Multinational comparison of new antidepressant use in older adults: a cohort study

Hyponatremia-associated hospital visits are not reduced by early electrolyte testing in older adults starting antidepressants

BACKGROUND

Clinical practice guidelines recommend early serum electrolyte monitoring when starting antidepressants in older adults due to the increased risk of hyponatremia. It is unclear whether this monitoring improves outcomes.

METHODS

Population-based, retrospective cohort study of Ontario adults aged ≥66 years who initiated therapy with a selective serotonin reuptake inhibitor (SSRI) or selective norepinephrine reuptake inhibitor (SNRI) between April 1, 2013, and January 31, 2020. The index date was the date of the first such prescription, and the exposure of interest was serum electrolyte measurement during the subsequent 7 days. The primary outcome was any emergency department or hospital admission with hyponatremia within 8-60 days of antidepressant initiation. Poisson regression models compared individuals who had versus did not have their serum electrolytes tested in the week following SSRI/SNRI initiation, weighting by propensity score-based overlap weights.

RESULTS

Among the 420,085 patients aged ≥66 years initiating treatment with an SSRI/SNRI, 26,808 (6.4%) had serum electrolytes measured in the subsequent 7 days and 6109 (1.5%) subsequently presented to hospital with hyponatremia. The time from drug initiation to hospitalization varied (median 29, interquartile range [IQR] 17-44 days), and the median sodium concentration measured in the community (136, IQR 133-138 mmol/L) was marginally higher than those at the time of hospitalization (132, IQR 130-134 mmol/L). Patients who underwent electrolyte testing in the week following SSRI/SNRI treatment were more likely to attend an emergency department (ED) or hospital with hyponatremia within 8-60 days relative to those who did not (relative risk = 2.31, 95% confidence interval: 2.16-2.46).

CONCLUSIONS

Testing serum electrolytes in the week after starting an SSRI/SNRI is not associated with a reduced risk of a hospital visit with hyponatremia. These findings do not support current guidelines recommending routine electrolyte monitoring.

Quercetin attenuates brain apoptosis in mice with chronic unpredictable mild stress-induced depression

BACKGROUND

Depression is a common psychiatric disorder with limited effective treatments. Research suggests that depression involves apoptosis mechanisms. Quercetin (QUE) has been reported to have anti-apoptotic activities. In this study, we aimed to investigate the effects and mechanisms of QUE in chronic unpredictable mild stress (CUMS)-induced depression.

METHODS

After establishing mouse models of CUMS-induced depression, the mice were randomly assigned into four groups: control, CUMS, CUMS+QUE, and CUMS+Fluoxetine (FLX). The body weight of the mice was measured during the study. Then, depression-associated behaviors were evaluated using the sucrose preference test (SPT), novelty suppressed feeding test (NSFT), forced swim test (FST) and tail suspension test (TST). Apoptosis in the hippocampus and prefrontal cortex was determined using flow cytometry. Bcl-2 and Nrf2 protein expressions in the hippocampus and prefrontal cortex were also detected. Furthermore, Western blot was used to measure the protein levels of p-ERK, ERK, p-CREB, CREB, and Nrf2 in brain tissues.

RESULTS

QUE or FLX administration increased the body weight of the CUMS mice. Behavioral tests indicated that CUMS mice developed a state of depression, but QUE or FLX treatment improved their depression-associated behaviors. Meanwhile, QUE or FLX treatment decreased apoptosis in the hippocampus and prefrontal cortex. Furthermore, the decreased Nrf2 protein expression, ERK and CREB phosphorylation in CUMS group were enhanced by QUE or FLX administration.

CONCLUSION

QUE could attenuate brain apoptosis in mice with CUMS-induced depression, and the mechanism may be related to the ERK/Nrf2 pathway, indicating that QUE could be a potential treatment for depression.

The relationship between relational continuity and family physician follow-up after an antidepressant prescription in older adults: a retrospective cohort study

BACKGROUND

Side effects can occur within hours to days of starting antidepressant medications, whereas full therapeutic benefit for mood typically takes up to four weeks. This mismatch between time to harm and lag to benefit often leads to premature discontinuation of antidepressants, a phenomenon that can be partially reversed through early doctor-patient communication and follow-up. We investigated the relationship between relational continuity of care - the number of years family physicians have cared for older adult patients - and early follow-up care for patients prescribed antidepressants.

METHODS

A retrospective cohort study was conducted on residents of Ontario, Canada aged 66 years or older who were dispensed their first antidepressant prescription through the provincial drug insurance program between April 1, 2016, and March 31, 2019. The study utilized multivariable regression to estimate the relationship between relational continuity and 30-day follow-up with the prescribing family physician. Separate estimates were generated for older adults living in urban, non-major urban, and rural communities.

RESULTS

The study found a small positive relationship between relational continuity of care and follow-up care by the prescribing family physician for patients dispensed a first antidepressant prescription (RRR = 1.005; 95% CI = 1.004, 1.006). The relationship was moderated by the patients' location of dwelling, where the effect was stronger for older adults residing in non-major urban (RRR = 1.009; 95% CI = 1.007, 1.012) and rural communities (RRR = 1.006; 95% CI = 1.002, 1.011).

CONCLUSIONS

Our findings do not provide strong evidence of a relationship between relational continuity of care and higher quality management of antidepressant prescriptions. However, the relationship is slightly more pronounced in rural communities where access to continuous primary care and specialized mental health services is more limited. This may support the ongoing need for the recruitment and retention of primary care providers in rural communities.

Prevalence, trends, and individual patterns of long-term antidepressant medication use in the adult Swiss general population

PURPOSE

Antidepressant use has increased in many European countries, mostly driven by longer treatment duration. The aim of this study was to provide prevalence rates of long-term users of antidepressants for the Swiss population over the last decade and to investigate associated factors for longer use.

METHODS

We examined the prevalence rates of individuals with at least one prescription for antidepressants using longitudinal health claims data for 2013 to 2021. We defined short- (< one year), medium- (one-two years), and long-term users (> two years) for 2015 to 2019. We applied a binary logistic regression model to investigate the effects of population (gender, age, area of living, language, health insurance plan, and nursing home) and treatment characteristics (psychiatric or psychotherapeutic care) on long-term compared to short- and medium-term users in 2019.

RESULTS

In 2021, 9% of the Swiss population (n = 770,698) received at least one antidepressant prescription, which remained stable since 2013. In 2019, the proportion of long-term users was 57.4%, with steady increase since 2015. The proportion of medium- and short-term users has decreased. Older age, being a woman, living in an urban area, living in a nursing home, being enrolled in a standard care plan, and receiving psychiatric or psychotherapeutic care were factors positively associated with being a long-term user.

CONCLUSION

The proportion of long-term users in Switzerland is high and steadily increasing. Given the ongoing debate about the confounding effects of relapse and withdrawal, more research is needed to investigate longer use of antidepressants that could indicate overprescribing.

Trends, Patterns and Associated User Characteristics of Antidepressant Prescriptions in Older Adults: A Nationwide Descriptive Cohort Study in Denmark

BACKGROUND AND OBJECTIVE

Antidepressant use in older adults (≥ 65 years) is understudied in large population-based samples, particularly in recent years and regarding user characteristics. We aimed to describe the trends, patterns, and associated user characteristics of all antidepressant prescriptions redeemed by older adults at community pharmacies in Denmark during 2015-2019.

METHODS

This register-based study used a cross-sectional design to characterize antidepressant prescription trends and patterns, and a cohort design to describe user characteristics associated with antidepressant prescription initiation. We used descriptive statistics to characterize trends and patterns, and Poisson regression for analyzing user characteristics.

RESULTS

During the years 2015-2019, 17.9% of 1.2 million older adults redeemed 4.84 million antidepressant prescriptions, where 48.5% were selective serotonin reuptake inhibitors, followed by noradrenergic and specific serotonergic antidepressants (26.2%), serotonin-norepinephrine reuptake inhibitors (12.7%), tricyclic antidepressants (11.2%), and others (1.4%). Amitriptyline and nortriptyline, considered potentially inappropriate medications, were among the 10 most frequently redeemed antidepressants. Only 60.5% of prescriptions had a treatment indication of depression. Prescription-proportion trends by drug classes and individual antidepressants remained consistent. A higher incidence rate ratio (IRR) and 95% confidence interval (CI) of initiating antidepressants was associated with female sex (IRR 1.20, 95% CI 1.07-1.34), older age (e.g., 81-85 years vs. 65-70 years: IRR 1.74, 95% CI 1.44-2.11), living in rural areas (North Denmark vs. Capital Region: IRR 1.31, 95% CI 1.09-1.58), and having somatic and psychiatric diagnoses (e.g., per one psychiatric diagnosis: IRR 1.10, 95% CI 1.05-1.15), while a lower ratio was associated with being non-Western (vs. Danish: IRR 0.50, 95% CI 0.28-0.89) and having hospital contacts for psychiatric treatment (per each contact: IRR 0.96, 95% CI 0.93-1.00).

CONCLUSION

SSRIs were the most commonly redeemed antidepressants, with consistent trends in Danish older adults. Besides clinical conditions, sociodemographics, e.g., sex, age, ethnicity, and place of residence, may influence antidepressant use.

Efficacy, safety, and tolerability of antidepressants for pain in adults: overview of systematic reviews

OBJECTIVE

To provide a comprehensive overview of the efficacy, safety, and tolerability of antidepressants for pain according to condition.

DESIGN

Overview of systematic reviews.

DATA SOURCES

PubMed, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials from inception to 20 June 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Systematic reviews comparing any antidepressant with placebo for any pain condition in adults.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data. The main outcome measure was pain; for headache disorders it was frequency of headaches. Continuous pain outcomes were converted into a scale of 0 (no pain) to 100 (worst pain) and were presented as mean differences (95% confidence intervals). Dichotomous outcomes were presented as risk ratios (95% confidence intervals). Data were extracted from the time point closest to the end of treatment. When end of treatment was too variable across trials in a review, data were extracted from the outcome or time point with the largest number of trials and participants. Secondary outcomes were safety and tolerability (withdrawals because of adverse events). Findings were classified from each comparison as efficacious, not efficacious, or inconclusive. Certainty of evidence was assessed with the grading of recommendations assessment, development, and evaluation framework.

RESULTS

26 reviews (156 unique trials and >25 000 participants) were included. These reviews reported on the efficacy of eight antidepressant classes covering 22 pain conditions (42 distinct comparisons). No review provided high certainty evidence on the efficacy of antidepressants for pain for any condition. 11 comparisons (nine conditions) were found where antidepressants were efficacious, four with moderate certainty evidence: serotonin-norepinephrine reuptake inhibitors (SNRIs) for back pain (mean difference -5.3, 95% confidence interval -7.3 to -3.3), postoperative pain (-7.3, -12.9 to -1.7), neuropathic pain (-6.8, -8.7 to -4.8), and fibromyalgia (risk ratio 1.4, 95% confidence interval 1.3 to 1.6). For the other 31 comparisons, antidepressants were either not efficacious (five comparisons) or the evidence was inconclusive (26 comparisons).

CONCLUSIONS

Evidence of efficacy of antidepressants was found in 11 of the 42 comparisons included in this overview of systematic reviews-seven of the 11 comparisons investigated the efficacy of SNRIs. For the other 31 comparisons, antidepressants were either inefficacious or evidence on efficacy was inconclusive. The findings suggest that a more nuanced approach is needed when prescribing antidepressants for pain conditions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022311073.

A National Retrospective Study of Antidepressants' Effects on Overdose and Self-Harm Among Adults Treated With Opioid Analgesics

OBJECTIVE

Because individuals with a history of depression who are receiving opioids are at higher risk for adverse events, the authors examined whether antidepressant treatment reduces risk for overdose and self-harm among individuals with a history of depression who receive opioids.

METHODS

Commercial insurance claims of individuals with a history of depression receiving opioids from 2007 to 2017 were used to quantify the association between antidepressant fills and adverse events among individuals after initiation of opioid treatment; the authors accounted for selection into treatment and used discrete-time, proportional hazards survival models.

RESULTS

Among 283,374 adults with a history of depression treatment, 8,203 experienced 47,486 adverse events from 2007 to 2017 in the 12 months after initiation of opioid treatment. Approximately half (N=144,052, 50.8%) filled an antidepressant prescription at least once in the 12 months after the opioid episode began. Individuals receiving antidepressants for at least 6 weeks had a reduced risk for any adverse event (adjusted odds ratio [AOR]=0.79, 95% confidence interval [CI]=0.65-0.97) as well as a reduced risk for opioid overdoses (AOR=0.78, 95% CI=0.64-0.96), overdoses from nonopioid controlled substances (AOR=0.76, 95% CI=0.62-0.94), overdoses from other substances (AOR=0.79, 95% CI=0.65-0.97), and other self-harm events (AOR=0.82, 95% CI=0.67-1.00).

CONCLUSIONS

Individuals with a history of depression who received opioid analgesics had a significantly lower risk for overdose and self-harm after they had been taking antidepressants for at least 6 weeks. Universal screening for mood disorders among individuals receiving opioids, and promptly providing evidence-based depression treatment when appropriate, may reduce adverse events.

Antidepressant Use and Risk of Myocardial Infarction: A Longitudinal Investigation of Sex-Specific Associations in the HUNT Study

OBJECTIVE

Antidepressants are thought to affect the risk of cardiovascular disease, although the nature of the association is unclear. Men and women have unique cardiovascular risk factors, and sex differences in depression as well as the efficacy of antidepressants are important to consider. We examined whether antidepressant use was associated with risk of having a myocardial infarction (MI) and whether this association was sex-specific.

METHODS

Data from The Trøndelag Health Study were used, gathered from a population in Norway ( N = 31,765), collected from 1995 to 2008. These data were combined with the Norwegian Cause of Death Registry and the Norwegian Prescription Database. We performed logistic regression models to examine the association of antidepressant use on risk of having a fatal or nonfatal MI, adjusting for depression, anxiety, diabetes, systolic blood pressure, cholesterol, waist-hip ratio, smoking, age, and sex. Results are presented as odds ratios (ORs) and 95% confidence intervals in parentheses.

RESULTS

The results indicated that antidepressant use was associated with a reduced risk of having MI at a later date (OR = 0.49 [0.38-0.64]). Although this association was somewhat stronger for women (OR = 0.46 [0.31-0.68]) compared with men (OR = 0.53 [0.37-0.75]), analysis did not identify a sex-specific association of antidepressant use on MI. Follow-up analyses on different subtypes of antidepressants showed that both selective serotonin reuptake inhibitor and tricyclic antidepressant were associated with a reduced risk of MI.

CONCLUSIONS

In this population study, the use of antidepressants was associated with a reduced risk of MI. This association was stronger for women, although we detected no interaction between sex and antidepressant use in terms of reduced risk of MI. Although limitations apply regarding causality, especially concerning a dose-response relationship, the results suggest that antidepressant use might reduce the risk of MI among both men and women.

Bioaccumulation potential of the tricyclic antidepressant amitriptyline in a marine Polychaete, Nereis virens

The continual discharge of pharmaceuticals from wastewater treatment plants (WWTPs) into the marine environment, even at concentrations as low as ng/L, can exceed levels that induce sublethal effects to aquatic organisms. Amitriptyline, a tricyclic antidepressant, is the most prescribed antidepressant in Norway, though the presence, potential for transport, and uptake by aquatic biota have not been assessed. To better understand the release and bioaccumulative capacity of amitriptyline, laboratory exposure studies were carried out with field-collected sediments. Influent and effluent composite samples from the WWTP of Stavanger (the 4th largest city in Norway) were taken, and sediment samples were collected in three sites in the proximity of this WWTP discharge at sea (WWTP discharge (IVAR), Boknafjord, and Kvitsøy (reference)). Polychaetes (Nereis virens) were exposed to field-collected sediments, as well as to Kvitsøy sediment spiked with 3 and 30 μg/g amitriptyline for 28 days. The WWTP influent and effluent samples had concentrations of amitriptyline of 4.93 ± 1.40 and 6.24 ± 1.39 ng/L, respectively. Sediment samples collected from IVAR, Boknafjord, and Kvitsøy had concentrations of 6.5 ± 3.9, 15.6 ± 12.7, and 12.7 ± 8.0 ng/g, respectively. Concentrations of amitriptyline were below the limit of detection in polychaetes exposed to sediment collected from Kvitsøy and IVAR, and 5.2 ± 2.8 ng/g in those exposed to Boknafjord sediment. Sediment spiked with 3 and 30 μg/g amitriptyline had measured values of 423.83 ± 33.1 and 763.2 ± 180.5 ng/g, respectively. Concentrations in worms exposed to the amended sediments were 9.5 ± 0.2 and 56.6 ± 2.2 ng/g, respectively. This is the first known study to detect measurable concentrations of amitriptyline in WWTP discharge in Norway and accumulation in polychaetes treated with field-collected sediments, suggesting that amitriptyline has the potential for trophic transfer in marine systems.

Inclusion of currently diagnosed or treated individuals in studies of depression screening tool accuracy: a meta-research review of studies published in 2018-2021

OBJECTIVES

Screening is done to improve health outcomes by identifying and effectively treating individuals with unrecognized conditions. Depression screening has been proposed to identify previously unrecognized depression cases. Including individuals already diagnosed or treated for depression in screening test accuracy studies could exaggerate accuracy and the yield of new cases from screening. The present study investigated (1) the proportion of depression screening tool accuracy primary studies published in 2018-2021 that excluded individuals with a confirmed depression diagnosis or who were already undergoing treatment; and (2) whether this has improved since the last review of studies published in 2013-2015, which found that five of 89 (5.6%) primary studies appropriately excluded such individuals.

METHODS

MEDLINE was searched from January 1, 2018 through May 21, 2021 for primary studies on depression screening tool accuracy.

RESULTS

Eighteen of 106 (17.0%; 95% Confidence Interval [CI], 11.0% to 25.3%) primary studies excluded currently diagnosed or treated individuals. This was 11.4% (95% CI, 2.8% to 20.0%) greater than in similar studies published in 2013-2015.

CONCLUSION

There has been an improvement since 2015, but the proportion of studies that exclude individuals already known to have depression remains low. This may bias research findings intended to inform clinical practice.

An analysis of antidepressant prescribing trends in England 2015-2019

Background Growing concerns about the impact of coronavirus disease 2019 (COVID-19) will likely lead to increased mental health diagnoses and treatment. To provide a pre-COVID-19 baseline, we have examined antidepressant prescribing trends for 5 years preceding COVID-19. Methods A retrospective analysis of anonymised data on medicines prescribed by GPs in England from the Open-Prescribing Database (January 2015 to December 2019) identified the 10 most prescribed antidepressant and, for comparison, cardiovascular medicines. Results Prescription items for the 10 most prescribed antidepressants rose 25% from 58 million (2015) to 72 million (2019). Citalopram was the most prescribed antidepressant; prescriptions for sertraline rose fastest at 2 million items year on year. Over the same period, costs for antidepressant prescribing fell 27.8%. Across all Clinical Commissioning Groups (CCGs) in England, antidepressant prescribing levels, adjusted for population were positively correlated with the index of multiple deprivation (IMD) score. In comparison, prescribing for the top 10 most prescribed cardiovascular medicines increased by 2.75% from 207 million (2015) to 213 million (2019) items. Limitations Anonymised data in the Open-Prescribing Database means no patient diagnoses or treatment plans are linked to this data. Conclusion Antidepressant prescribing, particularly sertraline, is increasing. Prescribing is higher in more deprived regions, but costs are falling to < 2% of all items prescribed. Absolute numbers of prescriptions for cardiovascular medicines are higher, likely reflecting the greater prevalence of cardiovascular disease, and are rising more slowly. This study will enable future work to look at the impact of COVID-19 on prescribing for mental health.

Older adults respond better to psychological therapy than working-age adults: evidence from a large sample of mental health service attendees

BACKGROUND

Older adults commonly experience depression and anxiety, yet are under-represented in psychological treatment services. There is uncertainty about the outcomes from psychological therapies for older adults relative to working-age adults. This study explored: pre-treatment differences between older and working-age patients with depression or anxiety disorders; whether outcomes from psychological therapy differ between groups controlling for pre-treatment clinical severity, functioning, and socio-demographics; and whether the impact of a long-term health condition (LTC) on outcome differs by age.

METHODS

Data on >100,000 patients treated with psychological therapies in eight Improving Access to Psychological Therapies services were analyzed. We compared pre-treatment characteristics and therapy outcomes for older (≥65 years) and working-age (18-64 years) patients, and investigated associations between age and outcomes.

RESULTS

Older adults had less severe clinical presentations pre-treatment. In adjusted models older adults were more likely to reliably recover (OR=1.33(95%CI=1.24-1.43)), reliably improve (OR=1.34(95%CI =1.24-1.45)), and attrition was less likely (OR=0.48(95%CI =0.43-0.53)). Effects were more pronounced in patients with anxiety disorders compared to depression. Having an LTC was associated with a much lower likelihood of reliable recovery for working-age patients but had only a modest effect for older adults.

LIMITATIONS

There are potential selection biases affecting the characteristics of older people attending these services. Residual confounding cannot be ruled out due to limits on data available.

CONCLUSIONS

Older adults experienced better outcomes from psychological treatments than working-age adults. Given the deleterious effects if mental health conditions go untreated, increasing access to psychological therapies for older people should be an international priority.

Epidemiology of undiagnosed depression in people with diabetes mellitus: a comparative analysis of Ireland, England and the USA

OBJECTIVES

Improving detection of depression in people with diabetes is recommended. However, little is known about how different health systems compare in depression detection. We estimated and compared the (1) prevalence of depression detection in people with and without diabetes, and (2) association between diabetes and undiagnosed depression across three health systems.

DESIGN

Cross-sectional analysis of three nationally representative studies: The Irish Longitudinal Study on Ageing, the English Longitudinal Study on Ageing and the Health and Retirement Study.

SETTING

Community-dwelling adults in Ireland, England and the USA.

PARTICIPANTS

Adults aged ≥50 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was depression diagnosis. The secondary outcome was any depression. Any depression was defined by the presence of self-reported doctor-diagnosed depression or current depression symptoms on the Centre for Epidemiological Studies-Depression scale. Depression diagnosis was categorised as: undiagnosed, symptomatic and diagnosed, and asymptomatic and diagnosed. We estimated age-standardised prevalence of depression diagnosis by country and diabetes status. Anyone who self-reported having ever received a doctor diagnosis of diabetes was classified as having diabetes. Among respondents with depression, we estimated the association between diabetes and undiagnosed depression by country using multivariable logistic regression.

RESULTS

The prevalence of depression (diagnosed and undiagnosed) was higher in people with diabetes in each country with absolute rates varying by country; undiagnosed prevalence (Ireland: diabetes 10.1% (95% CI 7.5% to 12.8%) vs no diabetes 7.5% (95% CI 6.8% to 8.2%), England: diabetes 19.3% (95% CI 16.5% to 22.2%) vs no diabetes 11.8% (95% CI 11.0% to 12.6%), USA: diabetes 7.4% (95% CI 6.4% to 8.4%) vs no diabetes 6.1% (95% CI 5.7% to 6.6%)). In the fully adjusted model, there was no clear pattern of association between diabetes status and undiagnosed depression; Ireland: OR=0.82 (95% CI 0.5 to 1.3), England: OR=1.47 (95% CI 1.0 to 2.1), USA: OR=0.80 (95% CI 0.7 to 1.0).

CONCLUSIONS

Although undiagnosed depression was more prevalent among people with diabetes, the relationship between diabetes and undiagnosed depression differed by country. Targeted efforts are needed to improve depression detection among community-dwelling older adults, particularly those with diabetes.

Changes in mood and health-related quality of life in Look AHEAD 6 years after termination of the lifestyle intervention

OBJECTIVE

The Action for Health in Diabetes (Look AHEAD) study previously reported that intensive lifestyle intervention (ILI) reduced incident depressive symptoms and improved health-related quality of life (HRQOL) over nearly 10 years of intervention compared with a control group (the diabetes support and education group [DSE]) in participants with type 2 diabetes and overweight or obesity. The present study compared incident depressive symptoms and changes in HRQOL in these groups for an additional 6 years following termination of the ILI in September 2012.

METHODS

A total of 1,945 ILI participants and 1,900 DSE participants completed at least one of four planned postintervention assessments at which weight, mood (via the Patient Health Questionnaire-9), antidepressant medication use, and HRQOL (via the Medical Outcomes Scale, Short Form-36) were measured.

RESULTS

ILI participants and DSE participants lost 3.1 (0.3) and 3.8 (0.3) kg [represented as mean (SE); p = 0.10], respectively, during the 6-year postintervention follow-up. No significant differences were observed between groups during this time in incident mild or greater symptoms of depression, antidepressant medication use, or in changes on the physical component summary or mental component summary scores of the Short Form-36. In both groups, mental component summary scores were higher than physical component summary scores.

CONCLUSIONS

Prior participation in the ILI, compared with the DSE group, did not appear to improve subsequent mood or HRQOL during 6 years of postintervention follow-up.

Evaluation of psychotropic medications use among elderly with psychiatric disorders in Saudi Arabia

AIMS

Potentially inappropriate psychotropic medications (PIPMs) prescribed to older adults with psychiatric disorders can inadvertently affect their health. The use of standards and guidelines can ensure prudent prescribing and minimize the risk of morbidities. This study assessed the pattern and prevalence of prescription of PIPMs to older individuals in outpatient psychiatric settings in Saudi Arabia, using the updated 2015 Beers criteria, as well as the probability of polypharmacy.

METHODS

The study was conducted in the outpatient psychiatric clinics of the only psychiatric hospital in Jazan region of Saudi Arabia. A retrospective cross-sectional review of electronic medical records was undertaken during 2018 to assess PIPM use and psychotropic polypharmacy. Descriptive statistics were generated and associations between PIPM use and baseline characteristics were assessed using multivariable logistic regression.

RESULTS

Overall, 68% of 1300 older adults received PIPMs, and 77.7% were on psychotropic polypharmacy. Amitriptyline, chlorpromazine, and trifluoperazine were extensively prescribed. Paroxetine (1.2%) and benzodiazepines were prescribed to a smaller proportion of the patients. Elderly with schizophrenia (AOR = 0.046, p < 0.001) and anxiety (AOR = 0.530, p = 0.036) were significantly less likely to have PIPMs than those with dementia. Likewise, elderly with depression and anxiety were less likely to have psychotropic polypharmacy as compared to those with dementia.

CONCLUSION

A substantial number of the elderly received PIPMs possibly based on implicit criteria. It is therefore important to provide mental health care providers in the region with educational programs to increase their awareness of PIPMs.

Electric field-assisted multiphase extraction to increase selectivity and sensitivity in liquid chromatography-mass spectrometry and paper spray mass spectrometry

In this work, for the first time, chromatographic paper was used for a multiphase extraction assisted by an electric field (MPEF) and directly coupled to paper spray mass spectrometry (PS-MS). Using this approach, five tricyclic antidepressants (TCAs) were determined in oral fluid. Firstly, the MPEF conditions were optimized using liquid chromatography-mass spectrometry (LC-MS/MS). The effects of the chromatographic paper and the types of electrolyte used in the acceptor phase, the organic solvent type and the amount used in the donor phase, the extraction time, and the applied electric potential were all investigated. After optimization, the analytes were extracted from the donor solution (sample and acetonitrile 1:1 (v/v)) over a period of 10 min at 300 V, crossing the free liquid membrane (1-octanol) and reaching the acceptor phase (chromatographic paper wetted with 400 mmol L^-1 acetic acid). The method using LC-MS/MS was validated, demonstrating a linear range from 2 to 12 ng mL^-1, with detection and quantification limits of 0.13-0.25 and 0.44-0.84 ng mL^-1, respectively, an intraday precision of less than 20%, and no matrix effect observed. The optimized MPEF conditions were then applied to determine TCAs by PS-MS and for this analysis cyclobenzaprine was used as an internal standard. The easy, fast and direct approach of coupling MPEF with PS-MS analysis, as well as the pre-concentration and the low standard deviation of replicates (less than 20%), demonstrates that this method can be useful for screening in clinical and toxicological analysis.

Treatment of Major Depressive Disorder in Japanese Patients with Cancer: A Matched Cohort Study Using Employer-Based Health Insurance Claims Data

BACKGROUND AND OBJECTIVE

Patients with cancer are at high risk of major depressive disorder (MDD), but little is known about their MDD treatment. We investigated the use of antidepressants and other drugs for MDD after cancer diagnosis, and patient characteristics associated with their use.

METHODS

Adults with a new cancer diagnosis were matched to cancer-free patients using a Japanese employee health insurance database (JMDC); this exploratory analysis included only cohort patients diagnosed with MDD between 6 months before and 12 months after the cancer diagnosis index month. Initial prescription frequencies of antidepressants and other MDD medications were compared between cancer and cancer-free groups and analyzed according to age, sex, and hospital characteristics.

RESULTS

Compared with the cancer-free group (n = 4097), significantly fewer patients in the cancer group (n = 1199) were prescribed antidepressants {622 (51.9%) [95% CI 49.0-54.7] vs 2385 (58.2%) [95% CI 56.7-59.7]}, particularly selective serotonin reuptake inhibitors. In contrast, prescription of other medications, especially antipsychotics and anxiolytics (tandospirone, hydroxyzine), was more frequent in the cancer group than in the cancer-free group. In the cancer group, women were prescribed antidepressants (mostly selective serotonin reuptake inhibitors) and other medications (mostly benzodiazepines) more than men. Antidepressant prescription decreased with age; patients aged < 40 years had the highest selective serotonin reuptake inhibitor and the lowest conventional antidepressant prescription rate compared with patients aged 40-64 years and ≥ 65 years. Lower selective serotonin reuptake inhibitor and benzodiazepine prescription rates were seen in large (≥ 100 beds) hospitals and in hospitals where patients received their cancer diagnosis.

CONCLUSIONS

These results suggest Japanese patients with cancer may be undertreated for MDD compared with cancer-free patients. However, when prescribed, medications may be chosen according to patient needs, including avoiding adverse effects and drug-drug interactions.

Multinational Investigation of Fracture Risk with Antidepressant Use by Class, Drug, and Indication

OBJECTIVES

Antidepressants increase the risk of falls and fracture in older adults. However, risk estimates vary considerably even in comparable populations, limiting the usefulness of current evidence for clinical decision making. Our aim was to apply a common protocol to cohorts of older antidepressant users in multiple jurisdictions to estimate fracture risk associated with different antidepressant classes, drugs, doses, and potential treatment indications.

DESIGN

Retrospective (2009-2014) cohort study.

SETTING

Five jurisdictions in the United States, Canada, United Kingdom, and Taiwan.

PARTICIPANTS

Older antidepressant users-subjects were followed from first antidepressant prescription or dispensation to first fracture or until the end of follow-up.

MEASUREMENTS

The risk of fractures with antidepressants was estimated by multivariable Cox proportional hazards models using time-varying measures of antidepressant dose and use vs nonuse, adjusting for patient characteristics.

RESULTS

Between 42.9% and 55.6% of study cohorts were 75 years and older, and 29.3% to 45.4% were men. Selective serotonin reuptake inhibitors (SSRIs) (48.4%-60.0%) were the predominant class used in North America compared with tricyclic antidepressants (TCAs) in the United Kingdom and Taiwan (49.6%-53.6%). Fracture rates varied from 37.67 to 107.18 per 1,000. The SSRIs citalopram (hazard ratio [HR] = 1.23; 95% confidence interval [CI] = 1.11-1.36 to HR = 1.43; 95% CI = 1.11-1.84) and sertraline (HR = 1.36; 95% CI = 1.10-1.68), the SNRI duloxetine (HR = 1.41; 95% CI = 1.06-1.88), TCAs doxepin (HR = 1.36; 95% CI = 1.00-1.86) and imipramine (HR = 1.16; 95% CI = 1.05-1.28), and atypicals (HR = 1.34; 95% CI = 1.14-1.58) increased fracture risk in some but not all jurisdictions. In the United States and the United Kingdom, fracture risk with all classes was higher when prescribed for depression than chronic pain, a trend that is likely explained by drug choice.

CONCLUSION

The fracture risk for patients may be reduced by selecting paroxetine, an SSRI with lower risk than citalopram, the SNRI venlafaxine over duloxetine, and the TCA amitriptyline over imipramine or doxepin. There is uncertainty about the risk associated with the atypical antidepressants. J Am Geriatr Soc 68:1494-1503, 2020.

Trends in Antidepressants Use in Spain between 2015 and 2018: Analyses from a Population-Based Registry Study with Reference to Driving

Antidepressants are considered driving-impairing medicines (DIM). This is a population-based registry study that shows the trend in the use of antidepressants in Castile and León, Spain, from 2015 to 2018. Data on antidepressant dispensations at pharmacies and the adjusted use of these medicines by the driver population are presented. For the purposes of analysis, population distribution by age and gender has been taken into account, as well as the three Driving Under the Influence of Drugs, alcohol, and medicines (DRUID) categories. Antidepressants were used by 8.56% of the general population and 5.66% of drivers. Antidepressants were used more commonly by females than by males (12.12% vs. 4.87%, χ² = 1325.124, p = 0.001), and users increased as the age increased, even if women who drive used less antidepressants after turning 60 years of age. Chronic use of antidepressants was relevant (8.28%) in the same way as daily use (3.15%). Most of the consumption included SSRIs (4.99%), which are also known as "other antidepressants" (3.71%). Regardless of antidepressants consumed, users took 2.75 ± 1.19 DIMs, which are mainly anxiolytics (58.80%) and opioids (26.43%). Lastly, regarding consumption of antidepressants according to the DRUID classification, category I predominated over categories II and III. Our findings should serve as a starting point for health and traffic authorities to raise awareness of the risk for traffic accidents, especially involving SSRIs.

Psychotropic Drug-Associated Pneumonia in Older Adults

The use of psychotropic drugs (antipsychotics, benzodiazepines and benzodiazepine-related drugs, and antidepressants) is common, with a prevalence estimates range of 19-29% among community dwelling older adults. These drugs are often prescribed for off-label use, including neuropsychiatric symptoms. The older adult population also has high rates of pneumonia and some of these cases may be associated with adverse drug events. In this narrative review, we summarize the findings from current observational studies on the association between psychotropic drug use and pneumonia in older adults. In addition to studies assessing the use of psychotropics, we included antiepileptic drugs, as they are also central nervous system-acting drugs, whose use is becoming more common in the aging population. The use of antipsychotics, benzodiazepine, and benzodiazepine-related drugs are associated with increased risk of pneumonia in older adults (≥ 65 years of age), and these findings are not limited to this age group. Minimal and conflicting evidence has been reported on the association between antidepressant drug use and pneumonia, but differences between study populations make it difficult to compare findings. Studies regarding antiepileptic drug use and risk of pneumonia in older persons are lacking, although an increased risk of pneumonia in antiepileptic drug users compared with non-users in persons with Alzheimer's disease has been reported. Tools such as the American Geriatric Society Beers Criteria and the STOPP/START criteria for potentially inappropriate medications aids prescribers to avoid these drugs in order to reduce the risk of adverse drug events. However, risk of pneumonia is not mentioned in the current criteria and more research on this topic is needed, especially in vulnerable populations, such as persons with dementia.

Antidepressant use and its relationship with current symptoms in a population-based sample of older Australians

BACKGROUND

Australia has the second highest per capita users of antidepressants globally, and their use is pronounced in older Australians. A better understanding of antidepressant use in older adults is important because the elderly are often prescribed multiple drugs, without review, for long periods.

METHODS

This study analysed questionnaire data obtained from the Personality and Total Health through life project. Individual respondent data was linked to Pharmaceutical Benefits Scheme (PBS) records. Associations between self-reported medicine use and current symptoms with antidepressant dispensing were examined.

RESULTS

1275 participants aged over 65 were included in the final analysis. One hundred and forty-six (11.5%) participants were dispensed an antidepressant within the specified timeframe. Of those, 38.4% self-reported that they use medicine for depression, 12.3% for anxiety, 17.8% for both depression and anxiety, 6.2% for sleep problems and 3.4% for pain. One fifth of those dispensed an antidepressant did not self-report use of the medicine. Being female or reporting symptoms of depression, anxiety or suicidality were significant predictors of being on an antidepressant. Increasing pain severity was also associated with increased likelihood of being on an antidepressant.

LIMITATIONS

We have presented a cross-sectional analysis, which can only provide associations between current symptoms and medicine use. We have only assessed respondents who received their scripts with PBS concession, which limits generalizability.

CONCLUSION

Our analysis highlights the high use of antidepressants in the elderly for various reasons. Our findings also uncovered a high amount of under-reporting of antidepressant use by respondents.

Inhibition of serotonin synthesis: A novel therapeutic paradigm

The rate-limiting enzyme in serotonin synthesis is tryptophan hydroxylase (TPH). There are two independent serotonin systems in the body characterized by two isoforms of TPH, TPH1 and TPH2. While TPH2 synthesizes serotonin in the brain, TPH1 is expressed in the gut and in other peripheral tissues and supplies platelets in the circulation with serotonin. This duality of the serotonin system is enforced by the blood-brain barrier which is impermeable for serotonin. In the brain serotonin acts as neurotransmitter and is a main target for the treatment of psychiatric disorders. In the periphery it is released by platelets at the site of activation and elicits numerous physiological effects. TPH1 deficient mice were shown to be protected from diverse diseases including hemostatic, inflammatory, fibrotic, gastrointestinal, and metabolic disorders and therefore serotonin synthesis inhibition emerged as a reasonable therapeutic paradigm. Recently the first TPH inhibitor, telotristat ethyl, came on the market for the treatment of carcinoid syndrome. This review summarizes the state of development and the therapeutic opportunities of such compounds.