D are excluded from antidepressant clinical trials. Third, caution is warranted when applying these findings to clinical populations with more severe depressions with respect to the fact that among clinical populations, severity of depression coincides with comorbidity, including such psychiatric disorders as anxiety disorders, personality disorders and substance abuse. In addition, the magnitudes of the size-effects of antidepressants versus placebo are clearly higher in severely depressed patients. Fourth, specific items on depression rating scales may induce greater antidepressant/placebo differences. For instance, the 17-item HAM-D contains three questions pertaining to sleep. It questions the fact that earlier onset may appear not only via a specific antidepressant effect but also via a non-specific effect on anxiety, sleep, physical pain or other accessory symptoms. Thus, current data do not clearly support claims that one drug reduces the symptoms of depression faster than another, though the existing literature suggests that escitalopram displays some superiority in terms of rapidity of action. Given the potential benefits of early-acting antidepressant treatments, the possibility of superior speed of onset of escitalopram presented here merits further study in adequately designed, prospective clinical trials. A definitive demonstration of early onset of action awaits the results of appropriately designed and powered clinical studies, which may include (1) a prospective definition of early onset of action, (2) more focused assessments of core emotional symptoms and cognitive deficits of depression by using specific and sensitive tools, (3) a data-analytic approach capable of capturing the dynamic nature of symptomatic change (for example, survival analysis), and (4) strategies to minimize biases and heterogeneity of response.

[Prescription of benzodiazepines by general practitioners in the private sector of Dakar: survey on knowledge and attitudes]

OBJECTIVE

The objective of this study was to evaluate knowledge and attitudes of general practitioners of the private sector, in Dakar, concerning prescription of benzodiazepines, in order to make, possibly, recommendations for their rational use.

METHOD

A survey was done in 2005 with a representative sample of 55 medical doctors. Medical doctors filled in the questionnaire which focused on the main benzodiazepines' indications, those prescribed and their rules of prescription.

RESULTS

The main indications were anxiety, convulsions, epilepsy and insomnia and the benzodiazepines prescribed in first intention were prazepam against anxiety and insomnia and diazepam against convulsions and epilepsy. Practically 17% of medical doctors ignored the existence of limited period of benzodiazepine use and 70.9% of medical doctors considered their training on benzodiazepines insufficient.

CONCLUSION

These results show the necessity to base continuous training for these general practitioners on the pharmacology of benzodiazepines.

Continued antidepressant treatment and suicide in patients with depressive disorder

Antidepressant use in Denmark, as in many developed countries, has substantially increased during recent years, coinciding with a decreasing suicide rate. In a nationwide observational cohort study with linkage of registers of all prescribed antidepressants and recorded suicides in Denmark from 1995 to 2000, we investigated the relation between continued treatment with antidepressants and suicide in a population of all patients discharged from hospital psychiatry with a diagnosis of depressive disorder. Patients discharged from hospital psychiatry with a diagnosis of depressive disorder had a highly increased rate of suicide. Those who continued treatment with antidepressants had a decreased rate of suicide compared with those who purchased antidepressants once (rate ratio: 0.31, 95% confidence interval: 0.26-0.36). Further, the rate of suicide decreased consistently with the number of prescriptions. On individualized data from a cohort of patients with a known history of depressive disorder, continued antidepressant treatment was associated with reduced risk of suicide.

Use of anxiolytic or hypnotic drugs and total mortality in a general middle-aged population

PURPOSE

The aim of the study was to evaluate the effect of the consumption of anxiolytic or hypnotic drugs on total mortality in a general population.

METHODS

We followed a cohort of 7225 men and 7726 women aged 40-42 years who underwent health surveys in 1985-1989 in two Norwegian counties, with respect to deaths. Mean follow-up period was 18 years. The subjects were categorised according to frequency of anxiolytic or hypnotic drug use during the last month: daily, every week, less than every week and not used during the last month.

RESULTS

The proportion of anxiolytic or hypnotic drug users was 6.6% among men and 16.2% among women. Altogether 402 men and 290 women died. There was an increase in risk of death with an increase in frequency of use. Crude hazard ratios for men and women daily using anxiolytics or hypnotics were 3.1 (95%CI 2.0, 4.8) and 2.7 (1.9, 4.0), respectively, as compared with non-users last month. After adjusting painkiller use and smoking the hazard ratios were lowered, being 2.4 (1.5-4.0) (men) and 2.1 (1.4-3.2) (women). After additional adjustments for other possible confounders the hazard ratios were further attenuated to 1.5 (0.9-2.7) for men and 1.7 (1.1-2.6) for women.

CONCLUSIONS

Daily users of anxiolytic or hypnotic drugs in our study showed higher crude mortality than non-users. However, after adjusting lifestyle and socio-economic variables the difference was markedly reduced suggesting that the remaining excess mortality is due to residual confounding.

L’association antidépresseur et anxiolytique aujourd’hui: bilan et prospective

SUMMARY

The potential for drug-drug interactions in psychiatric patients is very high as combination psychopharmacotherapy used to treat comorbid psychiatric disorders, to treat the adverse effects of a medication, to augment a medication effect or to treat concomitant medical illnesses, etc. Interactions can be pharmacodynamic or pharmacokinetic in nature. In clinical practice the benzodiazepines (BZD) are often prescribed together with antidepressant drugs for the treatment of depression. Although there has been no convincing evidence to show that such a combination is more effective than antidepressants alone and no clear indication for the use of this combination. Yet, anxiety frequently coexists with depression, and an anxiolytic is often added. But, it is BZD which are systematically prescribed together with antidepressants. However, BZD themselves have no antidepressive effects and we lack firm evidence for or against this combination therapy. We are focused on the pharmacodynamic interactions between anxiolytic such as BZD, and antidepressant drugs which may resulting in a reduction of the effects of one of the drugs. It is known that BZD decrease the serotoninergic transmission. Also, it may be suggested that combined BZD-specific serotonin reuptake inhibitors, should be avoided. This paper reviews, in vitro and in vivo and particularly in clinical, the evidences for drug interactions between BZD and antidepressant drugs. In clinical, all trials that compared antidepressant-benzodiazepine treatment with antidepressant alone for adult patients with major depression were sought by electronic searches of Medline and several other databases (1970 to 2005), combined with hand searching, reference searching and SciSearch.

Impact of cognitive behavior therapy on health-related quality of life among adult hypnotic users with chronic insomnia

Results were combined from representative surveys of health related quality of life (HRQoL; n=11,877; age range=16-104) with data from a randomized controlled trial of cognitive behavior therapy for chronic insomnia (n=209; age range=31-92). Secondary analyses of scores from the SF-36 measure of HRQoL were conducted in order: (a) to compare the health related quality of life profiles of adult hypnotic users with chronic insomnia with those of population norms, and (b) to assess the impact of cognitive behavior therapy (CBT) for insomnia on HRQoL outcomes over 6 months. Compared with the primary care reference values, HRQoL among the trial participants at baseline was generally poorer. The magnitude of these decrements reduced markedly with advancing age. In the evaluation of the CBT intervention, statistically significant differences in SF-36 scores in favor of the intervention were present for physical functioning, emotional role limitation, and mental health over 6 months. Overall, this study shows that the SF-36 can play an important role in describing HRQoL in this patient group, and in the evaluation of interventions within this group.

Do antidepressants prevent suicide?

As in many developed countries, the use of antidepressants in Denmark has been substantially increasing during recent years, coinciding with a decreasing suicide rate. We aimed to investigate the relationship between treatment with antidepressants and suicide on individualized data from a nationwide study comprising an observational cohort study with linkage of registers of all prescribed antidepressants and recorded suicides in Denmark during the period 1995-99. A total of 438 625 patients who purchased at least one prescription of antidepressants and 1073 862 individuals from the general population were included in the study. Patients who continued treatment with selective serotonin reuptake inhibitors (SSRIs) (i.e. who purchased SSRIs twice or more) had a decreased rate of suicide compared with patients who purchased SSRIs once only [rate ratio (RR)=0.63; 95% confidence interval (CI)=0.56-0.71]. Furthermore, the rate of suicide decreased consistently with the number of prescriptions. Similarly, among patients treated with newer antidepressants other than SSRIs, the rate of suicide was decreased compared with the rate for patients who purchased other newer antidepressants once only (RR=0.70; 95% CI=0.52-0.94). Continued antidepressant treatment with SSRIs or other newer antidepressants is found to be associated with a reduced risk of suicide.

Alcohol and/or benzodiazepine use: different accidents--different impacts?

1611 patients were included in this investigation. 16.7% of the patients were involved in traffic accidents, 38.2% were injured by a sudden fall, 3.5% were involved in an act of violence, 22.8% were injured by a sports related accident and 18.9% were hurt within a work-related accident. 19.5% of the patients tested positive for alcohol, 5.2% tested positive for benzodiazepines and 1.4% tested positive for both substances. Blood samples were positive for alcohol in 27% males and 7.7% females and for benzodiazepines in 6.3% males and in 3.5% females. The mean blood alcohol concentration (BAC) as well as the mean benzodiazepine plasma level were higher in patients injured in violent accidents compared to the other injury groups. This study provides epidemiologic information about the relationship between specific kinds of accidents and alcohol and/or benzodiazepine use in a large probability sample of emergency room patients. We found a high number of patients using alcohol, and a lower but still relavant number of benzodiazepine users in this large and unselected traumatology ER sample. This study adds evidence to the existing literature about the co-occurance of alcohol and/or benzodiazepine consumption and accident-related injuries.

The effects of diazepam on human self-aggressive behavior

RATIONALE

Diazepam, a benzodiazepine with a relatively rapid onset of clinical effects, has been associated with suicide and other self-aggressive acts. The evidence for this association, however, comes exclusively from retrospective non-experimental studies. Although suggestive, the results of these studies do not support a cause-and-effect relationship between benzodiazepine consumption and self-aggressive behavior.

OBJECTIVE

To experimentally examine the effect of diazepam on human self-aggressive behavior under controlled laboratory conditions.

METHOD

Forty-six healthy men and women were randomly assigned to receive placebo, or 5 mg or 10 mg diazepam in a double-blind, between-groups design. Participants were then provided the opportunity to self-administer electric shocks during a competitive reaction-time task (the self-aggression paradigm, SAP). Self-aggression was defined by the intensity of shock chosen.

RESULTS

Diazepam (10 mg) was associated with higher average shock self-administered than placebo. Subjects receiving 10 mg diazepam were also more likely to attempt to self-administer a shock that they were led to believe was "severe" and painful. Sedation effects were found, but diazepam consumption did not impair memory, attention, concentration, pain threshold, or reaction-time performance.

CONCLUSIONS

Clinically relevant diazepam doses may be associated with self-aggressive behaviors at levels that do not significantly impair basic cognitive processes or psychomotor performance.

Suicide attempts in high-dose benzodiazepine users

Substance use disorders are associated with increased suicidal behavior. The suicidal behavior in patients without a history of illegal substance abuse, who consume benzodiazepines (BZDs) regularly in doses higher than those recommended, has not been previously studied. The aim of this study was to investigate the factors associated with the past history of suicide attempts in high-dose regular BZD users (HDRUs). Fifty-five HDRUs were recruited from inpatient and outpatient psychiatric services, and were compared to 55 psychiatric controls, matched for demographic characteristics and psychiatric diagnoses to HDRUs (Controls A), and to 55 psychiatric controls matched only for demographic characteristics to HDRUs (Controls B). Both control groups were non-BZD users. Patients with previous or current use of illegal substances were excluded. There was a statistically significant difference in the history of suicide attempts, comparing HDRUs (17 attempters, 30.9%) with Controls B (two attempters, 3.6%), while the difference was not significant comparing HDRUs with Controls A (10 attempters, 18.2%). Using logistic regression analysis, it was found that only comorbid borderline personality disorder (BPD), not high-dose BZD use, was independently associated with a history of suicide attempt. The percentage of patients with a history of suicide attempt was significantly higher in HDRUs with comorbid BPD, compared to HDRUs without BPD.

Demographic and substance use factors related to violent and accidental injuries: results from an emergency room study

OBJECTIVE

The primary goal of this study was to identify demographic and substance use factors associated with violent injuries, accidental injuries, and medical conditions or illnesses (non-injured).

METHOD

Data were examined from a sample of 1701 admissions to emergency rooms at two Canadian hospitals. These patients were interviewed and provided urine samples to detect the presence of drug metabolites for alcohol, THC, benzodiazepines, barbiturates, morphine, and codeine.

RESULTS

Those with violent injuries were significantly (P<0.0001) more likely to be male and have lower incomes compared with both the accidental injury and non-injury groups. About 37% of violent injuries occurred at a bar or restaurant, which was significantly more than 3% for accidental injuries and 2% for non-injuries (P<0.00001). The violent injury group was significantly more likely than the other two groups to report feeling the effects of alcohol at the time of the injury and to report negative consequences of alcohol use (P<0.00001). Furthermore, about 42% of those with violent injuries had a blood alcohol level (BAL) over 80 mg% compared to only 4% with accidental injuries (P<0.00001) and 2% of non-injuries (P<0.00001). In terms of drug tests for other substances, the violent injury group was significantly more likely to test positive for benzodiazepines than the accidental injury group (P<0.01) while all between group comparisons for other drugs were not significant.

Association of road-traffic accidents with benzodiazepine use

BACKGROUND

Psychomotor studies suggest that commonly prescribed psychoactive drugs impair driving skills. We have examined the association between the use of psychoactive drugs and road-traffic accidents.

METHODS

We used dispensed prescribing as a measure of exposure in a within-person case-crossover study of drivers aged 18 years and over, resident in Tayside, UK, who experienced a first road-traffic accident between Aug 1, 1992, and June 30, 1995, and had used a psychoactive drug (tricyclic antidepressant, benzodiazepine, selective serotonin-reuptake inhibitor, or other psychoactive drug [mainly major tranquillisers]) between Aug 1, 1992, and the date of the accident. For each driver, the risks of having a road-traffic accident while exposed and not exposed to a drug were compared.

FINDINGS

19386 drivers were involved in a first road-traffic accident during the study period. 1731 were users of any study drug. On the day of the accident, 189 individuals were taking tricyclic antidepressants (within-patient exposure odds ratio for an accident 0.93 [95% CI 0.72-1.21]), 84 selective serotonin-reuptake inhibitors (0.85 [0.55-1.33]), 235 benzodiazepines (1.62 [1.24-2.12]), and 47 other psychoactive drugs (0.88 [0.62-1.25]). The risk associated with benzodiazepine use decreased with increasing driver's age and was greater when the breath test for alcohol was positive. A dose-response relation was evident with benzodiazepines. The increased risk with benzodiazepines was significant for long-half-life drugs, used as anxiolytics, and for short-half-life hypnotics (all zopiclone).

INTERPRETATION

Users of anxiolytic benzodiazepines and zopiclone were at increased risk of experiencing a road-traffic accident. Users of anxiolytic benzodiazepines and zopiclone should be advised not to drive.