Concurrent benzodiazepine use in older adults treated with antidepressants in Asia

Characteristics of high-dose benzodiazepine use: nationwide cohort study on new benzodiazepine users with 5-year follow-up

BACKGROUND

A nationwide register-based cohort study from Finland including 48 124 incident benzodiazepines and related drug (BZDR) users aged 18-65 years who initiated use in 2006 and were not dispensed BZDRs during 2004-2005. The follow-up was 5 years or until death, whichever occurred first.

AIMS

To investigate sociodemographic and clinical factors associated with high-dose use of BZDRs (i.e. Z-drugs) among new BZDR users.

METHOD

The temporal BZDR dose was calculated as a point estimate every 6 months after initiation as defined daily doses (DDDs) per day, based on the PRE2DUP method (an approach based on mathematical modelling of personal drug purchasing behaviours). Sociodemographic and clinical factors associated with dose categories were studied using multinomial logistic regression.

RESULTS

During the 5-year follow-up, very high-dose BZDR use was observed in 7.4% (n = 3557) and medium high-dose use in 25.5% (n = 12 266) of the users (corresponding to ≥30 mg and 10-29 mg in diazepam equivalents, respectively). Very high-dose use was more common among men compared with women (10.9% versus 4.6%). Very high-dose use patterns were especially observed in younger age groups (18- to 25-year-olds). Compared with oxazepam, initiating BZDR use with clonazepam (adjusted odds ratio 3.86, 95% CI 3.24-4.60), diazepam (2.05, 1.78-2.36) or alprazolam (1.76, 1.52-2.03) was associated with increased odds for very high-dose use. Both medium high-dose and very high-dose BZDR use were associated with a lower level of education. In all, 58% of very high-dose use occurred in BZDR users who received their first prescription from general practitioners.

CONCLUSIONS

Clinicians should be aware of the dose escalation risk especially when prescribing diazepam, alprazolam or clonazepam for psychiatric indications. If BZDRs are needed, our findings suggest favouring oxazepam.

Influence of β-catenin signaling on neurogenesis in neuropsychiatric disorders: Anxiety and depression

It has been proven that stress, mainly in the early years of life, can lead to anxiety and mood problems. Current treatments for psychiatric disorders are not enough, and some of them show intolerable side effects, emphasizing the urgent need for new treatment targets. Hence, a better understanding of the different brain networks, which are involved in the response to anxiety and depression, may evoke treatments with more specific targets. One of these targets is β-catenin that regulates brain circuits. β-Catenin has a dual response toward stress, which may influence coping or vulnerability to stress response. Indeed, β-catenin signaling involves several processes such as inflammation-directed brain repair, inflammation-induced brain damage, and neurogenesis. Interestingly, β-catenin reduction is accompanied by low neurogenesis, which leads to anxiety and depression. However, in another state, this reduction activates a compensatory mechanism that enhances neurogenesis to protect against depression but may precipitate anxiety. Thus, understanding the molecular mechanism of β-catenin could enhance our knowledge about anxiety and depression's pathophysiology, potentially improving clinical results by targeting it. Herein, the different states of β-catenin were discussed, shedding light on possible drugs that showed action on psychiatric disorders through β-catenin.

Benzodiazepines in complex biological matrices: Recent updates on pretreatment and detection methods

Benzodiazepines (BDZs) are used in clinics for anxiolysis, anticonvulsants, sedative hypnosis, and muscle relaxation. They have high consumptions worldwide because of their easy availability and potential addiction. They are often used for suicide or criminal practices such as abduction and drug-facilitated sexual assault. The pharmacological effects of using small doses of BDZs and their detections from complex biological matrices are challenging. Efficient pretreatment methods followed by accurate and sensitive detections are necessary. Herein, pretreatment methods for the extraction, enrichment, and preconcentration of BDZs as well as the strategies for their screening, identification, and quantitation developed in the past five years have been reviewed. Moreover, recent advances in various methods are summarized. Characteristics and advantages of each method are encompassed. Future directions of the pretreatment and detection methods for BDZs are also reviewed.

Analysis of Risk Factors for Inappropriate Prescribing of Psychotropic Drugs in Primary Health Care in Elderly Patients

Backround: Older people are at risk of inappropriate drug prescribing because pharmacodynamics and pharmacokinetics, and consequently the efficacy and safety of drugs, change after patient’s age.

Objective: The aim of study is to identify major significant risk factors for Potentially Inappropriate Medicines (PIM) of psychotropic drugs and Potential Prescription Omissions (PPO) of psychotropic drugs in population of patients over 65 years of age with associated pathological conditions according to Screening Tool of Older Person’s potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment (STOPP/START) criteria.

Material and method: The study was designed as a cross-sectional study involving 492 patients and 9 selected general practitioners. It was conducted in period from May 2020 to December 2021, after receiving decision from Ethics Committee of HC Kragujevac.

Results: 492 patients, mean age 71.77 ± 5.95, with 62.2% women, participated in the study. 164 PIMs were identified in 139 patients (28.2%). The most common were: use of benzodiazepines over 4 weeks (43.9%) with simultaneous use of different groups of antidepressants (20.3%). Patients with more than two psychotropic drugs have a higher risk for PIM [adjusted OR 2.83, 95% CI (1.98 - 4.140], p <0.001. 439 PPOs were also identified in 270 patients (54.8%). Risk factors for PPO are: age, number of illnesses, total number of medications, number patients, depression presence, patient’s place of residence, cigarettes usage and monthly income level.

Conclusion: STOPP/START criteria can have a major impact in recognizing inadequate prescribing of psychotropic drugs at patients over 65 years of age. Patients who use benzodiazepines more than four weeks and / or antidepressants may be at increased risk of PIM psychotropic drugs. The total number of drugs and presence of symptoms of depression bring higher risk of PPO psychotropic drugs.

Association between Androgen Deprivation Therapy and Risk of Dementia in Men with Prostate Cancer

The risk of dementia after androgen deprivation therapy (ADT) in patients with advanced prostate cancer (PCa) remains controversial. This study aimed to evaluate the association between ADT and the incidence of dementia in patients with PCa. We identified patients newly diagnosed with PCa in the National Health Insurance Database of Taiwan from 1 January 2002 to 30 June 2016 and in The Health Improvement Network of the United Kingdom (UK) from 1 January 1998 to 31 March 2018. We classified patients with PCa into ADT and ADT-naïve groups. Propensity score (PS) methods were used to minimize the differences in characteristics between the groups. We performed a Cox proportional hazard model to obtain the adjusted hazard ratio (HR) to compare the incidence of dementia between the groups. Our ADT group comprised 8743 and 73,816 patients in Taiwan and the UK, respectively, which were matched 1:1 to ADT-naïve patients by PS. The incidence rates of dementia in the ADT group were 2.74 versus 3.03 per 1000 person-years in the ADT naïve groups in Taiwan, and 2.81 versus 2.79 per 1000 person-years in the UK. There was no statistical difference between ADT and ADT-naïve groups (adjusted HR: 1.12; 95% confidence interval (CI): 0.87-1.43 in Taiwan and adjusted HR: 1.02; 95% CI: 0.85-1.23 in the UK). We found no association between the incidence of dementia and ADT in patients with advanced PCa in either database. Further studies are warranted to evaluate other possible triggers of incident dementia in patients receiving ADT for advanced PCa.

The state of psychiatric research in the Asia Pacific region

INTRODUCTION

This study aims to review recent scientific publications and research output in the field of psychiatry, from a series of countries in the Asia-Pacific region (Australia, India, Indonesia, Iran, Lebanon, Malaysia, and Nepal), with a view to identify themes and similarities across regions, as well as to examine the barriers and challenges in mental health research faced by countries in the region.

METHODS

Seven psychiatrists from seven countries reviewed recent published and ongoing research in psychiatry in their respective nations, with respect to themes, as well as any barriers or challenges faced by mental health researchers.

RESULTS

While the seven nations included in this review vary in terms of research capabilities and economic development level, they share many similarities both in terms of research direction, and with regards to challenges faced. Limitations in the form of sociocultural differences from the West, and a lack of funding were some of the barriers identified.

DISCUSSION

Mental health research in the region has been progressing well. However, more varied research in the form of qualitative or economic studies are lacking, as are multi-center studies. The similar issues that nations face with regards to research could perhaps benefit from collaborative efforts and initiatives for the furtherance of research in the region.

Risk of mortality associated with concomitant antidepressant and benzodiazepine therapy among patients with depression: a population-based cohort study

BACKGROUND

With antidepressants (ADs) having minimal therapeutic effects during the initial weeks of treatment, benzodiazepines (BZDs) are concomitantly used to alleviate depressive symptoms of insomnia or anxiety. However, with mortality risks associated with this concomitant use yet to be examined, it remains unclear as to whether this concomitant therapy offers any benefits in treating depression.

METHODS

We conducted a population-based cohort study using South Korea's nationwide healthcare database from 2002 to 2017. Of 2.6 million patients with depression, we identified 612,729 patients with incident depression and newly prescribed ADs or BZDs, by excluding those with a record of diagnosis or prescription within the 2 years prior to their incident diagnosis. We classified our study cohort into two discrete groups depending on the type of AD treatment received within 6 months of incident diagnosis-AD monotherapy and AD plus BZD (AD+BZD) therapy. We matched our study cohort in a 1:1 ratio using propensity scores to balance baseline characteristics and obtain comparability among groups. The primary outcome was all-cause mortality, and patients were followed until the earliest of outcome occurrence or end of the study period. We conducted multivariable Cox proportional hazards regression analysis to estimate adjusted hazards ratios (HRs) with 95% confidence intervals (CIs) for the risk of mortality associated with AD+BZD therapy versus AD monotherapy.

RESULTS

The propensity score-matched cohort had 519,780 patients with 259,890 patients in each group, where all baseline characteristics were well-balanced between the two groups. Compared to AD monotherapy, AD+BZD therapy was associated with an increased risk of all-cause mortality (adjusted HR, 1.04; 95% CI, 1.02 to 1.06).

CONCLUSIONS

Concomitantly initiating BZDs with ADs was associated with a moderately increased risk of mortality. Clinicians should therefore exercise caution when deciding to co-prescribe BZDs with ADs in treating depression, as associated risks were observed.

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.