Change in healthcare utilization and costs following initiation of benzodiazepine therapy for long-term treatment of generalized anxiety disorder: a retrospective cohort study

High-dose benzodiazepine use and QTc interval prolongation, a latent class analysis study

Benzodiazepine (BDZ) addiction is a widespread and multifaceted phenomenon. For many patients, especially females, the concomitant use of other drugs also increases their risk of QTc prolongation, possibly leading to complications such as seizures and even sudden death. However, the relationship between BDZ use and QTc prolongation is currently unclear. The present study aims to examine patterns of polysubstance use among a sample of Italian adults with BDZ dependence in relation with their QTc prolongation risk. We used Latent Class Analysis (LCA) on data collected from 251 inpatients of the Addiction Medicine Unit in Verona to group patients into three classes according to their substance use and their QTc prolongation risk. Results showed no significant relationship between QTc prolongation and BDZ use in any of the classes considered. We conclude that BDZs, even if used long-term and at high dosages, can be considered safe in terms of cardiovascular complications for patients.

Associations between insomnia symptoms and prescription opioid and benzodiazepine misuse in a nationally representative sample

BACKGROUND

There are complex associations between insomnia symptoms and misuse of prescription drugs. The aim of this study was to examine prospective associations between insomnia symptoms and prescription opioid and benzodiazepine misuse among a nationally representative sample of adults.

METHODS

Utilizing data from the National Longitudinal Study of Adolescent to Adult Health (N = 10,685), we conducted log-binomial regression to examine associations of insomnia symptoms at Wave IV (2008-2009; 24-32 years) with prescription opioid and benzodiazepine misuse at Wave V (2016-2018; 33-43 years). We adjusted analyses for prior insomnia symptoms and substance misuse, as well as potential demographic and health-related confounders.

RESULTS

Each unit increase in insomnia symptoms at Wave IV was associated with a small increase in the likelihood of prescription opioid (RR = 1.08, 95 % CI 1.01, 1.15) but not benzodiazepine (RR = 1.09, 95 % CI 0.99, 1.21) use at Wave V. Both prescription opioid (β = 0.20, 95 % CI 0.09, 0.031) and benzodiazepine (β = 0.21, 95 % CI 0.10, 0.33) misuse at Wave IV had small associations with elevated insomnia symptoms at Wave V.

CONCLUSIONS

Results support associations between prescription opioid and benzodiazepine misuse and later insomnia symptoms. There was a small association between insomnia symptoms and later prescription opioid misuse worthy of future study. These results fit within a broad line of research suggesting that insomnia symptoms are associated with future substance use and vice versa. Future research is needed explore mechanisms (e.g., mental health, pain) underlying these associations.

Cost-effectiveness of internet-supported cognitive behavioral therapy for university students with anxiety symptoms: A Markov-model analysis

Background and aim

High prevalence of anxiety symptoms has been reported globally in the university students. Cognitive behavioral therapy (CBT) is the recognized treatment for anxiety and is traditionally conducted face-to-face (f-CBT). The efficacy of internet-based CBT (i-CBT) for anxiety has been extensively studied, yet evidence on its cost-effectiveness is scarce. We aimed to evaluate the cost-effectiveness of guided low-intensity i-CBT for university students with mild anxiety symptoms from the societal perspective of Hong Kong.

Methods

A 5-year Markov model was designed to compare outcomes of guided i-CBT and f-CBT in a hypothetical cohort of university students with mild anxiety symptoms. Model inputs of cost and healthcare resources associated with anxiety were retrospectively collected from a cohort of university students with anxiety symptoms. Clinical and utility model inputs were retrieved from published literature. Model outcome measures were anxiety-related total cost (including direct medical and indirect costs) and quality-adjusted life-year (QALY). Sensitivity analyses were performed to examine the robustness of base-case results.

Results

In base-case analysis, i-CBT gained higher QALYs (2.9956 versus 2.9917) at lower total cost (US$6,101 versus US$6,246) than f-CBT. In one-way sensitivity analysis, the QALY gained by i-CBT was sensitive to the relative patient acceptance and adherence to CBT. In probabilistic sensitivity analysis, i-CBT was cost-effective in 90.9% of the time at the willingness-to-pay threshold of 138,210 per QALY (3× GDP per capita in Hong Kong). The probability of i-CBT to be cost-effective was 99.9% at a willingness-to-pay threshold of zero.

Conclusions

Guided i-CBT appears to be cost-saving and effective for management of university students with mild symptoms of anxiety from the societal perspective of Hong Kong. The cost-effectiveness of i-CBT is highly subject to the individual acceptance and adherence of CBT delivered by the internet platform.

Hospital initiation of benzodiazepines and Z-drugs in older adults and discontinuation in primary care

OBJECTIVE

To examine factors associated with continuation of hospital-initiated benzodiazepine receptor agonists (BZRAs) among adults aged ≥65 years, specifically instructions on hospital discharge summaries.

METHODS

This retrospective cohort study involved anonymised electronic record data on prescribing and hospitalisations for 38,229 patients aged ≥65 from forty-four GP practices in Ireland 2011-2016. BZRA initiations were identified among patients with no BZRA prescription in the previous 12 months. Multivariate regression examined whether instructions on discharge messages for hospital-initiated BZRA prescriptions was associated with continuation after discharge in primary care and time to discontinuation.

RESULTS

In total, 418 hospital-initiated BZRAs were identified, 48.8% being to males and mean patient age was 79.0 (SD 8.3) years. Almost 60% of these discharge summarieshad some BZRA instructions (e.g. duration). Approximately 40% (n = 166) were continued in primary care. Lower age, being prescribed a Z-drug or great number of medicines were associated with higher risk of continuation. Of those continued in primary care, in 98 cases (59.6%) the BZRA was discontinued during follow-up (after a mean 184 days). Presence of instructions was associated with higher likelihood of discontinuation (hazard ratio 1.71, 95%CI 1.11-2.62).

CONCLUSIONS

Improved communication to GPs after hospital discharge may be important in avoiding long-term BZRA use.

Healthcare costs and quality of life associated with the long-term outcome of anxiety disorders

BACKGROUND AND OBJECTIVES

Anxiety disorders are costly; however, the relationship with treatment outcome has been neglected. This study examined healthcare costs and quality of life by diagnostic status (treatment outcome and the presence of comorbidity) at long-term follow-up.

DESIGN AND METHODS

This cohort study comprized 317 patients entering treatment for at least one Axis I anxiety disorder. Four groups were identified based on diagnostic status at follow-up (recovered or disordered) and self-reported degree of interim treatment (high or low). A further grouping was established based on co-morbid diagnostic status at follow-up. Healthcare costs were calculated for the two years prior to treatment entry and the two years prior to follow-up using a repeated measures analysis of variance (ANOVA). Group differences in quality of life were assessed using a univariate ANOVA.

RESULTS

Over two thirds of the sustained recovery group was treatment-free at follow-up whilst the remainder required adjuvant drug therapy. Over half of those remaining disordered at follow-up incurred substantial healthcare costs and presented with treatment-resistant symptoms and severely impaired quality of life.

CONCLUSIONS

Despite substantial investment some patients were associated with a clinical anxiety diagnosis at follow-up, and multimorbidity was associated with considerably higher costs.

Transitioning from oral risperidone or paliperidone to once-monthly paliperidone palmitate: a real-world analysis among Veterans Health Administration patients with schizophrenia who have had at least one prior hospitalization

Objective: To address gaps in the literature on healthcare resource utilization (HRU) and costs among patients with schizophrenia and prior hospitalization who transition from oral risperidone or paliperidone (oral ris/pali) to once-monthly paliperidone palmitate (PP1M) in a real-world setting by comparing treatment patterns, HRU, and costs 12-months pre- and post-transition to PP1M among Veterans Health Administration (VHA) patients affected by schizophrenia who have had ≥1 hospitalization.Methods: VHA patients with schizophrenia (aged ≥18 years) who initiated oral ris/pali, had ≥1 all-cause inpatient stay, and transitioned to PP1M from January 2015-March 2017 were included from the VHA database. The first transition date to PP1M was identified as the index date. Patients were required to have continuous health plan eligibility for 12 months pre- and post-PP1M. Outcomes were compared using the Wilcoxon signed-rank and McNemar's test, as appropriate.Results: The study included 319 patients (mean [SD] age = 51.6 [4.2] years) during 12 months of baseline and follow-up. During pre-PP1M transition, 7.2% of the patients were adherent (proportion of days covered [PDC] ≥ 80%) to oral ris/pali. Post-PP1M transition, 27.6% of the patients were adherent to PP1M. Comparison of HRU outcomes from the pre- to post-PP1M transition revealed significantly lower all-cause inpatient stays (3.5 vs 1.4, p < .0001) and shorter inpatient length of stay (43.4 vs 18.3 days, p < .0001). Similar trends were seen for mental health and schizophrenia-related HRU. Cost outcome comparison indicated significantly lower all-cause inpatient costs ($64,702 vs $24,147, p < .0001), total medical costs ($87,917 vs $56,947, p < .0001), and total costs ($91,181 vs $69,106, p < .0001). A similar trend was observed for mental health and schizophrenia-related costs.Conclusions: Transitioning from oral ris/pali to PP1M may significantly improve HRU and provide potential cost savings in VHA patients with schizophrenia and ≥1 prior hospitalization.

[Use and abuse of benzodiazepines in primary healthcare: professional practices in Brazil and Cuba]

The current study aimed to grasp the healthcare aspects present at the basis of the indiscriminate use of benzodiazepines. Based on a partnership between a Brazilian university and a Cuban university, the study aimed to understand the practices related to the use of these drugs in primary care and the meanings healthcare workers assign to them. The research was part of a multiple case study in the cities of São Paulo and Diadema (Brasil), and Santiago de Cuba (Cuba). The fieldwork data collection strategy was based on individual interviews and focus groups. Data were analyzed thematically and yielded five themes: (i) no man's land: lack of management of benzodiazepine use by primary care workers; (ii) inadequate indications: the benzodiazepine prescribed for unjustifiable situations; (iii) salvation and perdition: the medicine as attenuating the difficulty of acting in mental health by primary care professionals; (iv) limited empowerment to work in mental health; and (v) fragmented care: dissociation of the psychosocial care network. Limited grasp of mental health issues by primary care workers, fragmented care, work overload with what are considered other priorities, deficiencies in the availability of therapeutic resources, and limited investment in specific training contribute to the inadequate use of benzodiazepines. Independently of the health contexts, the challenges are similar for the health systems and can only be confronted if they become a priority for the organizations' management and the health workers as a whole.

A 10-year evaluation on adolescents with anxiety disorders: are they at risk of bipolarity?

OBJECTIVE

Anxiety disorders are the most frequent disorders comorbid with bipolar disorder (BD) often preceding the BD onset. The presence of comorbid anxiety in patients diagnosed with BD is associated with worsening of their BD symptoms, increased risky behaviour, decreased response to pharmacological treatment and deterioration in their quality of life and global functioning. The aim of this study was to investigate if anxiety disorders in adolescence could be considered as predictors of BD.

METHODS

Adolescents with a primary anxiety disorder were recruited consecutively from the Mood and Anxiety Disorders Unit, Department of Neuroscience, University of Turin. Subjects were evaluated for Axis I psychiatric disorders, family history and global functioning, and followed up on average 10 years later.

RESULTS

A total of 29 patients (59.2%) were male and the mean age at the onset of anxiety disorder was 16.3 (±0.8). Ten years following recruitment, 11 (22.4%) patients fulfilled the criteria for BD. Of them, 10 (90.9%) had a family history of BD and four (36.4%) presented a comorbid substance use disorder.

CONCLUSIONS

Our study shows that both family history of BD and substance use disorder, in adolescent patients with a primary anxiety disorder, should be considered as potential predictors of BD onset.

'Big data' in mental health research: current status and emerging possibilities

PURPOSE

'Big data' are accumulating in a multitude of domains and offer novel opportunities for research. The role of these resources in mental health investigations remains relatively unexplored, although a number of datasets are in use and supporting a range of projects. We sought to review big data resources and their use in mental health research to characterise applications to date and consider directions for innovation in future.

METHODS

A narrative review.

RESULTS

Clear disparities were evident in geographic regions covered and in the disorders and interventions receiving most attention.

DISCUSSION

We discuss the strengths and weaknesses of the use of different types of data and the challenges of big data in general. Current research output from big data is still predominantly determined by the information and resources available and there is a need to reverse the situation so that big data platforms are more driven by the needs of clinical services and service users.

A Randomized, Placebo-Controlled Pilot Study of Quetiapine-XR Monotherapy or Adjunctive Therapy to Antidepressant in Acute Major Depressive Disorder with Current Generalized Anxiety Disorder

OBJECTIVES

To pilot efficacy and safety data of quetiapine-XR monotherapy or adjunctive therapy to antidepressant(s) in the acute treatment of MDD with current generalized anxiety disorder (GAD).

METHODS

The Mini International Neuropsychiatric Interview was used to ascertain the diagnosis of DSM-IV Axis I disorders. Eligible patients were randomly assigned to quetiapine-XR or placebo for up to 8 weeks. Changes from baseline to endpoint in Hamilton Depression Rating Scale-17 items (HAMD-17), Hamilton Anxiety Rating Scale (HAM-A), Clinical Global Impression-Severity (CGI-S), Quick Inventory of Depression Symptomatology-16 items Self-Report (QIDS-16-SR) total scores, and other outcome measures were analyzed with the last observation carried forward strategy and/or mixed-effects modeling for repeated measures.

RESULTS

Of the 34 patients screened, 23 patients were randomized to receive quetiapine-XR (n = 11) or placebo (n = 12), with 5 and 4 completing the study, respectively. The mean dose of quetiapine-XR was 154 ± 91 mg/d. The change from baseline to endpoint in the total scores of HAMD-17, HAM-A, QIDS-16-SR, and CGI-S were significant in the quetiapine-XR group, but only the change in HAM-A total score was significant in the placebo group. The differences in these changes between the two groups were only significant in CGI-S scores, with the rest of numerical larger in the quetiapine-XR group. The most common side effects from quetiapine-XR were dry mouth, somnolence/sedation, and fatigue.

CONCLUSIONS

In this pilot study, quetiapine-XR was numerically superior to placebo in reducing depressive and anxiety symptoms in patients with MDD and current GAD. Large sample studies are warranted to support or refute these preliminary findings.

Low stability of diagnostic classifications of anxiety disorders over time: A six-year follow-up of the NESDA study

BACKGROUND

Stability of diagnosis was listed as an important predictive validator for maintaining separate diagnostic classifications in DSM-5. The aim of this study is to examine the longitudinal stability of anxiety disorder diagnoses, and the difference in stability between subjects with a chronic versus a non-chronic course.

METHODS

Longitudinal data of 447 subjects with a current pure anxiety disorder diagnosis at baseline from the Netherlands Study of Depression and Anxiety were used. At baseline, 2-, 4-, and 6-year follow-up mental disorders were assessed and numbers (and percentages) of transitions from one anxiety disorder diagnosis to another were determined for each anxiety disorder diagnosis separately and for subjects with a chronic (i.e. one or more anxiety disorder at every follow-up assessment) and a non-chronic course.

RESULTS

Transition percentages were high in all anxiety disorder diagnoses, ranging from 21.1% for social anxiety disorder to 46.3% for panic disorder with agoraphobia at six years of follow-up. Transition numbers were higher in the chronic than in the non-chronic course group (p=0.01).

LIMITATIONS

Due to the 2 year sample frequency, the number of subjects with a chronic course may have been overestimated as intermittent recovery periods may have been missed.

CONCLUSIONS

These data indicate that anxiety disorder diagnoses are not stable over time. The validity of the different anxiety disorder categories is not supported by these longitudinal patterns, which may be interpreted as support for a more pronounced dimensional approach to the classification of anxiety disorders.