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Harding SL, Ellis KA, Boisseau J, Petreca V. Psychiatric Deprescribing: A Narrative Review. J Am Psychiatr Nurses Assoc 2024; 30:810-818. [PMID: 37392084 DOI: 10.1177/10783903231185353] [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] [Indexed: 07/02/2023]
Abstract
OBJECTIVE Psychiatric deprescribing is an intervention where psychiatric medications are reduced or discontinued with the goal to improve health and reduce unnecessary risks. The purpose of this study was to synthesize the literature related to psychiatric deprescribing to discuss practice and research implications. METHODS A structured search of the literature was conducted from May to September 2022, yielding 29 articles meeting inclusion criteria. Articles were reviewed and synthesized. RESULTS Psychiatric deprescribing is a complex process with many potential facilitators and barriers. The extant literature provides insight into current gaps in knowledge and implications for clinical practice and research. CONCLUSIONS In current clinical practice, psychiatric deprescribing is a priority but there are significant barriers. Several areas of future research could be pursued to better support evidence-based practice in this area.
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Affiliation(s)
- Shari L Harding
- Shari L. Harding, DNP, PMHNP-BC, CPRP, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Kerri A Ellis
- Kerri A. Ellis, DNP, ACNP-BC, PMHNP-BC, The University of Rhode Island, Kingston, RI, USA
| | - John Boisseau
- John Boisseau, DNP, PMHNP-BC, LifeStance Health, Inc., Boston, MA, USA
| | - Victor Petreca
- Victor Petreca, PhD, DNP, PMHNP-BC, Boston College, Chestnut Hill, MA, USA
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2
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Lindström AC, von Oelreich E, Eriksson J, Eriksson M, Mårtensson J, Larsson E, Oldner A. Onset of Prolonged High-Potency Benzodiazepine Use Among ICU Survivors: A Nationwide Cohort Study. Crit Care Explor 2024; 6:e1124. [PMID: 38984149 PMCID: PMC11233102 DOI: 10.1097/cce.0000000000001124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024] Open
Abstract
OBJECTIVES Exposure to critical illness and intensive care may lead to long-term psychologic and physical impairments. To what extent ICU survivors become prolonged users of benzodiazepines after exposure to critical care is not fully explored. This study aimed to describe the extent of onset of prolonged high-potency benzodiazepine use among ICU survivors not using these drugs before admission, identify factors associated with this use, and analyze whether such usage is associated with increased mortality. DESIGN Retrospective cohort study. SETTING Sweden, including all registered ICU admissions between 2010 and 2017. PATIENTS ICU patients surviving for at least 3 months, not using high-potency benzodiazepine before admission, were eligible for inclusion. INTERVENTIONS Admission to intensive care. MEASUREMENTS AND MAIN RESULTS A total of 237,904 patients were screened and 137,647 were included. Of these 5338 (3.9%) became prolonged users of high-potency benzodiazepines after ICU discharge. A peak in high-potency benzodiazepine prescriptions was observed during the first 3 months, followed by sustained usage throughout the follow-up period of 18 months. Prolonged usage was associated with older age, female sex, and a history of both somatic and psychiatric comorbidities, including substance abuse. Additionally, a longer ICU stay, a high estimated mortality rate, and prior consumption of low-potency benzodiazepines were associated with prolonged use. The risk of death between 6 and 18 months post-ICU admission was significantly higher among high-potency benzodiazepine users, with an adjusted hazard ratio of 1.8 (95% CI, 1.7-2.0; p < 0.001). No differences were noted in causes of death between users and nonusers. Conclusions Despite the lack of evidence supporting long-term treatment, prolonged usage of high-potency benzodiazepines 18 months following ICU care was notable and associated with an increased risk of death. Considering the substantial number of ICU admissions, prevention of benzodiazepine misuse may improve long-term outcomes following critical care.
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Affiliation(s)
- Ann-Charlotte Lindström
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Erik von Oelreich
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Jesper Eriksson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Mikael Eriksson
- Department of Anaesthesia and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Anaesthesia and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Johan Mårtensson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Emma Larsson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Anders Oldner
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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Liu TT, Frost ED, Donlon J, Gandhi RM, Mohammadi T, Murray BP, Shad MU, Koola MM. Surge of Midazolam Use in the Midst of Lorazepam Shortage. J Clin Psychopharmacol 2023; 43:520-526. [PMID: 37930205 DOI: 10.1097/jcp.0000000000001763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND Lorazepam is a widely prescribed benzodiazepine that is used to manage anxiety, insomnia, and status epilepticus and is used for pre-anesthetic care as well as several off-label indications including aggression, alcohol withdrawal, panic disorder, chemotherapy-associated anticipatory nausea, and catatonia. Recent increases in demand, manufacturing changes, and quality control issues have resulted in a shortage of injectable and oral lorazepam, prompting clinicians to use alternatives. One such alternative is midazolam, a drug that has been used primarily in the intensive care unit and anesthesia settings. PROCEDURES This article examines the significant pharmacologic differences between lorazepam and midazolam. In addition, this article provides dosage guidelines based on the current scientific knowledge and recommendations for conversion equivalencies. RESULTS The clinical preference for lorazepam can be attributed to its simpler metabolism with no active metabolites, better suitability for patients with less severe hepatic and renal impairment, less risk of adverse reactions, fewer drug-drug interactions, and greater desirability for special populations. In periods of shortages, midazolam has been shown to be effective for a number of off-label uses. To manage conditions that have not been extensively studied, clinicians may opt to use conversion equivalencies, with the caveat that guidelines may vary greatly between institutions and online sources; therefore, it would be best to start low and titrate slowly. CONCLUSIONS Our goal is to aid clinicians in safely and effectively prescribing midazolam during the shortage of injectable lorazepam so that patients are provided the same effects and benefits.
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Affiliation(s)
- Tonia T Liu
- From the Cooper Medical School of Rowan University, Camden, NJ
| | - Emma D Frost
- Department of Neurology, Cooper Neurological Institute, Cooper University Health Care, Camden, NJ
| | - Jack Donlon
- From the Cooper Medical School of Rowan University, Camden, NJ
| | - Roshni M Gandhi
- From the Cooper Medical School of Rowan University, Camden, NJ
| | | | | | - Mujeeb U Shad
- Department of Psychiatry, University of Nevada, Las Vegas, NV
| | - Maju Mathew Koola
- Department of Psychiatry and Behavioral Health, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, NJ
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Ganglberger W, Krishnamurthy PV, Quadri SA, Tesh RA, Bucklin AA, Adra N, Da Silva Cardoso M, Leone MJ, Hemmige A, Rajan S, Panneerselvam E, Paixao L, Higgins J, Ayub MA, Shao YP, Coughlin B, Sun H, Ye EM, Cash SS, Thompson BT, Akeju O, Kuller D, Thomas RJ, Westover MB. Sleep staging in the ICU with heart rate variability and breathing signals. An exploratory cross-sectional study using deep neural networks. FRONTIERS IN NETWORK PHYSIOLOGY 2023; 3:1120390. [PMID: 36926545 PMCID: PMC10013021 DOI: 10.3389/fnetp.2023.1120390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 02/13/2023] [Indexed: 03/02/2023]
Abstract
Introduction: To measure sleep in the intensive care unit (ICU), full polysomnography is impractical, while activity monitoring and subjective assessments are severely confounded. However, sleep is an intensely networked state, and reflected in numerous signals. Here, we explore the feasibility of estimating conventional sleep indices in the ICU with heart rate variability (HRV) and respiration signals using artificial intelligence methods Methods: We used deep learning models to stage sleep with HRV (through electrocardiogram) and respiratory effort (through a wearable belt) signals in critically ill adult patients admitted to surgical and medical ICUs, and in age and sex-matched sleep laboratory patients Results: We studied 102 adult patients in the ICU across multiple days and nights, and 220 patients in a clinical sleep laboratory. We found that sleep stages predicted by HRV- and breathing-based models showed agreement in 60% of the ICU data and in 81% of the sleep laboratory data. In the ICU, deep NREM (N2 + N3) proportion of total sleep duration was reduced (ICU 39%, sleep laboratory 57%, p < 0.01), REM proportion showed heavy-tailed distribution, and the number of wake transitions per hour of sleep (median 3.6) was comparable to sleep laboratory patients with sleep-disordered breathing (median 3.9). Sleep in the ICU was also fragmented, with 38% of sleep occurring during daytime hours. Finally, patients in the ICU showed faster and less variable breathing patterns compared to sleep laboratory patients Conclusion: The cardiovascular and respiratory networks encode sleep state information, which, together with artificial intelligence methods, can be utilized to measure sleep state in the ICU.
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Affiliation(s)
- Wolfgang Ganglberger
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
- Sleep and Health Zurich, University of Zurich, Zurich, Switzerland
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
| | - Parimala Velpula Krishnamurthy
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
| | - Syed A. Quadri
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
| | - Ryan A. Tesh
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
| | - Abigail A. Bucklin
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
| | - Noor Adra
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
| | - Madalena Da Silva Cardoso
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
| | - Michael J. Leone
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
| | - Aashritha Hemmige
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
| | - Subapriya Rajan
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
| | - Ezhil Panneerselvam
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
| | - Luis Paixao
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
| | - Jasmine Higgins
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
| | - Muhammad Abubakar Ayub
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
| | - Yu-Ping Shao
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
| | - Brian Coughlin
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
| | - Haoqi Sun
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Elissa M. Ye
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
| | - Sydney S. Cash
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - B. Taylor Thompson
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Oluwaseun Akeju
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | | | - Robert J. Thomas
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Pulmonary, Critical Care and Sleep, Boston, MA, United States
| | - M. Brandon Westover
- Department of Neurology, Massachusetts General Hospital, MGH, Boston, MA, United States
- Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, United States
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
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Production of Bi-Compartmental Tablets by FDM 3D Printing for the Withdrawal of Diazepam. Pharmaceutics 2023; 15:pharmaceutics15020538. [PMID: 36839860 PMCID: PMC9960133 DOI: 10.3390/pharmaceutics15020538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/27/2023] [Accepted: 02/04/2023] [Indexed: 02/09/2023] Open
Abstract
Diazepam (DZP) is a long-acting benzodiazepine to treat anxiety or acute alcohol withdrawal. Although this class of drugs should be taken for a short period of time, many patients take them for longer than recommended, which has been linked to an increased risk of dementia and dependence. The present work aimed at using the dual-nozzle system of fused deposition modeling (FDM) 3D printers to prepare tablets with gradual doses of DZP with constant mass and size. Placebo and DZP-loaded filaments were prepared by hot-melt extrusion and used to print the bi-compartmental tablets. Thermal processing allowed the conversion of crystalline DZP to its amorphous counterpart. Tablets with different DZP contents were effectively printed with a mass, thickness and diameter average of 111.6 mg, 3.1 mm, and 6.4 mm, respectively. Microscopic data showed good adhesion between the different layers in the printed tablets. The desired drug contents were successfully achieved and were within the acceptance criteria (European Pharmacopeia). The combination of a placebo and drug-loaded extrudates proved to be beneficial in the production of tablets by FDM for patients in need of drug withdrawal.
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Timko C, Hoggatt KJ, Esmaeili A, Lewis E, Lor MC, Maust DT, Nevedal AL. Long-Term Benzodiazepine Use and Discontinuation Among Patients in the U.S. Veterans Health Administration. Psychiatr Serv 2022; 73:1217-1224. [PMID: 35502517 DOI: 10.1176/appi.ps.202100617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Although long-term benzodiazepine use is not recommended, patients are often prescribed benzodiazepines for >30 days (long-term use). Data from the Veterans Health Administration (VHA) may inform efforts to discontinue such use. This study sought to describe benzodiazepine use and discontinuation among VHA patients and compared patients who continued and discontinued use. METHODS The study used nationwide electronic health record data for all VHA-enrolled patients (age ≥18) from fiscal year (FY) 2019 (N=6,032,613). The primary outcome, benzodiazepine discontinuation, was defined as no prescription refill for 120 days. RESULTS In FY2019, 3.5% of VHA enrollees were prescribed benzodiazepines for >30 days, which was 72.0% of those prescribed benzodiazepines. One-third of veterans prescribed long-term benzodiazepines discontinued use. Continuation was more likely among patients who were older, not Black, taking benzodiazepines longer, and taking higher doses. When demographic factors were controlled, patients who continued long-term use were more likely to have a diagnosis of anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, or psychosis and less likely to have depression or an alcohol or drug use disorder. Continuation was associated with a lower likelihood of sleep and cardiopulmonary disorders and of dementia. CONCLUSIONS Higher discontinuation prevalence among patients with substance use disorders, dementia, or cardiopulmonary disorders is encouraging. However, the challenge remains of discontinuing long-term use among patients who are White, older, or diagnosed as having anxiety, PTSD, bipolar disorder, or psychosis. There is a need to identify provider, patient, and contextual factors driving long-term benzodiazepine use in these patient groups to effectively apply evidence-based discontinuation strategies.
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Affiliation(s)
- Christine Timko
- Center for Innovation to Implementation (Timko, Lor, Nevedal) and Program Evaluation and Resource Center (Lewis), Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Timko); San Francisco VA Medical Center and Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco (Hoggatt); VA Health Economics Resource Center, Menlo Park, California (Esmaeili); Department of Psychiatry, University of Michigan, and Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor (Maust)
| | - Katherine J Hoggatt
- Center for Innovation to Implementation (Timko, Lor, Nevedal) and Program Evaluation and Resource Center (Lewis), Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Timko); San Francisco VA Medical Center and Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco (Hoggatt); VA Health Economics Resource Center, Menlo Park, California (Esmaeili); Department of Psychiatry, University of Michigan, and Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor (Maust)
| | - Aryan Esmaeili
- Center for Innovation to Implementation (Timko, Lor, Nevedal) and Program Evaluation and Resource Center (Lewis), Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Timko); San Francisco VA Medical Center and Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco (Hoggatt); VA Health Economics Resource Center, Menlo Park, California (Esmaeili); Department of Psychiatry, University of Michigan, and Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor (Maust)
| | - Eleanor Lewis
- Center for Innovation to Implementation (Timko, Lor, Nevedal) and Program Evaluation and Resource Center (Lewis), Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Timko); San Francisco VA Medical Center and Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco (Hoggatt); VA Health Economics Resource Center, Menlo Park, California (Esmaeili); Department of Psychiatry, University of Michigan, and Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor (Maust)
| | - Mai Chee Lor
- Center for Innovation to Implementation (Timko, Lor, Nevedal) and Program Evaluation and Resource Center (Lewis), Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Timko); San Francisco VA Medical Center and Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco (Hoggatt); VA Health Economics Resource Center, Menlo Park, California (Esmaeili); Department of Psychiatry, University of Michigan, and Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor (Maust)
| | - Donovan T Maust
- Center for Innovation to Implementation (Timko, Lor, Nevedal) and Program Evaluation and Resource Center (Lewis), Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Timko); San Francisco VA Medical Center and Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco (Hoggatt); VA Health Economics Resource Center, Menlo Park, California (Esmaeili); Department of Psychiatry, University of Michigan, and Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor (Maust)
| | - Andrea L Nevedal
- Center for Innovation to Implementation (Timko, Lor, Nevedal) and Program Evaluation and Resource Center (Lewis), Department of Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Timko); San Francisco VA Medical Center and Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco (Hoggatt); VA Health Economics Resource Center, Menlo Park, California (Esmaeili); Department of Psychiatry, University of Michigan, and Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor (Maust)
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7
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Waldrop G, Safavynia SA, Barra ME, Agarwal S, Berlin DA, Boehme AK, Brodie D, Choi JM, Doyle K, Fins JJ, Ganglberger W, Hoffman K, Mittel AM, Roh D, Mukerji SS, Der Nigoghossian C, Park S, Schenck EJ, Salazar‐Schicchi J, Shen Q, Sholle E, Velazquez AG, Walline MC, Westover MB, Brown EN, Victor J, Edlow BL, Schiff ND, Claassen J. Prolonged Unconsciousness is Common in COVID-19 and Associated with Hypoxemia. Ann Neurol 2022; 91:740-755. [PMID: 35254675 PMCID: PMC9082460 DOI: 10.1002/ana.26342] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 02/20/2022] [Accepted: 02/28/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The purpose of this study was to estimate the time to recovery of command-following and associations between hypoxemia with time to recovery of command-following. METHODS In this multicenter, retrospective, cohort study during the initial surge of the United States' pandemic (March-July 2020) we estimate the time from intubation to recovery of command-following, using Kaplan Meier cumulative-incidence curves and Cox proportional hazard models. Patients were included if they were admitted to 1 of 3 hospitals because of severe coronavirus disease 2019 (COVID-19), required endotracheal intubation for at least 7 days, and experienced impairment of consciousness (Glasgow Coma Scale motor score <6). RESULTS Five hundred seventy-one patients of the 795 patients recovered command-following. The median time to recovery of command-following was 30 days (95% confidence interval [CI] = 27-32 days). Median time to recovery of command-following increased by 16 days for patients with at least one episode of an arterial partial pressure of oxygen (PaO2 ) value ≤55 mmHg (p < 0.001), and 25% recovered ≥10 days after cessation of mechanical ventilation. The time to recovery of command-following was associated with hypoxemia (PaO2 ≤55 mmHg hazard ratio [HR] = 0.56, 95% CI = 0.46-0.68; PaO2 ≤70 HR = 0.88, 95% CI = 0.85-0.91), and each additional day of hypoxemia decreased the likelihood of recovery, accounting for confounders including sedation. These findings were confirmed among patients without any imagining evidence of structural brain injury (n = 199), and in a non-overlapping second surge cohort (N = 427, October 2020 to April 2021). INTERPRETATION Survivors of severe COVID-19 commonly recover consciousness weeks after cessation of mechanical ventilation. Long recovery periods are associated with more severe hypoxemia. This relationship is not explained by sedation or brain injury identified on clinical imaging and should inform decisions about life-sustaining therapies. ANN NEUROL 2022;91:740-755.
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Affiliation(s)
- Greer Waldrop
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Seyed A. Safavynia
- New York Presbyterian HospitalNew YorkNYUSA
- Department of AnesthesiologyWeill Cornell Medical CollegeNew YorkNYUSA
| | - Megan E. Barra
- Department of PharmacyMassachusetts General HospitalBostonMAUSA
- Center for Neurotechnology and NeurorecoveryMassachusetts General HospitalBostonMAUSA
| | - Sachin Agarwal
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - David A. Berlin
- New York Presbyterian HospitalNew YorkNYUSA
- Department of MedicineWeill Cornell Medical CollegeNew YorkNYUSA
| | - Amelia K Boehme
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
| | - Daniel Brodie
- New York Presbyterian HospitalNew YorkNYUSA
- Department of MedicineColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
| | - Jacky M. Choi
- Division of Biostatistics, Department of Population Health SciencesWeill Cornell Medical CollegeNew YorkNYUSA
| | - Kevin Doyle
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Joseph J. Fins
- New York Presbyterian HospitalNew YorkNYUSA
- Division of Medical Ethics, Department of MedicineWeill Cornell Medical CollegeNew YorkNYUSA
| | - Wolfgang Ganglberger
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | - Katherine Hoffman
- Division of Biostatistics, Department of Population Health SciencesWeill Cornell Medical CollegeNew YorkNYUSA
| | - Aaron M. Mittel
- New York Presbyterian HospitalNew YorkNYUSA
- Department of AnesthesiaColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
| | - David Roh
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Shibani S. Mukerji
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | - Caroline Der Nigoghossian
- New York Presbyterian HospitalNew YorkNYUSA
- Department of PharmacyNew York Presbyterian HospitalNew YorkNYUSA
| | - Soojin Park
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Edward J. Schenck
- New York Presbyterian HospitalNew YorkNYUSA
- Department of MedicineWeill Cornell Medical CollegeNew YorkNYUSA
| | - John Salazar‐Schicchi
- New York Presbyterian HospitalNew YorkNYUSA
- Department of MedicineColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
| | - Qi Shen
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Evan Sholle
- Information Technologies & Services DepartmentWeill Cornell MedicineNew YorkNYUSA
| | - Angela G. Velazquez
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Maria C. Walline
- New York Presbyterian HospitalNew YorkNYUSA
- Department of AnesthesiologyWeill Cornell Medical CollegeNew YorkNYUSA
| | - M. Brandon Westover
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | - Emery N. Brown
- Department of Brain and Cognitive ScienceInstitute of Medical Engineering and Sciences, the Picower Institute for Learning and Memory, and the Institute for Data Systems and Society, Massachusetts Institute of TechnologyBostonMAUSA
- Department of AnesthesiaCritical Care and Pain Medicine, Massachusetts General HospitalBostonMAUSA
| | - Jonathan Victor
- New York Presbyterian HospitalNew YorkNYUSA
- Department of NeurologyWeill Cornell Medical CollegeNew YorkNYUSA
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical CenterNew YorkNYUSA
| | - Brian L. Edlow
- Center for Neurotechnology and NeurorecoveryMassachusetts General HospitalBostonMAUSA
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | - Nicholas D. Schiff
- New York Presbyterian HospitalNew YorkNYUSA
- Department of NeurologyWeill Cornell Medical CollegeNew YorkNYUSA
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical CenterNew YorkNYUSA
| | - Jan Claassen
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
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Fernandes M, Neves I, Oliveira J, Santos O, Aguiar P, Atalaia P, Matos F, Freitas MC, Alvim A, Maria V. Discontinuation of chronic benzodiazepine use in primary care: a nonrandomized intervention. Fam Pract 2022; 39:241-248. [PMID: 35196378 DOI: 10.1093/fampra/cmab143] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Chronic benzodiazepine use is a challenge in primary care practice. Protocols to support safe discontinuation are still needed, especially in countries with high utilization rates. OBJECTIVES To evaluate the feasibility, effectiveness, and safety of a benzodiazepine discontinuation protocol in primary care setting. METHODS Nonrandomized, single-arm interventional study, at primary care units. Family physicians (FPs) recruited patients (18-85 years-old) with benzodiazepine dependence and chronic daily use ≥3 months. Patients with daily dosages ≥30 mg diazepam-equivalent, taking zolpidem, with a history of other substance abuse or major psychiatric disease were excluded. After the switch to diazepam, the dosage was gradually tapered according to a standardized protocol. Primary endpoint was the percentage of patients who stopped benzodiazepine at the intervention last visit. Dosage reduction, withdrawal symptoms, patients' and FPs' satisfaction with the protocol were evaluated. RESULTS From 66 enrolled patients (74% female; 66.7% aged >64 years; median time of benzodiazepine use was 120 months), 2 withdrew due to medical reasons and 3 presented protocol deviations. Overall, 59.4% of participants successfully stopped benzodiazepine (60.7% when excluding protocol deviations). Men had higher probability of success (relative risk = 0.51, P = 0.001). A total of 31 patients reported at least 1 withdrawal symptom, most frequently insomnia and anxiety. Most of participating FP considered the clinical protocol useful and feasible in daily practice. Among patients completing the protocol, 77% were satisfied. For the patients who reduced dosage, 85% kept without benzodiazepines after 12 months. CONCLUSION The discontinuation protocol with standardized dosage reduction was feasible at primary care and showed long-term effectiveness.
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Affiliation(s)
- Milene Fernandes
- Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina-Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal
| | - Inês Neves
- Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina-Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal
| | - Joana Oliveira
- Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina-Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal.,ACES Almada Seixal, Administração Regional de Saúde de Lisboa e Vale do Tejo, Largo Professor Arnaldo Sampaio, Lisboa 1549-010, Portugal
| | - Osvaldo Santos
- Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina-Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal.,Instituto de Saúde Ambiental, Faculdade de Medicina-Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal
| | - Pedro Aguiar
- Public Health Research Center, Escola Nacional de Saúde Pública-Universidade Nova de Lisboa, Av. Padre Cruz, Lisboa 1600-560, Portugal
| | - Paula Atalaia
- ACES Almada Seixal, Administração Regional de Saúde de Lisboa e Vale do Tejo, Largo Professor Arnaldo Sampaio, Lisboa 1549-010, Portugal
| | - Fátima Matos
- ACES Almada Seixal, Administração Regional de Saúde de Lisboa e Vale do Tejo, Largo Professor Arnaldo Sampaio, Lisboa 1549-010, Portugal
| | - Maria Carina Freitas
- ACES Almada Seixal, Administração Regional de Saúde de Lisboa e Vale do Tejo, Largo Professor Arnaldo Sampaio, Lisboa 1549-010, Portugal
| | - António Alvim
- ACES Almada Seixal, Administração Regional de Saúde de Lisboa e Vale do Tejo, Largo Professor Arnaldo Sampaio, Lisboa 1549-010, Portugal
| | - Vasco Maria
- Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina-Universidade de Lisboa, Av. Prof. Egas Moniz, Lisboa 1649-028, Portugal.,ACES Almada Seixal, Administração Regional de Saúde de Lisboa e Vale do Tejo, Largo Professor Arnaldo Sampaio, Lisboa 1549-010, Portugal
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Medications and Patient Factors Associated With Increased Readmission for Alcohol-Related Diagnoses. Mayo Clin Proc Innov Qual Outcomes 2022; 6:1-9. [PMID: 34977469 PMCID: PMC8704480 DOI: 10.1016/j.mayocpiqo.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective To investigate medication factors and patient characteristics associated with readmissions following alcohol-related hospitalizations. Patients and Methods Adult patients admitted from September 1, 2016, through August 31, 2019, who had an alcohol-related hospitalization were identified through electronic health records. Patient characteristics and medications of interest administered during hospitalization or prescribed at discharge were identified. Medications of interest included US Food and Drug Administration–approved medications for alcohol use disorder, benzodiazepines, barbiturates, gabapentin, opioids, and muscle relaxants. The primary outcome was to identify medications and patient factors associated with 30-day alcohol-related readmission. Secondary outcomes included medications and patient characteristics associated with multiple alcohol-related readmissions within a year from the index admission (ie, two or more readmissions) and factors associated with 30-day all-cause readmission. Results Characteristics of the 932 patients included in this study associated with a 30-day alcohol-related readmission included younger age, severity of alcohol withdrawal, history of psychiatric disorder, marital status, and the number of prior alcohol-related admission in the previous year. Benzodiazepine or barbiturate use during hospitalization or upon discharge was associated with 30-day alcohol-related readmission (P=.006). Gabapentin administration during hospitalization or upon discharge was not associated with 30-day alcohol-related readmission (P=.079). Conclusion The findings reinforce current literature identifying patient-specific factors associated with 30-day readmissions. Gabapentin use was not associated with readmissions; however, there was an association with benzodiazepine/barbiturate use.
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Gouraud C, Airagnes G, Kab S, Courtin E, Goldberg M, Limosin F, Lemogne C, Zins M. Changes in benzodiazepine use in the French general population after November 2015 terrorist attacks in Paris: an interrupted time series analysis of the national CONSTANCES cohort. BMJ Open 2021; 11:e044891. [PMID: 34535472 PMCID: PMC8451294 DOI: 10.1136/bmjopen-2020-044891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To determine whether the terrorist attacks occurring in Paris on November 2015 have changed benzodiazepine use in the French population. DESIGN Interrupted time series analysis. SETTING National population-based cohort. PARTICIPANTS 90 258 individuals included in the population-based CONSTANCES cohort from 2012 to 2017. OUTCOME MEASURES Benzodiazepine use was evaluated according to two different indicators using objective data from administrative registries: weekly number of individuals with a benzodiazepine delivered prescriptions (BDP) and weekly number of defined daily dose (DDD). Two sets of analyses were performed according to sex and age (≤50 vs >50). Education, income and area of residence were additional stratification variables to search for at-risk subgroups. RESULTS Among women, those with younger age (incidence rate ratios (IRR)=1.18; 95% CI=1.05 to 1.32 for BDP; IRR=1.14; 95% CI=1.03 to 1.27 for DDD), higher education (IRR=1.23; 95% CI=1.03 to 1.46 for BDP; IRR=1.23; 95% CI=1.01 to 1.51 for DDD) and living in Paris (IRR=1.27; 95% CI=1.05 to 1.54 for BDP) presented increased risks for benzodiazepine use. Among participants under 50, an overall increase in benzodiazepine use was identified (IRR=1.14; 95% CI=1.02 to 1.28 for BDP and IRR=1.12; 95% CI=1.01 to 1.25 for DDD) and in several strata. In addition to women, those with higher education (IRR=1.22; 95% CI=1.02 to 1.47 for BDP), lower income (IRR=1.17; 95% CI=1.02 to 1.35 for BDP) and not Paris residents (IRR=1.13; 95% CI=1.02 to 1.26 for BDP and IRR=1.13; 95% CI=1.03 to 1.26 for DDD) presented increased risks for benzodiazepine use. CONCLUSION Terrorist attacks might increase benzodiazepine use at a population level, with at-risk subgroups being particularly concerned. Information and prevention strategies are needed to provide appropriate care after such events.
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Affiliation(s)
- Clement Gouraud
- Centre Ambulatoire d'Addictologie, AP-HP.Centre-Université de Paris, Hôpital européen Georges-Pompidou, Paris, France
| | - Guillaume Airagnes
- Centre Ambulatoire d'Addictologie, AP-HP.Centre-Université de Paris, Hôpital européen Georges-Pompidou, Paris, France
| | - Sofiane Kab
- UMS 011, Population-based Epidemiological Cohorts, INSERM, Villejuif, France
| | - Emilie Courtin
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK
| | - Marcel Goldberg
- UMS 011, Population-based Epidemiological Cohorts, INSERM, Villejuif, France
| | - Frédéric Limosin
- Service de Psychiatrie de l'adulte et du sujet âgé, AP-HP.Centre-Université de Paris, Paris, France
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, Université de Paris, INSERM, Paris, France
| | - Cedric Lemogne
- Service de Psychiatrie de l'adulte et du sujet âgé, AP-HP.Centre-Université de Paris, Paris, France
- Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, Université de Paris, INSERM, Paris, France
| | - Marie Zins
- UMS 011, Population-based Epidemiological Cohorts, INSERM, Villejuif, France
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11
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Basińska-Szafrańska A. Delayed crises following benzodiazepine withdrawal: deficient adaptive mechanisms or simple pharmacokinetics? Detoxification assisted by serum-benzodiazepine elimination tracking. Eur J Clin Pharmacol 2021; 78:101-110. [PMID: 34515812 PMCID: PMC8724079 DOI: 10.1007/s00228-021-03205-x] [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] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 08/16/2021] [Indexed: 11/17/2022]
Abstract
Objective Rapid relapses after successful withdrawal occur even in apparently motivated benzodiazepine (BZD)-dependent patients. Regardless of known personality or biological (re-adaptation) issues, the aim of this open-label, single-arm, seminaturalistic study was to search for any detoxification errors contributing to failures. Methods The data came from 350 inpatients. Based on serum-BZD evolution criteria, the procedure was divided into four stages: substitution, accumulation, elimination and post-elimination observation. After switching the patients to a long-acting substitute (diazepam), to prevent data falsification due to unwanted overaccumulation, the doses were expeditiously reduced under laboratory feedback until accumulation stopped. With the start of effective elimination, the tapering rate slowed and was individually adjusted to the patient’s current clinical state. The tracking of both serum-BZD concentration and the corresponding intensity of withdrawal symptoms was continued throughout the entire elimination phase, also following successful drug withdrawal. Detoxification was concluded only after the patient's post-elimination stabilization. Results Regardless of various initial serum-BZD concentration levels and the customized dose-reduction rate, and despite the novel lab-driven actions preventing initial overaccumulation, elimination was systematically proven to be protracted and varied within the 2- to 95-day range after the final dose. Within this period, withdrawal syndrome culminated several times, with varying combinations of symptoms. The last crisis occurrence (typically 2–3 weeks after withdrawal) correlated with the final serum-BZD elimination. The factors that prolonged elimination and delayed the final crisis were patient age, duration of addiction, adjunct valproate medication and elimination stage start parameters growing with former overaccumulation. Conclusions The low-concentration detoxification stage is critical for patients’ confrontations with recurring withdrawal symptoms. Underestimated elimination time following drug withdrawal and premature conclusions of detoxification expose patients to unassisted withdrawal crises. Concentration tracking defines proper limits for medical assistance, preventing early relapses. Supplementary information The online version contains supplementary material available at 10.1007/s00228-021-03205-x.
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Measuring the Effectiveness of Benzodiazepine Prescriptions Control in Community Setting Using Prescription Drug Monitoring Program (PDMP). Community Ment Health J 2021; 57:920-925. [PMID: 32666418 DOI: 10.1007/s10597-020-00686-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 07/11/2020] [Indexed: 10/23/2022]
Abstract
Benzodiazepines have been widely prescribed for several years for the treatment of anxiety, insomnia, and post-traumatic stress disorder (PTSD). Benzodiazepines were meant to be for short term use but in clinical settings long term use has been the "norm" for the treatment. Benzodiazepines are known for addiction potential and have been involved in accidental overdose deaths. According to the National Institute on Drug Abuse (NIDA), there has been a tenfold increase in the number of deaths due to overdose from 1999 to 2017. Benzodiazepines contributed to staggering high figures of 11,537 deaths in 2017 alone. Kentucky was ranked 4th in overdose related deaths in 2015 by CDC. Seeing this rise in overdose deaths, our community mental health clinics (CMHC) took the initiative to protect the community by removing benzodiazepines from the approved formulary in all adult outpatient community mental health clinics (total six clinics) in 2016. This project was initiated to protect the community from overdose deaths. In order to see the decrease in the benzodiazepine prescriptions, we did a quarterly Kentucky All Schedule Prescription Electronic Reporting (KASPER) prescriber's reports to see the trend. The goal of this project was to monitor the trend of benzodiazepine prescription control in CMHC. Our hypothesis was implementation of CMHC "No Benzodiazepine" policy would decrease in the number of prescriptions. To implement this change, we made a committee to educate staff including physicians, APRN's and therapists. Patients were also educated and informed regarding benzodiazepine free policy. Education materials were posted in the clinics and handed over to patients. Patients were offered individual and group therapy sessions to learn coping skills to cope with their anxiety. Patients had the option of inpatient detoxification, if clinically indicated. No new patients were started on benzodiazepines and patients who were already on benzodiazepines were slowly titrated off. Slow titration over the course of a few months was done as needed and tolerated. Quarterly, prescriber's prescription reports were generated with the help of KASPER (KASPER is PDMP in the state of Kentucky). After analyzing quarterly reports over the span of 2 years, we concluded that there was a total of 89% decrease in benzodiazepine prescriptions. We are hoping to reach close to 100% in the next few years. We conduct a Mental Health Statistics Improvement Program (MHSIP) which is a general patient satisfaction survey done annually. We used this data to monitor the change with this new policy. Open patients report was run to monitor any change in case load before and after the implementation of the policy. After compilation of the KASPER/ PDMP data of all the prescribers- MD's and APRN's, we found an 89% decrease in the number of benzodiazepines prescriptions over the span of 2 years. We did the open patients report and did not find any decrease in case load. In 2016, there were 10,359 open patients and in 2018 there were 12,266 open patients. We reviewed the MHSIP general patient satisfaction survey that is done annually, and we did not find any major difference in overall satisfaction as compared to previous years. These practice- based interventions implementing harm reduction strategies suggest that, although it was a difficult task, with strict adherence to no benzodiazepine policy, we were able to achieve a stark drop in the number of benzodiazepine prescriptions, in the span of 2 years, and have been able to continue to maintain the low numbers of benzodiazepine prescriptions.
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Role of the prescriber in supporting patients to discontinue benzodiazepines: a qualitative study. Br J Gen Pract 2021; 71:e517-e527. [PMID: 33950855 PMCID: PMC8216269 DOI: 10.3399/bjgp.2020.1062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 02/22/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Given the prevalence of long-term benzodiazepine (BZD) prescribing, increased monitoring through the implementation of prescription monitoring programmes (PMPs) may be the necessary impetus to promote BZD deprescribing. Despite evidence promoting the importance of patient-centred care, GPs have not been sufficiently supported to implement these principles through current deprescribing practice. AIM To investigate patients' perception of their prescriber's influence on ceasing BZD use, including their willingness to take their advice, and to understand how a patient's stage of change influences the barriers and facilitators they perceive to discontinuing BZDs. DESIGN AND SETTING An online survey and qualitative interviews with 22 long-term users of BZD (≥6 months), aged 18-69 years, recruited from the general population in Victoria, Australia. METHOD Two groups of users of BZD participated, one in the process of reducing their BZD and one not reducing, and were categorised according to their stage of change. Data underwent thematic analysis to identify barriers and facilitators to reducing BZDs both at the patient level and the prescriber level. RESULTS BZD patients' perceptions of the prescriber influence were characterised by prescribing behaviours, treatment approach, and attitude. Barriers and facilitators to reducing their BZD were mapped against their stage of change. Irrespective of their stage of change, participants reported they would be willing to try reducing their BZD if they trusted their prescriber. CONCLUSION This study illustrates that, with a few key strategies at each step of the deprescribing conversation, GPs are well positioned to tackle the issue of long-term BZD use in a manner that is patient centred.
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Sozio SJ, Bian Y, Marshall SJ, Rivera-Núñez Z, Bacile S, Roychowdhury S, Youmans DC. Determining the efficacy of low-dose oral benzodiazepine administration and use of wide-bore magnet in assisting claustrophobic patients to undergo MRI brain examination. Clin Imaging 2021; 79:289-295. [PMID: 34198113 DOI: 10.1016/j.clinimag.2021.06.013] [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] [Received: 02/26/2021] [Revised: 05/29/2021] [Accepted: 06/06/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Claustrophobia remains a challenging barrier for a significant number of patients to successfully complete a Magnetic Resonance Imaging (MRI) examination. While use of wide-bore machines and pre-exam administration of a low-dose benzodiazepine are commonly employed, there is little published research to determine which modality is the most efficacious based on the patient's specific degree of claustrophobia. This retrospective case-control study examines the efficacy of using a low-dose oral benzodiazepine and wide-bore magnet to successfully aid the claustrophobic patient in completing an MRI Brain examination. METHODS 3966 non-contrast MRI brain examinations were considered for this study. The sample was filtered to include only patients who were older than 18 years of age, not currently experiencing symptoms which may hinder MRI examination, and did not undergo any additional MR studies at the time of their exam, resulting in a final sample of 2358 examinations for analysis. Patients were then sub-divided based on severity of claustrophobia and analyzed using logistic regression analysis. RESULTS Use of wide-bore magnet increased odds of successfully completing the MRI Brain examination in mild, moderately, and severely claustrophobic patients (OR: 1.79, 95% CI: 1.17-2.75). The administration of pre-examination low-dose oral benzodiazepine increased odds of successfully completing the MRI Brain examination in severely claustrophobic patients (OR: 6.21, 95% CI: 1.63-19.28). CONCLUSION Use of a wide-bore magnet is effective in assisting mild, moderately, and severely claustrophobic patients in completing an MRI Brain exam. However, the efficacy of low-dose oral benzodiazepine is limited to severely claustrophobic patients.
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Affiliation(s)
- Stephen J Sozio
- Penn Medicine, Princeton Medical Center, Department of Imaging, 1 Plainsboro Road, Plainsboro, NJ 08536, USA.
| | - Yanhong Bian
- Rutgers University, Graduate School of Education, 10 Seminary Place, New Brunswick, NJ 08901, USA
| | - Steven J Marshall
- Rutgers University, Graduate School of Biomedical Sciences, 675 Hoes Lane West, Piscataway, NJ 08854, USA
| | - Zorimar Rivera-Núñez
- Rutgers University, Environmental and Occupational Health Sciences Institute, 170 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Salvatore Bacile
- Penn Medicine, Princeton Medical Center, Department of Imaging, 1 Plainsboro Road, Plainsboro, NJ 08536, USA
| | - Sudipta Roychowdhury
- Rutgers Robert Wood Johnson Medical School, Department of Radiology, 1 Robert Wood Johnson Place, New Brunswick, NJ 08901, USA
| | - David C Youmans
- Penn Medicine, Princeton Medical Center, Department of Imaging, 1 Plainsboro Road, Plainsboro, NJ 08536, USA
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Paterson A, Khundakar M, Young A, Ling J, Chakraborty S, Rathbone AP, Watson S, Donaldson T, Anderson KN. The Smarter Sleep educational interventions: an initiative to reduce hypnotic prescribing in in-patient psychiatric care. BJPsych Bull 2021; 46:1-9. [PMID: 33949304 PMCID: PMC9768515 DOI: 10.1192/bjb.2021.41] [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: 09/28/2020] [Revised: 03/31/2021] [Accepted: 04/09/2021] [Indexed: 12/31/2022] Open
Abstract
AIMS AND METHOD In-patients on mental health wards are commonly prescribed hypnotics for the long-term management of disturbed sleep. Specific sleep disorders remain underdiagnosed and effective behavioural interventions are underused. We developed a suite of three educational interventions (a video, poster and handbook) about sleep, sleep disorders, the safe prescribing of hypnotics and use of psychological strategies (sleep hygiene and cognitive-behavioural therapy for insomnia, CBTi) using co-design and multiprofessional stakeholder involvement. This controlled before-and-after study evaluated the effectiveness of these interventions across seven in-patient psychiatric wards, examining their impact on hypnotic prescribing rates and staff confidence scores (data collected by retrospective drug chart analysis and survey respectively). RESULTS A marked reduction was seen in the percentage of patients prescribed hypnotics on in-patient prescription charts (-24%), with a 41% reduction in the number of hypnotics administered per patient (mean reduction -1.142 administrations/patient). CLINICAL IMPLICATIONS These simple educational strategies about the causes and treatment of insomnia can reduce hypnotic prescribing rates and increase staff confidence in both the medical and psychological management of insomnia.
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Affiliation(s)
- Alastair Paterson
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Martina Khundakar
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Anthony Young
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
- Faculty of Health Sciences and Wellbeing, University of Sunderland, UK
| | - Jonathan Ling
- Faculty of Health Sciences and Wellbeing, University of Sunderland, UK
| | | | - Adam Pattison Rathbone
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Stuart Watson
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Inpatient Services, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Tim Donaldson
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Kirstie N. Anderson
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Regional Sleep Disorders Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
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Abstract
ABSTRACT Despite the lack of evidence on the long-term effectiveness of benzodiazepines and their potential harmful effects, prescriptions of the drug have significantly increased in the US over the past decade. This article reviews best practices regarding primary care benzodiazepine prescriptions and how providers can best prevent and treat benzodiazepine use disorder and other harmful effects.
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Basińska-Szafrańska A. Metabolic diversity as a reason for unsuccessful detoxification from benzodiazepines: the rationale for serum BZD concentration monitoring. Eur J Clin Pharmacol 2021; 77:795-808. [PMID: 33388822 DOI: 10.1007/s00228-020-03048-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 11/17/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Many harms secondary to benzodiazepine (BZD) dependence force users towards detoxification treatment. However, even strongly motivated patients tolerate the process badly or experience early relapse. The detoxification procedure has not yet been standardized. The objective of this paper is to examine the hypothesis that faulty detoxification routines may have caused some failures. METHODS The detoxification approaches found in the literature were compared stage by stage. The review was used to identify possible common, across-the-board systematic errors. RESULTS The presented literature review confirms that the widespread divergence in the BZD metabolism rate is effectively neglected during detoxification routines. Without laboratory measurements, these differences, additionally interfered with by auxiliary drugs, undermine not only the scheduled but even the symptom-driven procedures. An initial substitution with a long-acting BZD, although recommended, may lead to over-accumulation. This excess, varying between patients and incompatible with the current tapering stage, may lead to repeated overestimation of the patient's adjustments to reduced doses. Consequently, the patient's good clinical presentation at withdrawal, resulting in a conclusion of detoxification, may actually reflect a persistently high serum BZD concentration. The low-concentration stage, if shifted past the end of treatment, exposes patients to unexpected, unassisted withdrawal crises. With laboratory feedback, these crises, unlike the symptoms related to deficient re-adaptation mechanisms, could be prevented. Moreover, by minimizing the high-concentration phase, time can be saved for properly assisted low-concentration challenges. CONCLUSION A customized detoxification procedure driven not only by the intensity of withdrawal symptoms but also by serum BZD monitoring may prevent some failures. As the standard regimen, it would make detoxification from BZDs more reliable and effective.
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Omichi C, Ayani N, Oya N, Matsumoto Y, Tanaka M, Morimoto T, Kadotani H, Narumoto J. Association between discontinuation of benzodiazepine receptor agonists and post-operative delirium among inpatients with liaison intervention: A retrospective cohort study. Compr Psychiatry 2021; 104:152216. [PMID: 33227543 DOI: 10.1016/j.comppsych.2020.152216] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/28/2020] [Accepted: 11/05/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Several studies have investigated the association between benzodiazepine receptor agonist (BZDRA) use during the perioperative period and an elevated incidence of delirium. However, no study has focused on the time course of BZDRA use, including continuation, discontinuation, initiation, and no use. This study aimed to examine the influence of the time course of BZDRA use on post-operative delirium. METHODS This retrospective cohort study was conducted by reviewing medical records. We included patients who were scheduled for surgery under general anesthesia and had been referred to a liaison psychiatrist for pre-operative psychiatric assessment. The patients were classified into four groups based on the pre- and post-operative time course of oral BZDRA use, as follows: continuation, discontinuation, initiation, and no use (never used). The primary outcome was the prevalence of post-operative delirium in non-intensive care unit settings. We also performed stratified analyses according to age, the presence of cognitive impairment, the presence of delirium history, and antipsychotic drug use on admission. RESULTS Among 250 patients, 78 (31%) developed post-operative delirium. The Discontinuation group had a higher rate of delirium (49%, 24/49) than the other groups (Continuation [14%, 4/29]; Initiation [38%, 3/8], Never used [29%, 47/164], p = 0.008). CONCLUSIONS Abrupt discontinuation of BZDRAs during the perioperative period may be a risk factor for post-operative delirium and should therefore be avoided.
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Affiliation(s)
- Chie Omichi
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Nobutaka Ayani
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan; Department of Psychiatry, National Hospital Organization, Maizuru Medical Center, 2410 Yukinaga, Maizuru, Kyoto 625-8502, Japan.
| | - Nozomu Oya
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Yoshihiro Matsumoto
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Maki Tanaka
- Department of Medical Safety Management, University Hospital, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, 1-1 Mukogawa, Nishinomiya, Hyogo 663-8501, Japan
| | - Hiroshi Kadotani
- Department of Sleep and Behavioral Sciences, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga 520-2192, Japan
| | - Jin Narumoto
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
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Javelot H, Llorca PM, Drapier D, Fakra E, Hingray C, Meyer G, Dizet S, Egron A, Straczek C, Roser M, Masson M, Gaillard R, Fossati P, Haffen E. [Informations on psychotropics and their adaptations for patients suffering from mental disorders in France during the SARS-CoV-2 epidemic]. Encephale 2020; 46:S14-S34. [PMID: 32376004 PMCID: PMC7196532 DOI: 10.1016/j.encep.2020.04.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 12/11/2022]
Abstract
The 2019-20 coronavirus pandemic (SARS-CoV-2; severe acute respiratory syndrome coronavirus 2) has dramatic consequences on populations in terms of morbidity and mortality and in social terms, the general confinement of almost half of the world's population being a situation unprecedented in history, which is difficult today to measure the impact at the individual and collective levels. More specifically, it affects people with various risk factors, which are more frequent in patients suffering from psychiatric disorders. Psychiatrists need to know: (i) how to identify, the risks associated with the prescription of psychotropic drugs and which can prove to be counterproductive in their association with COVID-19 (coronavirus disease 2019), (ii) how to assess in terms of benefit/risk ratio, the implication of any hasty and brutal modification on psychotropic drugs that can induce confusion for a differential diagnosis with the evolution of COVID-19. We carried out a review of the literature aimed at assessing the specific benefit/risk ratio of psychotropic treatments in patients suffering from COVID-19. Clinically, symptoms suggestive of COVID-19 (fever, cough, dyspnea, digestive signs) can be caused by various psychotropic drugs and require vigilance to avoid false negatives and false positives. In infected patients, psychotropic drugs should be used with caution, especially in the elderly, considering the pulmonary risk. Lithium and Clozapine, which are the reference drugs in bipolar disorder and resistant schizophrenia, warrant specific attention. For these two treatments the possibility of a reduction in the dosage - in case of minimal infectious signs and in a situation, which does not allow rapid control - should ideally be considered taking into account the clinical response (even biological; plasma concentrations) observed in the face of previous dose reductions. Tobacco is well identified for its effects as an inducer of CYP1A2 enzyme. In a COVID+ patient, the consequences of an abrupt cessation of smoking, particularly related with the appearance of respiratory symptoms (cough, dyspnea), must therefore be anticipated for patients receiving psychotropics metabolized by CYP1A2. Plasma concentrations of these drugs are expected to decrease and can be related to an increase risk of relapse. The symptomatic treatments used in COVID-19 have frequent interactions with the most used psychotropics. If there is no curative treatment for infection to SARS-CoV-2, the interactions of the various molecules currently tested with several classes of psychotropic drugs (antidepressants, antipsychotics) are important to consider because of the risk of changes in cardiac conduction. Specific knowledge on COVID-19 remains poor today, but we must recommend rigor in this context in the use of psychotropic drugs, to avoid adding, in patients suffering from psychiatric disorders, potentially vulnerable in the epidemic context, an iatrogenic risk or loss of efficiency.
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Affiliation(s)
- H Javelot
- Établissement Public de Santé Alsace Nord, Brumath, France; Laboratoire de toxicologie et pharmacologie neuro-cardiovasculaire, université de Strasbourg, Strasbourg, France.
| | - P-M Llorca
- CHU de Clermont-Ferrand, Clermont-Ferrand, France; Université Clermont Auvergne, Clermont-Ferrand, France
| | - D Drapier
- Pôle hospitalo-universitaire de psychiatrie adulte, centre hospitalier Guillaume-Régnier, Rennes, France; EA 4712, comportements et noyaux gris centraux, université de Rennes 1, Rennes, France
| | - E Fakra
- Pôle universitaire de psychiatrie, CHU de Saint-Étienne, Saint-Étienne, France
| | - C Hingray
- Pôle hospitalo-universitaire de psychiatrie d'adultes du Grand Nancy, centre psychothérapique de Nancy, Laxou, France; Département de neurologie, CHU de Nancy, Nancy, France
| | - G Meyer
- Service de pharmacie, Établissement Public de Santé Alsace Nord, Brumath, France; Service de pharmacie, CHU de Strasbourg, Strasbourg, France
| | - S Dizet
- Service de pharmacie, CHS de Sevrey, Chalon-sur-Saône, France
| | - A Egron
- Service de pharmacie, centre hospitalier de Cadillac, Cadillac, France
| | - C Straczek
- Département de pharmacie, CHU Henri-Mondor, Créteil, France; Institut Mondor de recherche biomédical, Inserm U955, équipe 15 neuropsychiatrie translationnelle, Créteil, France
| | - M Roser
- Institut Mondor de recherche biomédical, Inserm U955, équipe 15 neuropsychiatrie translationnelle, Créteil, France; Service de psychiatrie sectorisée, hôpital Albert-Chenevier, Créteil, France
| | - M Masson
- Nightingale Hospitals-Paris, clinique du Château de Garches, Garches, France; SHU, GHU psychiatrie et neurosciences, Paris, France
| | - R Gaillard
- GHU psychiatrie et neurosciences, université de Paris, Paris, France; Sous-section 49-03, Conseil national des universités (CNU), Paris, France
| | - P Fossati
- Inserm U1127, service de psychiatrie adultes, ICM, groupe hospitalier Pitié-Salpêtrière, Sorbonne université, AP-HP, Paris, France
| | - E Haffen
- CIC-1431 Inserm, service de psychiatrie, CHU de Besançon, Besançon, France; Laboratoire de neurosciences, université de Franche-Comté, Besançon, France
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De Stefano R, Bruno A, Muscatello MR, Cedro C, Cervino G, Fiorillo L. Fear and anxiety managing methods during dental treatments: a systematic review of recent data. ACTA ACUST UNITED AC 2020; 68:317-331. [PMID: 32052621 DOI: 10.23736/s0026-4970.19.04288-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The management of anxiety and fear of patients experiencing medical treatment is always a major issue. Dentistry is a branch of medicine that is daily in managing these problems, especially in the case of pediatric patients. Odontophobia can be managed in different ways, and the purpose of this study is to eventually review which methods are currently accepted and which are the most effective. EVIDENCE ACQUISITION The literature analysis was conducted on a number of articles, suitably skimmed, after a first research, obtained from the most common scientific databases. The number of works included in the review is 28. EVIDENCE SYNTHESIS From the RCTs evaluated we could highlight that there are different methods in the literature, equally effective and certainly conditioned by the systemic condition of the patient. Another chapter instead turns out to be that linked to the management of the syndromic patient. CONCLUSIONS It is clear that there are different methods and equally different ways to manage our patients in the event of non-cooperation in the case of dental care. In addition to proper management by the clinician, in the literature methods linked to audiovisual distractions, hypnosis or pharmacological methods that produce conscious sedation are effectively reported.
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Affiliation(s)
- Rosa De Stefano
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, G. Martino Polyclinic, University of Messina, Messina, Italy
| | - Antonio Bruno
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, G. Martino Polyclinic, University of Messina, Messina, Italy
| | - Maria R Muscatello
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, G. Martino Polyclinic, University of Messina, Messina, Italy
| | - Clemente Cedro
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, G. Martino Polyclinic, University of Messina, Messina, Italy
| | - Gabriele Cervino
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, G. Martino Polyclinic, University of Messina, Messina, Italy
| | - Luca Fiorillo
- Department of Biomedical and Dental Sciences, Morphological and Functional Images, G. Martino Polyclinic, University of Messina, Messina, Italy - .,Multidisciplinary Department of Medical-Surgical and Odontostomatological Specialties, Luigi Vanvitelli University of Campania, Naples, Italy
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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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