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Grimmsmann T, Himmel W. [Private Prescriptions In East And West Germany - A Secondary Data Analysis]. DAS GESUNDHEITSWESEN 2023; 85:1213-1219. [PMID: 38081175 PMCID: PMC10713339 DOI: 10.1055/a-2160-2679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND AND OBJECTIVE Benzodiazepines and Z-drugs are prescribed to a considerable extent as private prescription also for persons insured by a statutory health insurance (SHI), with formerly large differences between East and West Germany. The aim of the present study was to investigate whether these differences still exist today. METHOD This secondary data analysis used anonymized prescription data from general practitioners (GPs), community neurologists, and psychiatrists. SHI-insured patients with at least one prescription for a benzodiazepine or Z-substance between 2014 and 2020 were included. Differences between East and West Germany in the proportion of private prescriptions were the central outcome. Multiple regression analyses were performed to test whether the factors region (eastern vs. western Germany) and specialist group (GPs vs. neurologists/psychiatrists) were statistically significant predictors of the proportion of private prescriptions - taking into account the age and gender composition of patients in a practice. RESULTS From 867 practices, 2,200,446 prescriptions for Z-substances, benzodiazepine anxiolytics, and benzodiazepine hypnotics/sedatives were evaluated. More than 38% of these prescriptions were issued as private prescriptions: 53.6% in eastern Germany and 34.8% in western Germany. For Z-substances, the proportion of private prescriptions was particularly high (70.7% in eastern and 43.0% in western Germany). GPs issued private prescriptions far more frequently than neurologists and psychiatrists. The proportion of private prescriptions increased during the study period, comparatively strongly in the western states (from 33% to 39%) and slightly in the eastern states (from 53% to 54%). In the multivariate model, practice area (east/west) and specialist group were similarly strong predictors of the extent of private prescriptions, especially for Z-substances. CONCLUSION Contrary to a general alignment in life expectancy, morbidity risks, and health behaviour in East and West Germany, there is, despite convergence, still a significant difference in the proportion of private prescriptions for benzodiazepines and especially for Z-substances between the two regions. The groups of physicians who mainly prescribe these substances, namely neurologists and psychiatrists, on the one hand, and GPs, on the other, also differ considerably in the proportion of their private prescriptions for these substances.
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Affiliation(s)
- Thomas Grimmsmann
- Referat Arzneimittel und Methoden, Medizinischer Dienst
Mecklenburg-Vorpommern, Schwerin, Deutschland
| | - Wolfgang Himmel
- Institut für Allgemeinmedizin, Universitätsmedizin
Göttingen, Gottingen, Deutschland
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Kosto A, Lev D, Reiss N, Meged-Book T, Press Y. Discontinuation of benzodiazepines and Z-drugs in hospitalised population at the age of 60 and above. An open-label randomized controlled trial. Int J Geriatr Psychiatry 2023; 38:e6012. [PMID: 37807766 DOI: 10.1002/gps.6012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/25/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Treating insomnia with hypnotic drugs in elderly patients has many adverse effects. This study aims to assess the effect of two discontinuation methods of hypnotic drugs during acute hospitalization. METHODS We conducted an open-label randomized controlled trial that included participants aged 60 and above taking benzodiazepines or Z-Drugs for at least 3 months as a treatment for insomnia and were admitted to the hospital. In the prospective arm, patients were randomly assigned into two intervention groups. In the Minimal Intervention (MI) group, patients received an explanation of the dangers of long-term treatment and a recommendation to stop the treatment. In the Tapering Down Intervention (TDI) group, in addition to the explanation, patients received a tapering down table. In the retrospective arm (control group), we examined the use of hypnotic drugs among hospitalized patients 3 months after hospitalization, similar to the patients in the prospective arm. RESULTS 46 patients were enrolled in the MI group, 55 patients in the TDI group, and 114 patients in the control group. The mean age in the three groups was 75.0 ± 8.2, 75.9 ± 9.0, and 75.0 ± 7.9 years respectively (p = 0.85). After 3 months, seven (15.2%) of the patients in the MI group, 15 (27.3%) in the TD group, and 2 (1.8%) in the control group (p = 0.00003) were weaned from the hypnotic drugs treatment, without a significant difference between the intervention groups (p = 0.221). CONCLUSIONS A short intervention during hospitalization results in a significant decrease in hypnotic drug use.
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Affiliation(s)
- Amit Kosto
- Department of Internal Medicine, Soroka Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Danielle Lev
- Department of Internal Medicine, Soroka Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Nadav Reiss
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Psychiatry, Soroka Medical Center, Beer-Sheva, Israel
| | - Tehilah Meged-Book
- Department of Internal Medicine, Soroka Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yan Press
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
- Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer- Sheva, Israel
- Unit for Community Geriatrics, Division of Health in the Community, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Center for Multidisciplinary Research in Aging, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Soyka M, Wild I, Caulet B, Leontiou C, Lugoboni F, Hajak G. Long-term use of benzodiazepines in chronic insomnia: a European perspective. Front Psychiatry 2023; 14:1212028. [PMID: 37599882 PMCID: PMC10433200 DOI: 10.3389/fpsyt.2023.1212028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/20/2023] [Indexed: 08/22/2023] Open
Abstract
Chronic insomnia occurs in ~10% of the general population and has numerous negative health effects. The recommended first line treatment of cognitive behavior therapy for insomnia is not widely available for patients in Europe, so pharmacotherapies such as benzodiazepine receptor agonist agents (benzodiazepines and Z-drugs) are commonly used. However, their use is only recommended for ≤4 weeks due to unproven long-term efficacy in treatment of chronic insomnia, and the risk of tolerance, and the potential for dependence and misuse. In Europe, recommendations limiting the use of benzodiazepines (lowest dose and shortest duration) in chronic insomnia are not always followed, likely due to the lack of approved effective alternative therapies. Here we present a recent pilot survey of the pharmacological treatment landscape in chronic insomnia in five European countries (France, Germany, Italy, Spain, and the United Kingdom) and physicians' attitude toward treatment. The results suggest that benzodiazepines and Z-drugs are the most widely used treatments in chronic insomnia and are being used for longer than their recommended duration. Country variations in prescription rates were observed. Due to the known association between long-term benzodiazepine use and potential for developing dependence, further analysis of the literature was performed on the use and misuse of benzodiazepines. The results show that long-term use of benzodiazepines is associated with multiple consequences of treatment, including dependence, but also that previous use of benzodiazepines may increase the risk of opioid use disorder.
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Affiliation(s)
- Michael Soyka
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Munich, Germany
| | - Imane Wild
- Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | | | | | - Fabio Lugoboni
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| | - Göran Hajak
- University of Regensburg, Regensburg, Germany
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Social Foundation Bamberg, Teaching Hospital of the University of Erlangen, Bamberg, Germany
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Coteur K, Mamouris P, Vaes B, Van Nuland M, Matheï C, Schoenmakers B. Evolution of benzodiazepine receptor agonist prescriptions in general practice: A registry-based study. Front Public Health 2022; 10:1014734. [PMID: 36211642 PMCID: PMC9546292 DOI: 10.3389/fpubh.2022.1014734] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/05/2022] [Indexed: 01/27/2023] Open
Abstract
Background Contrary to most European guidelines, benzodiazepine receptor agonists (BZRA) are often used continuously at a low dosage, being the most common form of long-term use. In Belgium, BZRA use is monitored by analyzing self-report data about medication use in the last 24 h. This method provides insufficient insight into the terms of use of these psychoactive drugs. Aim To describe trends in BZRA prescribing in Flanders, Belgium, between 2000 and 2019. Design and setting Population-based trend analysis and a case-control study for the year 2019 were done with data from a morbidity registry in general practice. Methods Repeated cross-sectional and joinpoint regression analyses revealed trends in sex- and age-standardized prescription rates among adult patients (18+). Results Overall, BZRA prescriptions increased. The highest overall increase was found among male patients 18-44 years old, with an average annual percentage change of 2.5 (95% CI: 0.9, 4.3). Among 65+ female patients, a decrease was found since 2006, with an annual percentage change of -0.7 (95% CI: -1.3, -0.1). In 2019, 12% of registered patients received minimally one prescription, long-term use was observed in 5%, back pain was the most common morbidity significantly associated with a rise in BZRA prescriptions, and zolpidem was the most prescribed BZRA (22%). Conclusion Despite some statistically significant decreasing trends, an overall increase in BZRA prescriptions was observed throughout the 19-year study period, especially among long-term users of 18-44 years and 65-plus. Zolpidem became the most prescribed BZRA and warrants more attention.
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Chuang C, Hsiao FC, Cheng YW, Lin CP, Tung YC, Wu CT, Chen CY, Chu PH. Benzodiazepines in Patients with Heart Failure and Reduced Ejection Fraction. ACTA CARDIOLOGICA SINICA 2022; 38:573-583. [PMID: 36176374 PMCID: PMC9479043 DOI: 10.6515/acs.202209_38(5).20220406a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 04/06/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND In patients with heart failure (HF), anxiety or insomnia is prevalent and associated with poor clinical outcomes. Benzodiazepines (BZDs) are one of the most commonly prescribed medications for anxiety or insomnia in Taiwan. Evidence regarding the effects of BZDs on patients with heart failure and reduced ejection fraction (HFrEF) is inconclusive. OBJECTIVES To evaluate whether BZDs can mitigate the adverse effects of anxiety or insomnia on the prognosis of patients with HFrEF. METHODS Patients with HFrEF were identified from the Chang Gung Research Database between January 1, 2007 and December 31, 2018. Those who received BZD prescriptions were defined as the BZD group; patients in the BZD group were then paired with those who had never been prescribed BZDs after matching for age, sex, and baseline left ventricular ejection fraction, defined as the no-BZD group. Propensity score matching was used to balance baseline characteristics. Cox proportional hazards model and the Fine-Gray subdistribution hazard model were used to examine the association between BZD prescription and the risks of adverse cardiovascular outcomes. RESULTS After propensity score matching, there were 1,941 patients in both BZD and no-BZD groups. The composite of cardiovascular (CV) death or HF hospitalization (HFH) occurred in 64.4% and 54.4% of the patients in the BZD and no-BZD groups, respectively [hazard ratio (HR): 1.44; 95% confidence interval (CI): 1.32-1.56], which was mainly driven by HFH (HR: 1.52; 95% CI: 1.39-1.67). CONCLUSIONS In the patients with HFrEF, those who received BZD were at a higher overall risk of CV death and HFH.
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Affiliation(s)
- Chi Chuang
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center; College of Medicine, Chang Gung University, Taoyuan
| | - Fu-Chih Hsiao
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center; College of Medicine, Chang Gung University, Taoyuan
| | - Yu-Wen Cheng
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center; College of Medicine, Chang Gung University, Taoyuan
| | - Chia-Pin Lin
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center; College of Medicine, Chang Gung University, Taoyuan
| | - Ying-Chang Tung
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center; College of Medicine, Chang Gung University, Taoyuan
| | - Chia-Tung Wu
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center; College of Medicine, Chang Gung University, Taoyuan
| | - Ching-Yen Chen
- Department of Psychiatry, Chang Gung Memorial Hospital at Keelung, Keelung; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pao-Hsien Chu
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Medical Center; College of Medicine, Chang Gung University, Taoyuan
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The Characteristics of Benzodiazepine Prescribing in the Republic of Srpska, Bosnia and Herzegovina. Medicina (B Aires) 2022; 58:medicina58080980. [PMID: 35893095 PMCID: PMC9332377 DOI: 10.3390/medicina58080980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Benzodiazepines (BZDs) are among the most prescribed psychotropic drugs and significant number of patients use these drugs for longer periods than recommended. The objective of this study was to determine the factors associated with prescribing of BZDs at the primary healthcare level. Materials and Methods: A retrospective analysis of family physicians’ prescriptions from the databases of family medicine teams of the Republic of Srpska was performed. The number of BZDs users, as well as the total number of prescriptions, were determined. Thereafter, it was determined which specific BZD had been prescribed, in which dose, for how long, as well as the specific social and demographic characteristics of patients to whom the drugs were prescribed. Results: The results showed that 38.47% of patients used the BZDs for a period longer than six months. The most frequent BZDs prescribed were the intermediate-acting BZDs, primarily bromazepam (58.69%). Two thirds of patients were women. The average age of the patients was 60, 60.46% of patients were single, and 69.68% lived in urban areas. The longer uses of BZDs were recorded in women, the elderly, single people and those who lived in urban areas, while higher doses of BZDs were prescribed to men, as well as younger and married people. The highest positive correlation was found between the dose and length of use of BZD. Conclusions: A significant percentage of patients used BZDs for a time period longer than recommended. Caution is necessary when prescribing BZDs to women, the elderly, patients that live in urban areas and patients who are single. When prescribing BZDs, family physicians should be aware of their potential interactions and addictive potentials.
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Chen Y, Wang F, Cui L, Huang H, Kong S, Qian N, Zhang M, Lyu D, Wang M, Liu X, Cao L, Fang Y, Hong W. Short- and Long-Term Influences of Benzodiazepine and Z-Drug Use in Patients with Bipolar Disorder Combined Sleep Disturbance during Affective Period: A Nine-Month Follow-Up Analysis. DISEASE MARKERS 2022; 2022:6799898. [PMID: 35677635 PMCID: PMC9170399 DOI: 10.1155/2022/6799898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 11/17/2022]
Abstract
Background Sleep disturbances and benzodiazepine (BZD)/Z-drug use are common in patients with bipolar disorder (BD). Objective To investigate the short- and long-term effects of BZD/Z-drug use during acute affective episode. Methods Participants diagnosed with BD as well as sleep disturbance chose BZDs/Z-drugs or not at will. Manic and depressive symptoms were assessed by Mental Disorders Questionnaire (MDQ) and Quick Inventory of Depressive Symptoms (QIDS) as self-reporting surveys. The participants were assessed by trained evaluators at baseline and months 1, 3, 6, and 9. Results 61 patients with BD combined sleep disturbances were studied. At baseline, patients who used BZDs/Z-drugs had more amount of mood stabilizers (p = 0.038), other psychotropic medications (p = 0.040), and more risk of suicide attempt (p = 0.019). The BZD/Z-drug group had a significantly higher QIDS reductive ratio as compared with the no BZD/Z-drug group at month 1; no significant differences in the variability of MDQ, QIDS reductive ratio, or recurrence rate were found between these two groups at baseline, month 1, month 3, month 6, or month 9. Conclusions During acute affective episode, patients with BD combined sleep disturbance who took BZDs/Z-drugs tended to use more amount of mood stabilizers. Polytherapy of BZDs/Z-drugs or other psychiatric drugs could increase suicide attempt during an acute affective episode. BZD/Z-drug use, however, had a significant effect on helping depressive symptoms alleviate during affective period.
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Affiliation(s)
- Yiming Chen
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fan Wang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lvchun Cui
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haijing Huang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shuqi Kong
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Nuoshi Qian
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengke Zhang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dongbin Lyu
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Meiti Wang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaohua Liu
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lan Cao
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiru Fang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai, China
- CAS Center for Excellence in Brain Science and Intelligence Technology, Shanghai, China
| | - Wu Hong
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai, China
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Zamboni L, Toldo S, Fusina F, Mattiello M, Mannari V, Campagnari S, Schiavone V, Congiu A, Verlato G, Chiamulera C, Lugoboni F. Study protocol-Evoked craving in high-dose benzodiazepine users. Front Psychiatry 2022; 13:956892. [PMID: 36311534 PMCID: PMC9608779 DOI: 10.3389/fpsyt.2022.956892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Benzodiazepine (BDZ) abuse, especially concerning high doses of BDZs, is an impairing substance use disorder (SUD) that is often difficult to treat. Craving and cue reactivity (CR) are two important phenomena that have a prominent role in maintaining addiction and triggering relapses in BDZ abuse; nevertheless, they have rarely been addressed in scientific literature. The present study aims to fill these gaps by implementing a highly innovative virtual reality (VR) design to assess the impact of substance-related environmental cues on BDZ craving, as well as their influence on patients' affective states. Therefore, on one hand, this research will contribute to the assessment of VR feasibility in the study of these phenomena, and, on the other, it will help disentangle the role that CR and craving have on mood and attention, which are equally important factors to consider when treating SUDs. We will recruit a healthy control group and a patient group comprising people seeking treatment for BDZ detoxification. The experimental design will consist of the presentation of three VR scenarios, one neutral, one BDZ-related but without BDZ cues, and another with BDZ cues. The craving will be measured through a virtual analog scale (VAS); the Profile of Mood States (POMS) and Alcohol Attention Scale (AAS) questionnaires in a modified version will also be administered. We will additionally control for VR-induced feelings of sickness by administering the Simulator Sickness Questionnaire (SSQ), and the Presence Questionnaire (PQ) will be used to investigate participants' sense of presence in virtual environments. We expect patients to exhibit higher levels of craving, and that the craving will be higher after exposure to a cue-related virtual environment as compared to a neutral scenario.
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Affiliation(s)
- Lorenzo Zamboni
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Policlinico "G.B. Rossi", Verona, Italy.,Department of Neurosciences, University of Verona, Verona, Italy
| | - Silvia Toldo
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Francesca Fusina
- Padova Neuroscience Center, University of Padua, Padua, Italy.,Department of General Psychology, University of Padua, Padua, Italy
| | - Matteo Mattiello
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Policlinico "G.B. Rossi", Verona, Italy.,Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Vanessa Mannari
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Simone Campagnari
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Policlinico "G.B. Rossi", Verona, Italy
| | - Valentina Schiavone
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Alessio Congiu
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Policlinico "G.B. Rossi", Verona, Italy
| | - Giuseppe Verlato
- Diagnostics and Public Health-Unit of Epidemiology and Medical Statistics, University of Verona, Verona, Italy
| | - Cristiano Chiamulera
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Fabio Lugoboni
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Policlinico "G.B. Rossi", Verona, Italy
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Casari R, Metastasio A, Zamboni L, Biasioli M, Campagnari S, Lugoboni F. Addiction of High Dose of Benzodiazepine: Verona Detox Approach With Flumazenil. Front Psychiatry 2022; 13:857376. [PMID: 35432044 PMCID: PMC9008883 DOI: 10.3389/fpsyt.2022.857376] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Since the 1990s there has been evidence of the significant role Flumazenil (FLU) has in benzodiazepines (BZD) detoxes. The Verona Detox approach has been developed for high dose BZD and Z-drug detoxification via continuous subcutaneous infusion of FLU, a selective BZD receptor antagonist acting on the BZD subunit of the GABA-A receptor. Flumazenil is licensed in the United Kingdom and other countries to treat only BZD overdose although numerous studies have demonstrated its effectiveness in rapidly resetting GABA-A receptors, quickly reducing tolerance and dependence from BZD, and providing a safe and rapid detox from benzodiazepines. OBJECTIVE The aim of this article is to provide all healthcare professional who are interested in BZD detoxification with an approach and clear practical information on how to administer FLU. METHOD In this article we outline the approach in detail, describing all medical and nursing procedures day by day. This detox treatment is indicated for patients abusing from at least 5 Defined Daily Dose (DDD) of BZDs or Z-drugs. The process lasts 7 days, and is conducted under medical supervision (daily reviews) and continuous nursing (24/7). During this period, 7mg of FLU is administered (1 mg/24) through an elastomeric pump, via continuous subcutaneous infusion. CONCLUSION To this day, the largest database of FLU detoxification was published by our group, showing how this treatment is safe, with very little side effects even in patients with significant medical comorbidities.
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Affiliation(s)
- Rebecca Casari
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy
| | | | - Lorenzo Zamboni
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy.,Department of Neurosciences, University of Verona, Verona, Italy
| | - Martino Biasioli
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy
| | - Simone Campagnari
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy
| | - Fabio Lugoboni
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy
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Withdrawal from Long-Term Use of Unusually High-Dose Oxazepam. Case Rep Psychiatry 2021; 2021:2140723. [PMID: 34777889 PMCID: PMC8589494 DOI: 10.1155/2021/2140723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 09/27/2021] [Accepted: 10/11/2021] [Indexed: 11/25/2022] Open
Abstract
Benzodiazepine (BZD) misuse is a worldwide problem that healthcare professionals encounter in daily practice. High-dose BZD withdrawal is usually a long process that may require referral to an inpatient rehabilitation unit. Relapses after withdrawal are common. BZD withdrawal can cause complications including seizures, suicidal behavior, anxiety, and depression. Guidelines describe tapering protocols for modest doses; however, protocols for exceptionally high-dose BZD withdrawal are not well described. Herein, we describe a BZD tapering protocol for a patient with daily use of high-dose (1800 mg) oxazepam (OXP). The BZD tapering was administered in an inpatient psychiatric hospital, and the outcome was evaluated monthly after discharge for three months. This report describes a unique case of high-dose OXP withdrawal and also outlines an optional protocol to apply when clinicians encounter these unusual cases.
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Yamamoto S, Kawamura Y, Yamamoto K, Yamaguchi Y, Tamura Y, Izawa S, Nakagawa H, Wakita Y, Hijikata Y, Ebi M, Funaki Y, Ohashi W, Ogasawara N, Sasaki M, Maekawa M, Kasugai K. Internet Survey of Japanese Patients With Chronic Constipation: Focus on Correlations Between Sleep Quality, Symptom Severity, and Quality of Life. J Neurogastroenterol Motil 2021; 27:602-611. [PMID: 34642281 PMCID: PMC8521473 DOI: 10.5056/jnm20135] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/14/2020] [Accepted: 02/18/2021] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Chronic constipation and lifestyle factors can affect sleep quality. We evaluated the relationship between chronic constipation and sleep in the Japanese population. Methods This cross-sectional internet-based survey included 3000 subjects with constipation, classified according to sleep status (good/poor). Primary endpoints were Bristol stool form scale (BSFS) score and correlations between sleep disorder criteria of the Pittsburgh Sleep Quality Index (PSQI) and sleep status (good/poor sleep). Secondary endpoints included correlations between quality of life (QOL) and mood, medical, lifestyle, and sleep factors. Results The proportion of participants with BSFS category 4 (normal stool) was significantly higher in the good sleep group (P < 0.001). Sleep disturbance (P < 0.05), sleep quality, and duration, use of hypnotic medication, and daytime dysfunction of PSQI (all P < 0.001) significantly correlated with poor sleep. In the poor sleep group, QOL was significantly worse and anxiety and depression levels were significantly higher (all P < 0.001) compared with the good sleep group. Anemia and smoking (both P < 0.05), recent body weight increases, and poor eating habits (all P < 0.001) were significantly higher in the poor sleep group. Male sex, onset associated with change in frequency of stools, sensation of incomplete evacuation for at least 25% of defecations, and manual maneuvers to facilitate at least 25% of defecations correlated with poor sleep. Conclusions Subjects with constipation and poor sleep experienced severe symptoms and had poor QOL. These data support the need for a multifocal treatment approach, including lifestyle advice and pharmacotherapy.
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Affiliation(s)
- Sayuri Yamamoto
- Division of Gastroenterology, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Aichi, Japan
| | - Yurika Kawamura
- Division of Gastroenterology, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Aichi, Japan
| | - Kazuhiro Yamamoto
- Division of Gastroenterology, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Aichi, Japan
| | - Yoshiharu Yamaguchi
- Division of Gastroenterology, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Aichi, Japan
| | - Yasuhiro Tamura
- Division of Gastroenterology, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Aichi, Japan
| | - Shinya Izawa
- Division of Gastroenterology, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Aichi, Japan
| | - Hiroaki Nakagawa
- Division of General Medicine, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Aichi, Japan
| | - Yoshinori Wakita
- Division of General Medicine, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Aichi, Japan
| | - Yasutaka Hijikata
- Division of Gastroenterology, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Aichi, Japan
| | - Masahide Ebi
- Division of Gastroenterology, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Aichi, Japan
| | - Yasushi Funaki
- Division of Gastroenterology, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Aichi, Japan
| | - Wataru Ohashi
- Division of Biostatistics, Clinical Research Center, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Aichi, Japan
| | - Naotaka Ogasawara
- Division of Gastroenterology, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Aichi, Japan
| | - Makoto Sasaki
- Division of Gastroenterology, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Aichi, Japan
| | - Masato Maekawa
- Division of General Medicine, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Aichi, Japan
| | - Kunio Kasugai
- Division of Gastroenterology, Aichi Medical University School of Medicine, Yazakokarimata, Nagakute, Aichi, Japan
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Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for the Discontinuation of Long-Term Benzodiazepine Use in Insomnia and Anxiety Disorders. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910222. [PMID: 34639523 PMCID: PMC8508349 DOI: 10.3390/ijerph181910222] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/15/2021] [Accepted: 09/23/2021] [Indexed: 01/23/2023]
Abstract
Benzodiazepines have proven to be highly effective for treating insomnia and anxiety. Although considered safe when taken for a short period of time, a major risk–benefit dilemma arises in the context of long-term use, relating to addiction, withdrawal symptoms, and potential side effects. For these reasons, benzodiazepines are not recommended for treating chronic sleep disorders, anxiety disorders, nor for people over the age of 65, and withdrawal among long-term users is a public health issue. Indeed, only 5% of patients manage to discontinue using these drugs on their own. Even with the help of a general practitioner, this rate does not exceed 25 to 30% of patients, of which approximately 7% manage to remain drug-free in the long term. Cognitive Behavioral Therapies (CBT) offer a crucial solution to this problem, having been shown to increase abstinence success to 70–80%. This article examines traditional and novel CBT techniques in this regard, such as Acceptance and Commitment Therapy, which address both the underlying condition (insomnia/anxiety) and the substance-related disorder. The theoretical framework and evidence supporting the use of these approaches are reviewed. Finally, current research gaps are discussed, and key research perspectives are proposed.
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Lonchampt S, Gerber F, Aubry JM, Desmeules J, Kosel M, Besson M. Prevalence of Polypharmacy and Inappropriate Medication in Adults With Intellectual Disabilities in a Hospital Setting in Switzerland. Front Psychiatry 2021; 12:614825. [PMID: 34248693 PMCID: PMC8267250 DOI: 10.3389/fpsyt.2021.614825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/18/2021] [Indexed: 01/06/2023] Open
Abstract
Background: Polypharmacy and inappropriate prescription are frequent in vulnerable and multi-morbid populations. Adults with intellectual disability (ID) are at risk of being polymedicated because they often present with multiple comorbidities and challenging behaviors. Aim: The objective of this study was thus to evaluate the prevalence of potentially inappropriate medications (PIM) and polypharmacy in a hospital unit dedicated to adults with ID. Methods: A 10-month prospective observational study took place at a hospital unit specializing in the care of adults with ID in Geneva, Switzerland. Once a week, health and prescription data were collected and screened for PIM according to preset definitions. Results: Fourteen patients consented to participate, leading to 20 hospitalization events assessed during the study. Hospitalizations lasted 12.8 weeks on average. ID severities ranged from mild to profound, all degrees of severity being equally represented. One hundred percent of the patients were polymedicated (defined as five drugs or more prescribed simultaneously). A mean number of 9.4 drugs were prescribed per week, including 5.3 psychotropic drugs. The number of prescribed drugs remained stable throughout the hospitalizations. Antipsychotics were the most prescribed drug class (19% of all prescribed drugs), followed by benzodiazepines (13%) and laxatives (12%). A total of 114 PIM were recorded with an average of 5.7 PIM per hospitalization. Conclusions: This study showed that polypharmacy and inappropriate prescription are very common in adults with ID, even though the literature and expert positions advocate for deprescription in these patients. Specific prescribing and deprescribing guidelines are needed for that specific population.
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Affiliation(s)
- Sophie Lonchampt
- Psychopharmacology Unit, Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Intensive Care, Pharmacology and Emergency, Geneva University Hospitals, Geneva, Switzerland
- Unit for Treatment and Assessment of In and Out Patients With Learning Disabilities and Autism Spectrum Disorders, Division of Psychiatric Specialties, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Science, School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Fabienne Gerber
- Unit for Treatment and Assessment of In and Out Patients With Learning Disabilities and Autism Spectrum Disorders, Division of Psychiatric Specialties, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland
| | - Jean-Michel Aubry
- Division of Psychiatric Specialties, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland
| | - Jules Desmeules
- Faculty of Science, School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Intensive Care and Pharmacology, Geneva University Hospitals, Geneva, Switzerland
| | - Markus Kosel
- Unit for Treatment and Assessment of In and Out Patients With Learning Disabilities and Autism Spectrum Disorders, Division of Psychiatric Specialties, Department of Psychiatry, Geneva University Hospitals, Geneva, Switzerland
| | - Marie Besson
- Psychopharmacology Unit, Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Intensive Care, Pharmacology and Emergency, Geneva University Hospitals, Geneva, Switzerland
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Ma G, Sun L, Qie Z, He J, Cui F. Factors Associated with Benzodiazepines Prolonged-Term Use in Post-Stroke Subjective Sleep Disturbance: A Single-Centre Retrospective Study from China. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:2469-2481. [PMID: 34135574 PMCID: PMC8200158 DOI: 10.2147/dddt.s298552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 05/25/2021] [Indexed: 01/01/2023]
Abstract
Purpose To investigate the prevalence of short- and long-term benzodiazepine and z-drugs (BZD) for the treatment of post-stroke subjective sleep disturbance (SSD) and to evaluate the risk factors associated with prolonged BZD treatment in this patient body. Patients and Methods Between 1st January 2018 and 1st December 2018, we identified 542 inpatients suffering from acute stroke in Heyuan People’s Hospital. Of these, 290 inpatients were included in our final analysis. These patients were divided into three groups according to the treatment they received: non/occasional BZD (non-BZD), short-term BZD (short-term) and prolonged-term BZD (prolonged-term) treatment. We investigated the prevalence of each BZD treatment term and identified differences between the groups. Univariate logistic regression analysis was used to identify potential predictors for the prolonged use of BZD. Multinomial logistic regression analysis was used to assess the correlation between the prolonged use of BZD and potential predictors. Results The prevalence of cases receiving short and prolonged BZD treatments were 40.35% and 31.72%, respectively; none of the patients received polysomnography (PSG) screening from obstructive sleep apnoea (OSP). Treatment strategies were limited to BZD and traditional Chinese medicine; none of the patients received cognitive-behavioral treatment (CBT) or other forms of treatment. Logistic regression analysis showed that the short-term use was associated with z-drugs (odds ratio [OR]: 2.189, 95% confidence interval [CI]: 1.419–3.378), non-communication barriers (OR =0.535, 95% CI: 0.325–0.880) and posterior circulation infarct (POCI) (OR =2.199, 95% CI: 1.112–4.349). The prolonged-term use was associated with z-drugs (OR =3.012, 95% CI: 1.637–5.542), non-communication barriers (OR =0.530, 95% CI: 0.307–0.916), partial anterior circulation infarct (PACI) (OR =0.455, 95% CI: 0.250–0.827), and non pain after stroke (OR =0.315, 95% CI: 0.207–0.480). Conclusion The status of BZD abuse for post-stroke SSD is worrying. Additional research attention and treatment options are needed for the treatment of post-stroke SSD. In particular, the potential combination of stroke and OSP appears to be underestimated and neglected. Post-stroke SSD patients should receive more comprehensive assessment and rigid follow-up to avoid the prolonged use of BZD. Additional and effective therapeutic strategies (such as positive pressure ventilation treatment or CBT) are urgently needed for cause-specific intervention.
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Affiliation(s)
- Guozhong Ma
- Department of Neurology, Heyuan People's Hospital, Heyuan, Guangdong Province, 517000, People's Republic of China
| | - Liuqing Sun
- Department of Neurology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, Hainan Province, 572013, People's Republic of China
| | - Zhiwei Qie
- Beijing Institute of Radiation Medicine, Beijing, 100850, People's Republic of China
| | - Jinzhao He
- Department of Neurology, Heyuan People's Hospital, Heyuan, Guangdong Province, 517000, People's Republic of China
| | - Fang Cui
- Department of Neurology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, Hainan Province, 572013, People's Republic of China
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Mansueto G, Lugoboni F, Casari R, Bertoldi A, Cosci F. Mono- and poly-therapy with benzodiazepines or Z-drugs: Results from a tertiary-care Addiction Unit study. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2021; 32:295-320. [PMID: 34120917 DOI: 10.3233/jrs-210014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Using benzodiazepines (BZDs) or Z-drugs in poly-therapy is a critical issue. OBJECTIVE Identifying factors influencing the use of BZDs/Z-drugs in poly- vs mono-therapy in patients with or without substance use disorders (SUDs). METHODS 986 inpatients were analysed. Socio-demographic and clinical variables were collected. BZD/Z-drug doses were compared via the Defined Daily Dose (DDD) and standardized as diazepam dose equivalents. Mann-Whitney, Chi-square, Fisher test, hierarchical multivariate regression analyses were run referring to the whole sample and to subjects with current SUDs, lifetime SUDs, current and lifetime SUDs, non-SUDs. RESULTS In the whole sample the variance of being mono- vs poly-therapy users was explained by BZD/Z-drug formulation, DDD, duration of treatment, age of first BZDs/Z-drugs use (ΔR2 = 0.141, p < 0.001). Among those with current SUDs (ΔR2 = 0.278, p = 0.332) or current and lifetime SUDs (ΔR2 = 0.154, p = 0.419), no variables explained the variance of being mono-vs poly-therapy users. Among lifetime SUDs subjects, the variance of being mono- vs poly-therapy users was explained by BZD/Z-drug formulation and age of first BZD/Z-drug use (ΔR2 = 0.275, p < 0.001). Among non-SUDs subjects, the variance of being mono- vs poly-therapy users was explained by DDD and duration of treatment (ΔR2 = 0.162, p = 0.001). CONCLUSIONS Tablets, high drug doses, long duration of treatment, and early age of first use were more likely associated to poly- than mono-therapy. This suggests that patients have different clinical features and a pharmacological prescription should be tailored to them also based on the variables here analysed.
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Affiliation(s)
- Giovanni Mansueto
- Department of Health Sciences, University of Florence, Florence, Italy.,Clinical Pharmacopsychology Laboratory, University of Florence, Florence, Italy.,Department of Psychology, Sigmund Freud University, Milan, Italy
| | - Fabio Lugoboni
- Addiction Medicine Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Rebecca Casari
- Addiction Medicine Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Anna Bertoldi
- Addiction Medicine Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Fiammetta Cosci
- Department of Health Sciences, University of Florence, Florence, Italy.,Clinical Pharmacopsychology Laboratory, University of Florence, Florence, Italy.,Department of Psychiatry & Psychology, School for Mental Health & Neuroscience, Maastricht University, Maastricht, The Netherlands
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16
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Inoue Y, Watanabe T, Takashima S, Takase T, Ishikawa K, Kubota N, Yardley J, Moline M. Efficacy and safety of lemborexant in adults with insomnia: comparing Japanese and non-Japanese subgroups from the global, phase 3, randomized, double-blind, placebo-controlled SUNRISE 2 study. J Clin Sleep Med 2021; 17:1067-1074. [PMID: 33576735 DOI: 10.5664/jcsm.9148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVE Whether there are racial differences in the efficacy/safety of hypnotics has not been sufficiently investigated. We aimed to evaluate the efficacy/safety of lemborexant 5 mg and lemborexant 10 mg vs placebo once daily in a subset of Japanese patients with insomnia and to compare the results with those of non-Japanese patients. METHODS This subanalysis reports the results of the first 6 months (period 1, placebo-controlled) of SUNRISE 2, a 12-month, global, randomized, double-blind, phase 3 study. Changes in patient-reported sleep onset latency, patient-reported sleep efficiency, and patient-reported wake after sleep onset with lemborexant 5 mg or lemborexant 10 mg vs placebo were evaluated. Treatment-emergent adverse events were evaluated for safety. RESULTS In total, 949 patients were randomized (Japanese, n = 161; non-Japanese, n = 788). Groups were balanced at baseline except for the male/female ratio (P = .0002) and body mass index (P < .0001) in the Japanese vs non-Japanese subgroups. Overall, the efficacy and safety of lemborexant were similar between subgroups. In the Japanese subgroup, the subjective sleep onset latency change from baseline was significant after 7 nights and 6 months with lemborexant 10 mg vs placebo, the subjective sleep efficiency change from baseline was significant after 7 nights with lemborexant 10 mg vs placebo, and the subjective wake after sleep onset change from baseline was significant at 6 months with lemborexant 5 mg vs placebo. The incidence and severity of treatment-emergent adverse events were consistent between both subgroups. CONCLUSIONS Lemborexant 5 mg and 10 mg improved sleep onset and sleep maintenance over 6 months and was well-tolerated in both the Japanese and non-Japanese patients. The safety profiles of lemborexant 5 mg and 10 mg were consistent between the subgroups. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Long-term Study of Lemborexant in Insomnia Disorder (SUNRISE 2); URL: https://clinicaltrials.gov/ct2/show/NCT02952820; Identifier: NCT02952820; and Registry: ClinicalTrialsRegister.eu; Identifier: 2015-001463-39.
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Affiliation(s)
- Yuichi Inoue
- Department of Somnology, Tokyo Medical University, Tokyo, Japan
| | | | | | | | | | | | - Jane Yardley
- Eisai Ltd., Hatfield, Hertfordshire, United Kingdom
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The prevalence and prescribing patterns of benzodiazepines and Z-drugs in older nursing home residents in different European countries and Israel: retrospective results from the EU SHELTER study. BMC Geriatr 2021; 21:277. [PMID: 33902474 PMCID: PMC8077828 DOI: 10.1186/s12877-021-02213-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 04/06/2021] [Indexed: 11/11/2022] Open
Abstract
Background Benzodiazepines (BZDs) and Z-drugs have high potential for developing frequent adverse drug events in older adults (e.g., psychomotor sedation, drug-related dementia, deliria, drug dependence, etc.). Knowledge of the prevalence and patterns of the use of BZDs/Z-drugs in vulnerable older patients is important in order to prevent and reduce the burden caused by their drug-related complications. Our study focused on international comparisons of the prevalence, country-specific prescribing patterns and risk factors of regular BZD/Z-drug use in nursing home (NH) residents. Methods This cross-sectional study retrospectively analysed data of 4156 NH residents, prospectively assessed in the Services and Health in the Elderly in Long TERm care (SHELTER) project conducted from 2009 to 2014. Residents aged 65+ in 57 NHs in 7 European countries and Israel were assessed by the InterRAI Long-Term Care Facilities instrument. Descriptive statistics and multiple logistic regression models were used to describe the country-specific prevalence, patterns and risk factors of BZD/Z-drug use. Results The mean age of the participants was 83.4 ± 9.4 years, 73% were female and 27.7% used BZDs/Z-drugs. The prevalence of BZD/Z-drug use differed significantly across countries, ranging from 44.1% in Israel to 14.5% in Germany. The most frequently prescribed were zopiclone (17.8%), lorazepam (17.1%) and oxazepam (16.3%). Lorazepam, oxazepam and diazepam were used in most of the countries. Brotizolam, temazepam and zolpidem showed highest prevalence in Israel (99.4% of all regular users of this medication in the sample), the Netherlands (72.6%) and France (50.0%), respectively. Residing in Israel was the most significant factor associated with the use of BZDs/Z-drugs or BZDs only (odds ratio [OR] 6.7; 95% confidence interval [CI] 4.8–9.2 and OR 9.7, 95%CI 6.5–14.5, respectively). The use of Z-drugs only was most significantly associated with residing in France (OR 21.0, 95%CI 9.0–48.9). Conclusions Despite global recommendations and warnings, the preference for and extent of use of individual BZDs and Z-drugs in vulnerable NH residents differ significantly across countries. The strong association with country of residence compared to clinical and functional factors denotes that prescribing habits, social, cultural, behavioural, and regulatory factors still play an important role in the current diverse use of these medications. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02213-x.
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18
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Hashimoto K, Takeuchi T, Koyama A, Hiiragi M, Suka S, Hashizume M. Effect of relaxation therapy on benzodiazepine use in patients with medically unexplained symptoms. Biopsychosoc Med 2020; 14:13. [PMID: 32670396 PMCID: PMC7346372 DOI: 10.1186/s13030-020-00187-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 07/03/2020] [Indexed: 12/31/2022] Open
Abstract
Background The change in the benzodiazepine (BZD) use of patients with medically unexplained symptoms (MUS) following the application of relaxation therapy were examined. Methods Of the 221 outpatients with MUS using BZD, 42 received relaxation therapy. Change in BZD use was compared using a relaxation group (n = 42) and a control group that had 84 MUS patients whose baseline was matched by optimal matching algorithms. Logistic regression analysis was done to evaluate the effect of BZD-dependent factors on the BZD dose of the relaxation group. Results Compared with the control group, the number of patients who decreased the amount of BZD and the number of patients whose subjective symptoms of MUS improved were significantly higher in the relaxation group (p < 0.05). In addition, a factor that made it difficult to reduce the BZD of MUS patients who had undergone relaxation was a long history of BZD use, for more than 6 months (odds ratio, 0.06, 95% confidence interval, 0.01–0.36). Conclusions Relaxation therapy for patients with MUS may help reduce BZD use; however, early intervention is important to prevent BZD dependence.
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Affiliation(s)
- Kazuaki Hashimoto
- Department of Psychosomatic Medicine, Toho University Graduate School of Medicine, 5-21-16 Omori-Nishi, Ota-ku, Tokyo, 143-8540 Japan
| | - Takeaki Takeuchi
- Department of Psychosomatic Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Akiko Koyama
- Department of Psychosomatic Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Miki Hiiragi
- Department of Psychosomatic Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Shunsuke Suka
- Department of Psychosomatic Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Masahiro Hashizume
- Department of Psychosomatic Medicine, Toho University Graduate School of Medicine, 5-21-16 Omori-Nishi, Ota-ku, Tokyo, 143-8540 Japan
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Wise T, Patrick F, Meyer N, Mazibuko N, Oates AE, van der Bijl AH, Danjou P, O’Connor SM, Doolin E, Wooldridge C, Rathjen D, Macare C, Williams SC, Perkins A, Young AH. Cholinergic Modulation of Disorder-Relevant Neural Circuits in Generalized Anxiety Disorder. Biol Psychiatry 2020; 87:908-915. [PMID: 32107005 PMCID: PMC7198974 DOI: 10.1016/j.biopsych.2019.12.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 11/25/2019] [Accepted: 12/11/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Generalized anxiety disorder is associated with hyperactivity in the amygdala-prefrontal networks, and normalization of this aberrant function is thought to be critical for successful treatment. Preclinical evidence implicates cholinergic neurotransmission in the function of these systems and suggests that cholinergic modulation may have anxiolytic effects. However, the effects of cholinergic modulators on the function of anxiety-related networks in humans have not been investigated. METHODS We administered a novel α7 nicotinic acetylcholine receptor-negative allosteric modulator, BNC210, to 24 individuals (3 male subjects) with generalized anxiety disorder and assessed its effects on neural responses to fearful face stimuli. RESULTS BNC210 reduced amygdala reactivity to fearful faces relative to placebo and similarly to lorazepam and also reduced connectivity between the amygdala and the anterior cingulate cortex, a network involved in regulating anxious responses to aversive stimuli. CONCLUSIONS These results demonstrate for the first time that the function of disorder-relevant neural circuits in generalized anxiety disorder can be beneficially altered through modulation of cholinergic neurotransmission and suggest potential for this system as a novel target for anxiolytic pharmacotherapy.
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Affiliation(s)
- Toby Wise
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Wellcome Trust Centre for Neuroimaging, University College London, London, UK; Max Planck UCL Centre for Computational Psychiatry and Ageing Research, London, UK; Department of Humanities and Social Sciences, California Institute of Technology, Pasadena, California.
| | - Fiona Patrick
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK,Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Nicholas Meyer
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Ndaba Mazibuko
- Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | | | | | | | | | | | - Caroline Wooldridge
- Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | | | - Christine Macare
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Steven C.R. Williams
- Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK,National Institute for Health Research Biomedical Research Centre, South London, London, UK
| | - Adam Perkins
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK,National Institute for Health Research Biomedical Research Centre, South London, London, UK
| | - Allan H. Young
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK,National Institute for Health Research Biomedical Research Centre, South London, London, UK
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20
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Tamburin S, Mantovani E, Bertoldi A, Federico A, Casari R, Lugoboni F. High-Dose Dependence and Cognitive Side Effects to Medical Prescription of Etizolam. Front Psychiatry 2020; 11:601827. [PMID: 33329156 PMCID: PMC7671959 DOI: 10.3389/fpsyt.2020.601827] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/12/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction: The use of novel designer drugs has increased worldwide over the years. Etizolam is a designer benzodiazepine (BZD) that has raised concern because of its growing non-medical use, liability to tolerance and dependence, and related harms. Studies exploring the abuse liability and cognitive effects of etizolam outside the therapeutic doses are lacking. Aims: To explore the abuse liability of etizolam and the characteristics of patients affected by etizolam high-dose dependence in a nationwide tertiary referral addiction unit. To document the cognitive changes to etizolam high-dose use. Design and Methods: Sociodemographic and clinical data on subjects with etizolam high-dose use were retrospectively collected from a database of 1,293 patients consecutively admitted to the Addiction Medicine Unit, Verona University Hospital, Italy for detoxification from high-dose BZDs or Z-drugs dependence. Thorough neuropsychological testing explored the cognitive side effects of high-dose etizolam use. Results: We found eleven etizolam high-dose users, of which eight used etizolam only, and three used etizolam with other BZDs/zolpidem. All the patients were prescribed etizolam for medical reasons, i.e., anxiety and/or insomnia. Neuropsychological evaluation showed deficits of working memory, visuospatial memory and executive function in a 27-year-old woman who used etizolam 15 mg daily. Discussion: Our findings suggest that abuse and dependence liability of etizolam should be considered a public health and social problem. They offer preliminary evidence on the cognitive side effects of etizolam high-dose use. Conclusions: This report offers new information on the potential harms of etizolam in patients who are prescribed this drug for medical reasons.
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Affiliation(s)
- Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Elisa Mantovani
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Anna Bertoldi
- Addiction Medicine Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Angela Federico
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Rebecca Casari
- Addiction Medicine Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Fabio Lugoboni
- Addiction Medicine Unit, Department of Medicine, Verona University Hospital, Verona, Italy
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21
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Heinemann S, Neukirchen F, Nau R, Hummers E, Himmel W. Patient-reported factors associated with the desire to continue taking sleep-inducing drugs after hospital discharge: A survey of older adults. Pharmacoepidemiol Drug Saf 2019; 28:1014-1022. [PMID: 31179613 PMCID: PMC6618328 DOI: 10.1002/pds.4806] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/26/2019] [Accepted: 04/27/2019] [Indexed: 11/08/2022]
Abstract
Purpose To find out whether any prior experiences with sleep‐inducing drugs before hospitalization and positive experiences with these drugs during hospitalization influence a patient's wish to continue taking sleep‐inducing drugs after hospitalization. Methods We surveyed older hospital patients about use of sleep‐inducing drugs before, during, and after hospitalization and compared these answers with their hospital chart using the kappa statistic. The association between the wish to continue these drugs after discharge and the perceived benefits, experience of side effects, and prior experience with sleep‐inducing drugs was determined by multivariable logistic regression. Results Agreement between patient responses and the hospital file was high (κ = 0.7). Seventeen percent (83/483) of the participants reported prior experience before their hospital stay; 45% received a sleep‐inducing drug during hospitalization; 17% wished to continue taking them after discharge. Of the 400 patients who had no prior experience with sleep‐inducing drugs, 147 (37%) became first‐time users in the hospital, and 27% (40/147) of these wished to continue this medication after discharged. Strong predictors for this wish were the reduction of sleep onset problems (adjusted odds ratio, 6.26; 95% confidence interval, 2.38‐16.44) and any prior experience with sleep‐inducing drugs (4.08; 1.97‐8.48). Conclusions Many older patients become first‐time users of sleep‐inducing drugs in the hospital. Especially the experience of sleep onset improvements influences the wish to continue sleep‐inducing drug use after discharge. Avoiding first‐time use should become a goal of hospital policy and be taken into account when weighing the benefits and risks of sleep‐inducing drugs.
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Affiliation(s)
- Stephanie Heinemann
- Department of General Practice, University Medical Center, Göttingen, Germany
| | - Freya Neukirchen
- Department of General Practice, University Medical Center, Göttingen, Germany
| | - Roland Nau
- Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany.,Institute of Neuropathology, University Medical Center, Göttingen, Germany
| | - Eva Hummers
- Department of General Practice, University Medical Center, Göttingen, Germany
| | - Wolfgang Himmel
- Department of General Practice, University Medical Center, Göttingen, Germany
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22
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Using benzodiazepines and Z-drugs for managing primary insomnia in adults in Saudi Arabia: an e-Delphi study to aid the development of clinical guidelines. Sleep Breath 2019; 23:1133-1139. [PMID: 30729406 PMCID: PMC6867977 DOI: 10.1007/s11325-019-01794-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 01/13/2019] [Accepted: 01/26/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE This study aims to obtain consensus statements required for the development of clinical guidelines for the use of benzodiazepines (BZDs) and Z-drugs for the management of primary insomnia in adults in Saudi Arabia. METHODS Three rounds of the e-Delphi technique using a Bristol Online Survey (BOS) were conducted between May and August 2018. The Director of the Saudi Sleep Medicine Group helped recruit the country's sleep medicine experts. Snowballing was used to forward invitation emails, information sheets, and the survey to known sleep medicine experts and physicians deemed to be interested in the field. All participants' details were anonymised except to the researcher. RESULTS Fifteen experts from four different regions and specialities in Saudi Arabia participated in Round 1. Twenty-one statements originated from participants' responses. In Round 2, there were 17 respondents and 16 of the statements obtained the required consensus of 70% or higher. Eleven experts participated in Round 3 and eight statements received 100% agreement, two received 91%, and six received 82%. Having obtained the required consensus of 80% or higher in Round 3, these 16 statements fulfilled the criteria to be included in future guidelines. The five statements that failed to attain the required consensus were rejected as inappropriate for inclusion in Saudi Arabian clinical guidelines. CONCLUSIONS The items that achieved the required consensus can be included in future guidelines for the use of BZDs and Z-drugs in the treatment of primary insomnia in adults to standardize best practices in sleep medicine in Saudi Arabia.
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23
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Mendelevich VD. Addictophobia in modern psychiatry (benzodiazepines and other psychopharmacological drugs). Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:75-81. [DOI: 10.17116/jnevro20191191275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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24
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Madruga CS, Paim TL, Palhares HN, Miguel AC, Massaro LTS, Caetano R, Laranjeira RR. Prevalence of and pathways to benzodiazepine use in Brazil: the role of depression, sleep, and sedentary lifestyle. ACTA ACUST UNITED AC 2018; 41:44-50. [PMID: 30328968 PMCID: PMC6781701 DOI: 10.1590/1516-4446-2018-0088] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 04/12/2018] [Indexed: 12/21/2022]
Abstract
Objective: This study aimed to determine the prevalence of benzodiazepine (BZD) use in Brazil and to investigate the direct and indirect effects of alcohol consumption, sedentary lifestyle (SL), depressive symptoms (DS), and sleep dissatisfaction (SD) on BZD use. Methods: The Second Brazilian Alcohol and Drugs Survey (II BNADS) used stratified cluster probabilistic sampling to select 4,607 individuals aged 14 years and older from the Brazilian household population. Results: The lifetime and 12-month prevalence of BZD use was 9.8 and 6.1%, respectively. Older participants (age 40 and older) and women had higher rates. Alcohol use disorder, DS, and SD were significantly more prevalent in BZD users. The parallel multiple mediator model showed a positive direct effect of alcohol consumption on BZD use, with significant positive indirect effects of SL, SD, and DS as simultaneous mediators leading to higher BZD intake. Other statistically significant indirect pathways were DS alone, SD alone, and all of the above except SL. Conclusion: The prevalence of BZD use in Brazil is high compared to that of other countries. Knowledge of the main risk factors and pathways to consumption can guide prevention initiatives and underlie the development of better tailored and effective treatment strategies.
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Affiliation(s)
- Clarice S Madruga
- Instituto Nacional de Ciência e Tecnologia para Políticas Públicas do Álcool e Outras Drogas (INPAD), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.,Departamento de Psiquiatria, UNIFESP, São Paulo, SP, Brazil
| | - Thales L Paim
- Instituto Nacional de Ciência e Tecnologia para Políticas Públicas do Álcool e Outras Drogas (INPAD), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.,Departamento de Psiquiatria, UNIFESP, São Paulo, SP, Brazil
| | - Hamer N Palhares
- Instituto Nacional de Ciência e Tecnologia para Políticas Públicas do Álcool e Outras Drogas (INPAD), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Andre C Miguel
- Instituto Nacional de Ciência e Tecnologia para Políticas Públicas do Álcool e Outras Drogas (INPAD), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.,Departamento de Psiquiatria, UNIFESP, São Paulo, SP, Brazil
| | - Luciana T S Massaro
- Instituto Nacional de Ciência e Tecnologia para Políticas Públicas do Álcool e Outras Drogas (INPAD), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.,Departamento de Psiquiatria, UNIFESP, São Paulo, SP, Brazil
| | | | - Ronaldo R Laranjeira
- Instituto Nacional de Ciência e Tecnologia para Políticas Públicas do Álcool e Outras Drogas (INPAD), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.,Departamento de Psiquiatria, UNIFESP, São Paulo, SP, Brazil
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25
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The interplay of context factors in hypnotic and sedative prescription in primary and secondary care-a qualitative study. Eur J Clin Pharmacol 2018; 75:87-97. [PMID: 30215101 PMCID: PMC6326988 DOI: 10.1007/s00228-018-2555-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 09/03/2018] [Indexed: 11/18/2022]
Abstract
Purpose Non-medical or contextual factors strongly influence physicians’ prescribing behavior and may explain why drugs, such as benzodiazepines and Z-drugs, are still frequently prescribed in spite of well-known adverse effects. This study aimed to explore which contextual factors influence the prescription of hypnotics and sedatives and to compare their role in primary and secondary care. Methods Understanding medical practices as games with specific rules and strategies and performed in a largely habitual, not fully conscious manner, we asked a maximum variation sample of 12 hospital doctors and 12 general practitioners (GPs) about their use of hypnotics and sedatives. The interviews were analyzed by qualitative content analysis. Results Hospital doctors’ and GPs’ use of hypnotics and sedatives was influenced by a variety of contextual factors, such as the demand of different patient groups, aims of management, time resources, or the role of nurses and peers. Negotiating patient demands, complying with administrative regulations, and finding acceptable solutions for patients were the main challenges, which characterized the game of drug use in primary care. Maintaining the workflow in the hospital and finding a way to satisfy both nurses and patients were the main challenges in secondary care. Conclusions Even if doctors try to act rationally, they cannot escape the interplay of contextual factors such as handling patient needs, complying with administrative regulations, and managing time resources. Doctors should balance these factors as if they were challenges in a complex game and reflect upon their own practices. Electronic supplementary material The online version of this article (10.1007/s00228-018-2555-9) contains supplementary material, which is available to authorized users.
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26
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Pinyopornpanish K, Jiraporncharoen W, Thaikla K, Yoonut K, Angkurawaranon C. Sedative and Analgesic Drugs Online: A Content Analysis of the Supply and Demand Information Available in Thailand. Subst Use Misuse 2018; 53:641-647. [PMID: 28910188 DOI: 10.1080/10826084.2017.1355386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Evidence from other countries has suggested that many controlled drugs are also offered online, even though it is illegal to sell these drugs without a license. OBJECTIVES To evaluate the current contents related to the supply and demand of sedatives and analgesic drugs available online in Thailand, with a particular focus on Facebook. METHODS A team of reviewers manually searched for data by entering keywords related to analgesic drugs and sedatives. The contents of the website were screened for supply and demand-related information. FINDINGS A total of 5,352 websites were found publicly available. The number of websites and Facebook pages containing the information potentially related to the supply and demand of analgesic drugs and sedatives was limited. Nine websites sold sedatives, and six websites sold analgesics directly. Fourteen Facebook pages were found, including 7 sedative pages and 7 analgesic pages. Within one year, the three remaining active pages multiplied in the number of followers by three- to nine-fold. The most popular Facebook page had over 2,900 followers. CONCLUSIONS Both the internet and social media contain sites and pages where sedatives and analgesics are illegally advertised. These websites are searchable through common search engines. Although the number of websites is limited, the number of followers on these Facebook pages does suggest a growing number of people who are interested in such pages. Our study emphasized the importance of monitoring and developing potential plans relative to the online marketing of prescription drugs in Thailand.
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Affiliation(s)
- Kanokporn Pinyopornpanish
- a Department of Family Medicine, Faculty of Medicine , Chiang Mai University , Sriphum, Muang, Chiang Mai , Thailand
| | - Wichuda Jiraporncharoen
- a Department of Family Medicine, Faculty of Medicine , Chiang Mai University , Sriphum, Muang, Chiang Mai , Thailand
| | - Kanittha Thaikla
- b Drug Abuse Research Unit, Research Institute for Health Science , Chiang Mai University , Sriphum, Muang, Chiang Mai , Thailand
| | - Kulyapa Yoonut
- a Department of Family Medicine, Faculty of Medicine , Chiang Mai University , Sriphum, Muang, Chiang Mai , Thailand
| | - Chaisiri Angkurawaranon
- a Department of Family Medicine, Faculty of Medicine , Chiang Mai University , Sriphum, Muang, Chiang Mai , Thailand
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27
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Yu X, Franks NP, Wisden W. Sleep and Sedative States Induced by Targeting the Histamine and Noradrenergic Systems. Front Neural Circuits 2018; 12:4. [PMID: 29434539 PMCID: PMC5790777 DOI: 10.3389/fncir.2018.00004] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 01/11/2018] [Indexed: 01/07/2023] Open
Abstract
Sedatives target just a handful of receptors and ion channels. But we have no satisfying explanation for how activating these receptors produces sedation. In particular, do sedatives act at restricted brain locations and circuitries or more widely? Two prominent sedative drugs in clinical use are zolpidem, a GABAA receptor positive allosteric modulator, and dexmedetomidine (DEX), a selective α2 adrenergic receptor agonist. By targeting hypothalamic neuromodulatory systems both drugs induce a sleep-like state, but in different ways: zolpidem primarily reduces the latency to NREM sleep, and is a controlled substance taken by many people to help them sleep; DEX produces prominent slow wave activity in the electroencephalogram (EEG) resembling stage 2 NREM sleep, but with complications of hypothermia and lowered blood pressure—it is used for long term sedation in hospital intensive care units—under DEX-induced sedation patients are arousable and responsive, and this drug reduces the risk of delirium. DEX, and another α2 adrenergic agonist xylazine, are also widely used in veterinary clinics to sedate animals. Here we review how these two different classes of sedatives, zolpidem and dexmedetomideine, can selectively interact with some nodal points of the circuitry that promote wakefulness allowing the transition to NREM sleep. Zolpidem enhances GABAergic transmission onto histamine neurons in the hypothalamic tuberomammillary nucleus (TMN) to hasten the transition to NREM sleep, and DEX interacts with neurons in the preoptic hypothalamic area that induce sleep and body cooling. This knowledge may aid the design of more precise acting sedatives, and at the same time, reveal more about the natural sleep-wake circuitry.
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Affiliation(s)
- Xiao Yu
- Department of Life Sciences, Imperial College London, London, United Kingdom
| | - Nicholas P Franks
- Department of Life Sciences, Imperial College London, London, United Kingdom.,Centre for Neurotechnology, Imperial College London, London, United Kingdom.,UK Dementia Research Institute, Imperial College London, London, United Kingdom
| | - William Wisden
- Department of Life Sciences, Imperial College London, London, United Kingdom.,Centre for Neurotechnology, Imperial College London, London, United Kingdom.,UK Dementia Research Institute, Imperial College London, London, United Kingdom
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van der Kooij MA, Hollis F, Lozano L, Zalachoras I, Abad S, Zanoletti O, Grosse J, Guillot de Suduiraut I, Canto C, Sandi C. Diazepam actions in the VTA enhance social dominance and mitochondrial function in the nucleus accumbens by activation of dopamine D1 receptors. Mol Psychiatry 2018; 23:569-578. [PMID: 28727688 PMCID: PMC5822450 DOI: 10.1038/mp.2017.135] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 05/10/2017] [Accepted: 05/15/2017] [Indexed: 01/07/2023]
Abstract
Benzodiazepines can ameliorate social disturbances and increase social competition, particularly in high-anxious individuals. However, the neural circuits and mechanisms underlying benzodiazepines' effects in social competition are not understood. Converging evidence points to the mesolimbic system as a potential site of action for at least some benzodiazepine-mediated effects. Furthermore, mitochondrial function in the nucleus accumbens (NAc) has been causally implicated in the link between anxiety and social competitiveness. Here, we show that diazepam facilitates social dominance, ameliorating both the competitive disadvantage and low NAc mitochondrial function displayed by high-anxious rats, and identify the ventral tegmental area (VTA) as a key site of action for direct diazepam effects. We also show that intra-VTA diazepam infusion increases accumbal dopamine and DOPAC, as well as activity of dopamine D1- but not D2-containing cells. In addition, intra-NAc infusion of a D1-, but not D2, receptor agonist facilitates social dominance and mitochondrial respiration. Conversely, intra-VTA diazepam actions on social dominance and NAc mitochondrial respiration are blocked by pharmacological NAc micro-infusion of a mitochondrial complex I inhibitor or an antagonist of D1 receptors. Our data support the view that diazepam disinhibits VTA dopaminergic neurons, leading to the release of dopamine into the NAc where activation of D1-signaling transiently facilitates mitochondrial function, that is, increased respiration and enhanced ATP levels, which ultimately enhances social competitive behavior. Therefore, our findings critically involve the mesolimbic system in the facilitating effects of diazepam on social competition and highlight mitochondrial function as a potential therapeutic target for anxiety-related social dysfunctions.
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Affiliation(s)
- M A van der Kooij
- Laboratory of Behavioral Genetics, Brain Mind Institute, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - F Hollis
- Laboratory of Behavioral Genetics, Brain Mind Institute, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - L Lozano
- Laboratory of Behavioral Genetics, Brain Mind Institute, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - I Zalachoras
- Laboratory of Behavioral Genetics, Brain Mind Institute, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - S Abad
- Laboratory of Behavioral Genetics, Brain Mind Institute, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - O Zanoletti
- Laboratory of Behavioral Genetics, Brain Mind Institute, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - J Grosse
- Laboratory of Behavioral Genetics, Brain Mind Institute, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - I Guillot de Suduiraut
- Laboratory of Behavioral Genetics, Brain Mind Institute, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - C Canto
- Nestlé Institute of Health Sciences SA, Lausanne, Switzerland
| | - C Sandi
- Laboratory of Behavioral Genetics, Brain Mind Institute, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland,Brain Mind Institute, École Polytechnique Fédérale de Lausanne (EPFL), Station 19, Lausanne CH-1015, Switzerland. E-mail:
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Jacob L, Rapp MA, Kostev K. Long-term use of benzodiazepines in older patients in Germany: a retrospective analysis. Ther Adv Psychopharmacol 2017; 7:191-200. [PMID: 28740636 PMCID: PMC5505440 DOI: 10.1177/2045125317696454] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The purpose of this study was to analyze the prevalence of long-term benzodiazepine use in older adults treated in general and neuropsychiatric practices in Germany. METHODS This study included 32,182 patients over the age of 65 years who received benzodiazepine prescriptions for the first time between January 2010 and December 2014 in general and neuropsychiatric practices in Germany. Follow up lasted until July 2016. The main outcome measure was the proportion of patients treated with benzodiazepines for >6 months. RESULTS The proportion of patients with benzodiazepine therapy for >6 months increased with age (65-70 years: 12.3%; 71-80 years: 15.5%; 81-90 years: 23.7%; >90 years: 31.6%) but did not differ significantly between men (15.5%) and women (17.1%). The proportion of patients who received benzodiazepines for >6 months was higher among those with sleep disorders (21.1%), depression (20.8%) and dementia (32.1%) than among those with anxiety (15.5%). By contrast, this proportion was lower among people diagnosed with adjustment disorders (7.7%) and back pain (3.8%). CONCLUSION Overall, long-term use of benzodiazepines is common in older people, particularly in patients over the age of 80 and in those diagnosed with dementia, sleep disorders, or depression.
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Affiliation(s)
- Louis Jacob
- Faculty of Medicine, University of Paris 5, Paris, France
| | - Michael A Rapp
- Department of Social and Preventive Medicine, University of Potsdam, Germany
| | - Karel Kostev
- Epidemiology, Real World Evidence Solutions, IMS Health, Darmstädter Landstraße 108, 60598 Frankfurt am Main, Germany
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30
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Loscertales HR, Wentzky V, Dürsteler K, Strasser J, Hersberger KE, Arnet I. Successful withdrawal from high-dose benzodiazepine in a young patient through electronic monitoring of polypharmacy: a case report in an ambulatory setting. Ther Adv Psychopharmacol 2017; 7:181-187. [PMID: 28540039 PMCID: PMC5431399 DOI: 10.1177/2045125317690502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 12/15/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Dependence on high-dose benzodiazepines (BZDs) is well known and discontinuation attempts are generally unsuccessful. A well established protocol for high-dose BZD withdrawal management is lacking. We present the case of withdrawal from high-dose lorazepam (>20 mg daily) in an unemployed 35-year-old male outpatient through agonist substitution with long-acting clonazepam and electronic monitoring over 28 weeks. METHODS All medicines were repacked into weekly 7 × 4 cavity multidose punch cards with an electronic monitoring system. The prescribed daily dosages of BZDs were translated into an optimal number of daily tablets, divided into up to four units of use. Withdrawal was achieved by individual leftover of a small quantity of BZDs that was placed in a separate compartment. Feedback with visualization of intake over the past week was given during weekly psychosocial sessions. RESULTS Stepwise reduction was obtained by reducing the mg content of the cavities proportionally to the leftovers, keeping the number of cavities in order to maintain regular intake behavior, and to determine the dosage decrease. At week 28, the primary objectives were achieved, that is, lorazepam reduction to 5 mg daily and cannabis abstinence. Therapy was continued using multidrug punch cards without electronic monitoring to maintain the management system. At week 48, a smaller size weekly pill organizer with detachable daily containers was dispensed. At week 68, the patient's therapy was constant with 1.5 mg clonazepam + 5 mg lorazepam daily for anxiety symptoms and the last steps of withdrawal were started. CONCLUSIONS Several key factors led to successful withdrawal from high-dose BZD in this outpatient, such as the use of weekly punch cards coupled with electronic monitoring, the patient's empowerment over the withdrawal process, and the collaboration of several healthcare professionals. The major implication for clinical care is reduction by following the leftovers, and not a diktat from the healthcare professionals.
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Affiliation(s)
- Hèctor R Loscertales
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Valerie Wentzky
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Kenneth Dürsteler
- Division of Addictive Disorders, University of Basel Psychiatric Clinics, Basel, Switzerland
| | - Johannes Strasser
- Division of Addictive Disorders, University of Basel Psychiatric Clinics, Basel, Switzerland
| | - Kurt E Hersberger
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Isabelle Arnet
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland
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31
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Wolf IK, Du Y, Knopf H. Changes in prevalence of psychotropic drug use and alcohol consumption among the elderly in Germany: results of two National Health Interview and Examination Surveys 1997-99 and 2008-11. BMC Psychiatry 2017; 17:90. [PMID: 28279159 PMCID: PMC5345233 DOI: 10.1186/s12888-017-1254-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 03/04/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Psychotropic drug use and alcohol consumption among older adults need to be monitored over time as their use or combined use bears risks of harms. Representative data on changes in prevalence, patterns and co-relates of substance use are lacking in Germany. METHODS Participants were older adults (60-79 years) from two German National Health Surveys: 1997-99 (GNHIES98, N = 1,606) and 2008-11 (DEGS1, N = 2,501). Included were drugs acting on the nervous system used during the last 7 days. Alcohol consumption was measured by frequency (daily drinking) and quantity (risky drinking: ≥20/10 g/day alcohol for men/women). Changes in prevalence adjusted for potential socio-economic and health-related confounders were calculated by logistic regression models approximated by the SAS LSMEANS statement. RESULTS The prevalence of overall psychotropic drug use (20.5% vs. 21.4%) remained constant between the two surveys. Significant changes were observed in the use of some psychotropics (all GNHIES98 vs. DEGS1): Synthetic antidepressants (3.9% vs. 6.9%), St. John's wort (2.9% vs. 1.1%), benzodiazepines (3.7% vs. 2.5%), benzodiazepine related drugs (0.2% vs. 0.8%), narcotic analgesics (3.0% vs. 4.1%), anti-dementia drugs (2.2% vs. 4.2%) and anti-epileptics (1.0% vs. 2.3%). Significant changes were also observed in long-term use of synthetic anti-depressants (3.2% vs. 5.9%), St. John's wort (2.0% vs. 0.6%) and opioid analgesics (1.0% vs. 2.2%). Further, we found significant changes in benzodiazepines use (3.3% vs. 1.4%) among men, opioids use (2.9% vs. 7.3%) among people with a lower social status, and overall psychotropics (26.8% vs. 32.5%) as well as opioids use (4.4% vs. 8.1%) among those with a worse health status. Moderate alcohol consumption increased significantly (58.0% vs. 66.9%). Risky drinking remained unchanged (16.6% vs. 17.0%). In spite of significant increases in daily alcohol drinking (13.2% vs. 18.4%) psychotropic drug use combined with daily drinking remained unchanged (1.8% vs. 2.7%). CONCLUSIONS Although prevalence of overall psychotropic drug use remained stable, changes in the use of some psychotropic drug groups and alcohol consumption patterns have been observed. Further studies are required to investigate resulting health consequences and public health relevance of those outcomes.
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Affiliation(s)
- Ingrid-Katharina Wolf
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, General-Pape-Str. 64-66, D-12101, Berlin, Germany.
| | - Yong Du
- 0000 0001 0940 3744grid.13652.33Department of Epidemiology and Health Monitoring, Robert Koch Institute, General-Pape-Str. 64-66, D-12101 Berlin, Germany
| | - Hildtraud Knopf
- 0000 0001 0940 3744grid.13652.33Department of Epidemiology and Health Monitoring, Robert Koch Institute, General-Pape-Str. 64-66, D-12101 Berlin, Germany
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Pohontsch NJ, Heser K, Löffler A, Haenisch B, Parker D, Luck T, Riedel-Heller SG, Maier W, Jessen F, Scherer M. General practitioners' views on (long-term) prescription and use of problematic and potentially inappropriate medication for oldest-old patients-A qualitative interview study with GPs (CIM-TRIAD study). BMC FAMILY PRACTICE 2017; 18:22. [PMID: 28212616 PMCID: PMC5395870 DOI: 10.1186/s12875-017-0595-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 01/26/2017] [Indexed: 12/13/2022]
Abstract
Background Potentially inappropriate medication (PIM) is defined as medication with uncertain therapeutic effects and/or potential adverse drug reactions outweighing the clinical benefits. The prescription rate of PIM for oldest-old patients is high despite the existence of lists of PIM (e.g. the PRISCUS list) and efforts to raise awareness. This study aims at identifying general practitioners’ views on PIM and aspects affecting the (long-term) use of PIM. Methods As part of the CIM-TRIAD study, we conducted semi-structured, qualitative interviews with 47 general practitioners, discussing 25 patients with and 22 without PIM (according to the PRISCUS list). The interview guideline included generic and patient-specific questions. Interviews were digitally recorded and transcribed verbatim. We content analyzed the interviews using deductive and inductive category development. Results The majority of the general practitioners were not aware of the PRISCUS list. Agents deemed potentially inappropriate from the general practitioners’ point of view and the PRISCUS list are not completely superimposable. General practitioners named their criteria to identify appropriate medication for elderly patients (e.g. renal function, cognitive state) and emphasized the importance of monitoring. We identified prescription- (e.g. benzodiazepines on alternative private prescription), medication- (e.g. subjective perception that PIM has no alternative), general practitioner- (e.g. general practitioner relies on specialists), patient- (e.g. “demanding high-user”, positive subjective benefit-risk-ratio) and system-related aspects (e.g. specialists lacking holistic view, interface problems) related to the (long term) use of PIM. Conclusions While the PRISCUS list does not seem to play a decisive role in general practice, general practitioners are well aware of risks associated with PIM. Our study identifies some starting points for a safer handling of PIM, e.g. stronger dissemination of the PRISCUS list, better compensation of medication reviews, “positive lists”, adequate patient information, multifaceted interventions and improved communication between general practitioners and specialists. Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0595-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nadine Janis Pohontsch
- Department of General Practice/Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Kathrin Heser
- Department of Psychiatry and Psychotherapy, University of Bonn, Sigmund-Freud-Straße 25, 53105, Bonn, Germany
| | - Antje Löffler
- Institute of Health, Brandenburg University of Technology, Großenhainer Straße 57, 01968, Senftenberg, Germany
| | - Britta Haenisch
- German Center for Neurodegenerative Diseases (DZNE), Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Germany
| | - Debora Parker
- German Center for Neurodegenerative Diseases (DZNE), Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Germany
| | - Tobias Luck
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany
| | - Steffi G Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany
| | - Wolfgang Maier
- Department of Psychiatry and Psychotherapy, University of Bonn, Sigmund-Freud-Straße 25, 53105, Bonn, Germany
| | - Frank Jessen
- German Center for Neurodegenerative Diseases (DZNE), Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Germany.,Clinic and polyclinic for psychiatry and psychotherapy, University Medical Center Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Martin Scherer
- Department of General Practice/Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Wolter DK. [Discontinuation of benzodiazepines in old age : When and if so, how?]. Z Gerontol Geriatr 2017; 50:115-122. [PMID: 28105500 DOI: 10.1007/s00391-016-1171-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/02/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022]
Abstract
Although viewed critically in geriatrics, benzodiazepine use is still common among old people. Before reducing the dosage the following questions must be considered: 1. Are there indications for benzodiazepine treatment and will discontinuation cause relevant rebound symptoms of the initial disorder treated? 2. To what extent do the patient and other key persons consider discontinuation to be reasonable and will they support discontinuation? 3. Is the target complete withdrawal, a dose reduction or shift to another benzodiazepine drug which is more suitable in old age for pharmacokinetic reasons? This article provides assistance in answering these questions and some guidelines for the practical management of discontinuation. It is mandatory 1) to periodically address the problem of long-term benzodiazepine use when counseling the patient and key persons and 2) to be aware that several intermediate steps exist between continuation and complete discontinuation, which may be considered successful treatment.
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Affiliation(s)
- Dirk K Wolter
- Gerontopsykiatrisk Afdeling, Psykiatrien, Kresten Philipsens Vej 15 B, 6200, Aabenraa, Dänemark.
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Heinemann S, Weiß V, Straube K, Nau R, Grimmsmann T, Himmel W, Hummers-Pradier E. Understanding and reducing the prescription of hypnotics and sedatives at the interface of hospital care and general practice: a protocol for a mixed-methods study. BMJ Open 2016; 6:e011908. [PMID: 27496238 PMCID: PMC4985818 DOI: 10.1136/bmjopen-2016-011908] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Hypnotics and sedatives, especially benzodiazepines and Z-drugs, are frequently prescribed for longer periods than recommended-in spite of potential risks for patients. Any intervention to improve this situation has to take into account the interplay between different actors, interests and needs. The ultimate goal of this study is to develop-together with the professionals involved-ideas for reducing the use of hypnotics and sedatives and then to implement and evaluate adequate interventions in the hospital and at the primary and secondary care interface. METHODS AND ANALYSIS The study will take place in a regional hospital in northern Germany and in some general practices in this region. We will collect data from doctors, nurses, patients and a major social health insurer to define the problem from multiple perspectives. These data will be explored and discussed with relevant stakeholders to develop interventions. The interventions will be implemented and, in a final step, evaluated. Both quantitative and qualitative data, including surveys, interviews, chart reviews and secondary analysis of social health insurance data, will be collected to obtain a full understanding of the frequency and the reasons for using hypnotics and sedatives. ETHICS AND DISSEMINATION Approval has been granted from the ethics review committee of the University Medical Center Göttingen, Germany. Results will be disseminated to researchers, clinicians and policy makers in peer-reviewed journal articles and conference publications. One or more dissemination events will be held locally during continuous professional development events for local professionals, including (but not confined to) the study participants.
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Affiliation(s)
- Stephanie Heinemann
- Department of General Practice, University Medical Center, Göttingen, Germany
- Department of Health Sciences, University of Applied Sciences, Fulda, Germany
| | - Vivien Weiß
- Department of General Practice, University Medical Center, Göttingen, Germany
| | - Kati Straube
- Department of General Practice, University Medical Center, Göttingen, Germany
- Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
| | - Roland Nau
- Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
| | - Thomas Grimmsmann
- German Health Insurance Medical Service (MDK) Mecklenburg-Vorpommern, Schwerin, Germany
| | - Wolfgang Himmel
- Department of General Practice, University Medical Center, Göttingen, Germany
| | - Eva Hummers-Pradier
- Department of General Practice, University Medical Center, Göttingen, Germany
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Reuther G. Severe Collateral Damage. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:603. [PMID: 26377535 PMCID: PMC4577671 DOI: 10.3238/arztebl.2015.0603a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Wolter DK. Additional Information to Increase Accuracy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:603. [PMID: 26377536 PMCID: PMC4577672 DOI: 10.3238/arztebl.2015.0603b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Dirk K Wolter
- *Psykiatrien i Region Syddanmark, Gerontopsykiatrisk Afdeling Haderslev, Danmark,
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Bschor T. The Use of Antidepressants in Patients With Benzodiazepine Dependence. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:603-604. [PMID: 26377537 PMCID: PMC4577673 DOI: 10.3238/arztebl.2015.0603c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Tom Bschor
- *Abteilung für Psychiatrie, Schlosspark-Klinik, Berlin, and Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl Gustav Carus Dresden,
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Hoffmann K. In Reply. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:604. [PMID: 26377538 PMCID: PMC4577674 DOI: 10.3238/arztebl.2015.0604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Knut Hoffmann
- *Klinik für Psychiatrie, Psychotherapie und Präventivmedizin, LWL-Universitätsklinikum Bochum,
Ruhr-Universität Bochum,
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