Off-label prescribing of psychotropics in a psychiatric patient population in Australia

BACKGROUND

This study aimed to investigate the practice of off-label prescribing in both in- and outpatient psychiatry practice.

METHODS

One-hundred inpatient and 100 outpatient medical records from adult patients of an Australian psychiatry service from 2020 to 2021 were examined to determine the prevalence of off-label prescribing as defined by Therapeutic Goods Administration (TGA) indications, adherence to Royal Australian and New Zealand College of Psychiatrists (RANZCP) treatment guidelines, frequency of off-label prescription, and the quality of documentation and informed consent process.

RESULTS

Most prescribing events in both in- and outpatient settings were either on-label or off-label but consistent with RANZCP guidelines. Patients with a schizoaffective disorder diagnosis or displaying aggression were most likely to receive off-label prescriptions. There was no significant difference between in- and outpatient groups in the quality of documentation or consent process.

CONCLUSIONS

In general, off-label prescribing across groups was common, but many decisions were then in line with RANZCP recommendations. That there is a discrepancy between clinical and regulatory bodies has implications for how off-label status is decided.

Trends and Prevalence of Psychotropic Medication Use in Children and Adolescents in the Period Between 2013 and 2023: A Systematic Review

Mental health problems among children and adolescents are a significant global public health concern, with a prevalence of approximately 10-20%. Psychotropic medications, including stimulants, antipsychotics, antidepressants, and mood stabilizers, have been proven effective in treating various psychiatric disorders among children and adolescents. Despite the common use of these medications, they have various side effects and complications. This systematic review aimed to assess the trends and prevalence of psychotropic medication use among children and adolescents from 2013 to 2023. A comprehensive literature search was conducted in PubMed, Web of Science, Ovid, Scopus, and Cochrane databases using relevant keywords. Two independent researchers screened the studies for inclusion and exclusion criteria. Data were extracted using a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA), including information on study characteristics, participant demographics, psychiatric disorders, and psychotropic medications. The risk of bias assessment was performed using the ROBINS-I (Risk of Bias in Non-randomized Studies of Interventions) tool for non-randomized studies of interventions (NRSI) and Risk of Bias 2 (ROB2) for the randomized clinical trial. Data synthesis was conducted through a qualitative interpretation of the findings. A total of 52 papers were identified through the search, with 37 remaining after duplicate removal. After applying the inclusion and exclusion criteria, nine articles were considered suitable for the systematic review. A total of 9,034,109 patients suffered from several psychiatric diseases, such as autism, major depressive disorder, Down syndrome, attention-deficit/hyperactivity disorder, adjustment disorder, anxiety, bipolar disorder, conduct disorder, depression, personality disorder, psychotic disorder, tic disorder, pervasive developmental disorder, and disruptive behavior disorder. Stimulants showed a consistent prevalence rate over the years. Antidepressants, including selective serotonin reuptake inhibitors, have demonstrated variations over the years, with a substantial increase in 2015, followed by a decrease in subsequent years. In addition, antipsychotics, including atypical antipsychotics, have varied over the years; however, their use increased in 2023. Anticonvulsants and anxiolytics were also utilized, albeit at lower prevalence rates. This systematic review provides an overview of the trends and prevalence of psychotropic medication use among children and adolescents from 2013 to 2023. The prevalence of antipsychotic prescribing has shown fluctuations among different countries over the years, with a decline in recent years but a slight increase in 2023. Further research is warranted to explore the factors influencing these trends and to assess the long-term effectiveness and safety of psychotropic medications in children and adolescents.

Patterns and factors associated with the prescription of psychotropic medications after diagnosis of cancer in Chinese patients: A population-based cohort study

PURPOSE

Patients with cancer may be prescribed psychotropic medications to address their psychiatric symptoms and disorders. This study examined the patterns and factors associated with the prescription of psychotropics after cancer diagnosis using a population-based database in Hong Kong.

METHODS

Patients who were diagnosed with malignant cancer and had no documented psychiatric diagnosis or psychotropic medications prior to cancer diagnosis, were included. Multivariable log-binomial models were used to explore the associations between predictive factors and psychotropic medications use.

RESULTS

Among 9337 patients, 1868 patients (20.0%) were newly prescribed with psychotropic medications after cancer diagnoses, most commonly hypnotics (50.3%) and antidepressants (32.8%). About one-third (31.4%) were prescribed chronic psychotropics (≥90 days). Approximately 48.3% of patients who were prescribed psychotropic medications received their prescriptions within 1 year after diagnosed with cancer. Only 18.6% of those prescribed psychotropic medications had a registered psychiatric diagnosis. Patients with multiple comorbidities (adjusted risk ratio[aRR] = 2.74; CI = 2.46-3.05) and diagnosed with oral (aRR = 1.89; CI = 1.52-2.35) or respiratory cancers (aRR = 1.62; CI = 1.36-1.93) were more likely to be prescribed psychotropics.

CONCLUSIONS

The use of psychotropic medication is common (20%) among patients with cancer. Our findings highlight the importance of identification and documentation of psychiatric needs among patients with cancer.

Psychotropic Medication and Psychosocial Service Use Among Transition Age Youth With Autism Spectrum Disorder

People with autism spectrum disorder (ASD) experience high rates of psychotropic medication utilization and barriers to psychosocial services, yet limited literature explores use of these services and the association between a mental health condition (MH) and use. Using national multipayer claims data, this study estimates a multinomial logistic regression model to discern psychotropic medication and psychosocial service use among transition age youth (TAY) with ASD (12-26 years; N = 52,083) compared to a matched cohort of those without ASD (12-26 years; N = 52,083). Approximately one-third of TAY with ASD and no MH condition receive only psychotropic medication and the likelihood of using both psychosocial services and medication is higher only when TAY with ASD have a co-occurring MH condition.

Adverse childhood experiences and psychotropic medication prescription among cancer patients

BACKGROUND

This study aimed at identifying and characterizing adverse childhood experiences (ACEs) in a sample of cancer patients and subsequently evaluating the relationship between ACEs and prescription of psychotropic medication among them. Individuals with ACEs have a higher risk of mental health conditions and are more likely to be prescribed psychotropic medications.

METHODS

A sample of 178 adult patients receiving Supportive Oncology & Survivorship (SOS) services at Huntsman Cancer Hospital in Utah was obtained. ACEs and Brief Resilient Coping Scale (BRCS) questionnaires were administered confidentially. A multivariable mixed effect model, adjusting for sex, age, and insurance type while controlling for zip-codes clustering were employed.

RESULTS

Compared to the prevalence of ACEs in the general population, from the CDC-Kaiser Permanente ACEs Study, we found no significant difference in the prevalence of people who had experienced an adverse childhood event (ACEs score > = 1) between our study of cancer patients and the CDC-Kaiser study (67.4% vs. 63.6%, p = 0.29372), but found a significant difference in the prevalence of people who had experienced severe adverse childhood experiences (ACES score > =4) (25.3% vs. 12.1%, p < 0.00001). Furthermore, this study reveals a significant association between an increase of one unit in the total ACEs score and the odds of psychotropic medication prescription in the past 12 months (OR: 1.233; 95% CI: 1.025, 1.483). Those with a total ACEs score of three or more were found to have 280% higher odds of being prescribed psychotropic medication compared to those with ACEs ≤ 2 (OR: 3.822; 95% CI: 1.404,10.407).

CONCLUSION

A significant proportion of cancer patients have a history of ACEs, and thus trauma-informed care approach is essential during their treatment.

Navigating the Challenges: Predictors of Non-Adherence to Psychotropic Medications Among Patients with Severe Mental Illnesses in Ethiopia

Background

Psychotropic medications, consisting of antidepressants, mood stabilizers, antipsychotics, and anxiolytics, are the pillars of managing mental illnesses. Since there is impairment in judgment, attitude, and stability in patients with severe mental conditions, they are vulnerable to non-adherence, which compromises treatment outcome. Nevertheless, a lack of studies investigating medication non-adherence and its predictors in severe mental illnesses patients in Ethiopia has been noticed. The purpose of this study was to evaluate the extent of non-adherence to psychotropic medication and its predictors in patients with severe mental illnesses in Ethiopia.

Patients and Methods

A cross-sectional study was carried out among severely ill mental patients attending outpatient psychiatry department at Debre Markos Comprehensive Specialized Hospital. Stratified sampling strategy was used to enroll patients with a variety of mental diseases. The determinants of non-adherence were identified using logistic regression analysis. Statistical significance was determined by a p-value of <0.05 and a 95% confidence range.

Results

The prevalence of non-adherence to psychotropic medication was 50.9%. Missing regular follow-up [AOR (95% CI): 2.36 (1.24-4.47)], current substance use [AOR (95% CI): 2.48 (1.44-4.27)], negative attitude towards treatment [AOR (95% CI); 3.87 (2.26-6.62)], experience of side effects [AOR (95% CI); 4.84 (2.74-8.54)], medication use for more than 3 years [AOR (95% CI); 7.16 (3.93-13.06)], and no family support [AOR (95% CI); 2.07 (1.19-3.58)] were predictors of psychotropic medication non-adherence.

Conclusion

This study generalized that most of the patients were non-adherent to their medications. Missing regular follow-up, current substance use, negative attitude towards treatment, experience of side effects, Medication use for more than 3 years and absence of family support were found to influence medication adherence of the patients. In order to correct patients', caregivers', and societal misconceptions regarding the significance of treatment adherence, we recommend the need to implement psycho-educational programs.

Receptor-Independent Therapies for Forensic Detainees with Schizophrenia-Dementia Comorbidity

Forensic institutions throughout the world house patients with severe psychiatric illness and history of criminal violations. Improved medical care, hygiene, psychiatric treatment, and nutrition led to an unmatched longevity in this population, which previously lived, on average, 15 to 20 years shorter than the public at large. On the other hand, longevity has contributed to increased prevalence of age-related diseases, including neurodegenerative disorders, which complicate clinical management, increasing healthcare expenditures. Forensic institutions, originally intended for the treatment of younger individuals, are ill-equipped for the growing number of older offenders. Moreover, as antipsychotic drugs became available in 1950s and 1960s, we are observing the first generation of forensic detainees who have aged on dopamine-blocking agents. Although the consequences of long-term treatment with these agents are unclear, schizophrenia-associated gray matter loss may contribute to the development of early dementia. Taken together, increased lifespan and the subsequent cognitive deficit observed in long-term forensic institutions raise questions and dilemmas unencountered by the previous generations of clinicians. These include: does the presence of neurocognitive dysfunction justify antipsychotic dose reduction or discontinuation despite a lifelong history of schizophrenia and violent behavior? Should neurolipidomic interventions become the standard of care in elderly individuals with lifelong schizophrenia and dementia? Can patients with schizophrenia and dementia meet the Dusky standard to stand trial? Should neurocognitive disorders in the elderly with lifelong schizophrenia be treated differently than age-related neurodegeneration? In this article, we hypothesize that gray matter loss is the core symptom of schizophrenia which leads to dementia. We hypothesize further that strategies to delay or stop gray matter depletion would not only improve the schizophrenia sustained recovery, but also avert the development of major neurocognitive disorders in people living with schizophrenia. Based on this hypothesis, we suggest utilization of both receptor-dependent and independent therapeutics for chronic psychosis.

Inside the Bell Jar of Social Media: A Descriptive Study Assessing YouTube Coverage of Psychotropic Medication Adherence

The global mental health crisis is a longstanding one that impacts a multitude of patient populations worldwide. Within this crisis, psychiatric medication adherence is yet another complex public health challenge that continues to persist and contribute towards the chronic nature of the increased incidence and prevalence of psychiatric morbidities, which in turn result in the sequalae of substantial costs to humanity, the healthcare system, lost productivity, functioning and disability among patients with mental disorders. Psychotropic medication adherence is a significant part of psychiatric care and treatment across severity levels of mental illness. This health behavior is also filled with complexities, given the abundance of social and behavioral determinants as well as intrinsic and extrinsic factors that surround this health behavior. Examining contexts for promoting this health behavior change is crucial in determining directions for addressing it more optimally. There have been several published studies on considerations and interventions to address this health behavior; however, to date, no studies have been published on assessing coverage and directions of content across social media platforms, which trend as a rising health communication medium in our digital era. The present study is the first of its kind to dive into exploring the nature of widely viewed content and deliverers of this content on a prominent social media platform, YouTube, as the basis to determine potential directions for future intervention that can extend to reaching more patients struggling with this high-risk health behavior across the world, given the global reach of social media.

Sedative administration in Spanish hospitals in the context of perinatal loss: findings from a mixed-methods study

This article explores the contexts, processes and motivations behind the administration of sedatives (minor tranquilisers) in the time around perinatal loss. Using a mixed methods design, an online survey of 796 women and 13 narrative interviews were conducted. The participants had experienced a stillbirth or termination of pregnancy from 16 weeks or a neonatal death in Spanish hospitals. The quantitative (univariate and CHAID decision-tree) and qualitative (narrative-linguistic) analysis found that sedative administration was pervasive across care contexts and appears to be naturalised despite contradicting practice recommendations. Sedative administration was associated with emotional control and avoidance of loss, lack of accompaniment and on occasion with managing disruptive patients. Lack of informed consent was very common, with little explanation of side-effects prior to administration. In the participants' narratives, health professionals tended to construct sedatives as benign, but for some women the effects were counterproductive to loss and grief and related to persistent regrets about decisions. The study concludes that, in the context of perinatal loss, sedative administration was highly integrated into the fabric of medicalised care. As a socio-political and cultural practice underscored by gender-based care dynamics, there seems to be an imbalance between benefit and risk to women's welfare.

Motor synchronization and impulsivity in pediatric borderline personality disorder with and without attention-deficit hyperactivity disorder: an eye-tracking study of saccade, blink and pupil behavior

Shifting motor actions from reflexively reacting to an environmental stimulus to predicting it allows for smooth synchronization of behavior with the outside world. This shift relies on the identification of patterns within the stimulus - knowing when a stimulus is predictable and when it is not - and launching motor actions accordingly. Failure to identify predictable stimuli results in movement delays whereas failure to recognize unpredictable stimuli results in early movements with incomplete information that can result in errors. Here we used a metronome task, combined with video-based eye-tracking, to quantify temporal predictive learning and performance to regularly paced visual targets at 5 different interstimulus intervals (ISIs). We compared these results to the random task where the timing of the target was randomized at each target step. We completed these tasks in female pediatric psychiatry patients (age range: 11-18 years) with borderline personality disorder (BPD) symptoms, with (n = 22) and without (n = 23) a comorbid attention-deficit hyperactivity disorder (ADHD) diagnosis, against controls (n = 35). Compared to controls, BPD and ADHD/BPD cohorts showed no differences in their predictive saccade performance to metronome targets, however, when targets were random ADHD/BPD participants made significantly more anticipatory saccades (i.e., guesses of target arrival). The ADHD/BPD group also significantly increased their blink rate and pupil size when initiating movements to predictable versus unpredictable targets, likely a reflection of increased neural effort for motor synchronization. BPD and ADHD/BPD groups showed increased sympathetic tone evidenced by larger pupil sizes than controls. Together, these results support normal temporal motor prediction in BPD with and without ADHD, reduced response inhibition in BPD with comorbid ADHD, and increased pupil sizes in BPD patients. Further these results emphasize the importance of controlling for comorbid ADHD when querying BPD pathology.

Prevalence and determinants of psychotropic medication use in Poland

OBJECTIVES

The aim of the study was to assess the prevalence of psychotropic medication use among adult population in Poland in past 12 months, and to analyse the relationship between psychotropic medication use and sociodemographic factors as well as mental health disorders experienced by respondents.

METHODS

Composite International Diagnostic Instrument (WHO CIDI 3.0) was used in Polish survey of general population aged 18-64. Respondents were randomly selected from the population register. Ten thousand interviews were completed with a response rate of 50,4%.

RESULTS

In the general population, psychotropic medicines were used by almost 5% of the respondents in the past 12 months. These medicines were used more often by women, respondents from the oldest age group, with low level of education, retirees, unemployed, singles and residents of small and large cities. Among those experiencing mental health problems in the past 12 months, psychotropic medications were taken by up to 17% of the respondents. Pharmacological treatment was most often endorsed by over 40% of persons with symptoms of major depression and any mood disorders, while approximately 25% of respondents with major depression confirmed antidepressant use. Gender differences were small and mostly insignificant.

CONCLUSIONS

The results indicate the need to improve access to mental health treatment and to educate better general practitioners (GPs) for appropriate diagnosing and treatment of mental health disorders.

Association between use of psychotropic medications prior to SARS-COV-2 infection and trajectories of COVID-19 recovery: Findings from the prospective Predi-COVID cohort study

Psychological disturbances are frequent following COVID-19. However, there is not much information about whether pre-existing psychological disorders are associated with the severity and evolution of COVID-19. We aimed to explore the associations between regular psychotropic medication use (PM) before infection as a proxy for mood or anxiety disorders with COVID-19 recovery trajectories. We used data from the Predi-COVID study. We followed adults, tested positive for SARS-CoV-2 and collected demographics, clinical characteristics, comorbidities and daily symptoms 14 days after inclusion. We calculated a score based on 16 symptoms and modeled latent class trajectories. We performed polynomial logistic regression with PM as primary exposure and the different trajectories as outcome. We included 791 participants, 51% were men, and 5.3% reported regular PM before infection. We identified four trajectories characterizing recovery dynamics: "Almost asymptomatic," "Quick recovery," "Slow recovery," and "Persisting symptoms". With a fully adjusted model for age, sex, socioeconomic, lifestyle and comorbidity, we observed associations between PM with the risks of being in more severe trajectories than "Almost Asymptomatic": "Quick recovery" (relative risk (95% confidence intervals) 3.1 (2.7, 3.4), "Slow recovery" 5.2 (3.0, 9.2), and "Persisting symptoms"11.7 (6.9, 19.6) trajectories. We observed a gradient of risk between PM before the infection and the risk of slow or no recovery in the first 14 days. These results suggest that a pre-existing psychological condition increases the risk of a poorer evolution of COVID-19 and may increase the risk of Long COVID. Our findings can help to personalize the care of people with COVID-19.

Losing a child to adolescent cancer: A register-based cohort study of psychotropic medication use in bereaved parents

PURPOSE

To investigate the short- and long-term risk of psychotropic medication use in parents who lose a child to cancer diagnosed in adolescence.

METHODS

This is a Swedish nationwide register-based study including 184 bereaved mothers and 184 bereaved fathers of 184 children diagnosed with cancer in adolescence. Logistic regression analyses, adjusted for sociodemographic characteristics and history of mental health problems, were performed to estimate risk of a prescription of psychotropic medication (anxiolytics, hypnotics/sedatives, antidepressants) in cancer-bereaved parents from 1 year before to 5 years after the child's death, with a general population sample of non-bereaved parents (n = 3291) as referents.

RESULTS

At the year of the child's death, 28%-36% of mothers and 11%-20% of fathers had a prescription of anxiolytics, hypnotics/sedatives or antidepressants. The corresponding percentages for non-bereaved mothers and fathers were 7%-12% and 4%-7%, respectively. Compared to non-bereaved mothers, bereaved mothers showed higher odds of prescriptions from 1 year before up to four (anxiolytics) and 5 years (hypnotics/sedatives and antidepressants) after the child's death. Bereaved fathers showed higher odds than non-bereaved fathers of prescriptions from 1 year before up to the year of (anxiolytics and hypnotics/sedatives) and 1 year after (antidepressants) the child's death. No differences in odds between bereaved and non-bereaved fathers were found at 2 years after the child's death. Being unmarried, born outside Sweden, and having a history of mental health problems were associated with higher odds of prescribed medications.

CONCLUSIONS

Indicative of mental health problems of clinical importance, cancer-bereaved parents had a higher prevalence of use of psychotropic medication. A decrease in medication use was evident with time, but still at 5 years after the child's death mothers displayed a higher use while fathers showed no difference to non-bereaved fathers after 2 years.

Educational level and the use of mental health services, psychotropic medication and psychotherapy among adults with a history of physician diagnosed mental disorders

BACKGROUND

The prevalence of mental disorders is increased among people of low socioeconomic status or educational level, but it remains unclear whether their access to treatment matches their increased need.

AIMS

Our objective was to examine whether educational level as an indicator of socioeconomic status is associated with use of mental health services, psychotropic medication and psychotherapy in Finland.

METHOD

Cross-sectional data from a follow-up survey of a longitudinal, population-based cohort study were used to form a sample of 3,053 men and women aged 24 to 68 with a current or previous physician diagnosed mental disorder. The prevalence of mental disorders, mental health service use and educational level were assessed with self-report questionnaire. Educational level was determined by the highest educational attainment and grouped into three levels: high, intermediate and low. The associations between educational level and mental health service -related outcomes were assessed with binary logistic regression. Covariates in the fully adjusted model were age, gender and number of somatic diseases.

RESULTS

Compared to high educational level, low educational level was associated with higher odds of using antidepressants (OR 1.35, 95% CI [1.09, 1.66]), hypnotics (OR 1.33, 95% CI [1.07, 1.66]) and sedatives (OR 2.17, 95% CI [1.69, 2.78]), and lower odds of using mental health services (OR 0.80, 95% CI [0.65, 0.98]). No associations were found between educational level and use of psychotherapy.

CONCLUSIONS

The results do not suggest a general socioeconomic status related mismatch. A pharmacological emphasis was observed in the treatment of low educational background participants, whereas overall mental health service use was emphasized among high educational background participants.

The UK psychiatrists' experience of rationalising antipsychotics in adults with intellectual disabilities: A qualitative data analysis of free-text questionnaire responses

BACKGROUND

Overprescribing of off-licence psychotropic medications, particularly antipsychotics, for challenging behaviours in people with intellectual disabilities without a psychiatric disorder is a significant public health concern. In the United Kingdom, the National Health Service England launched an initiative in 2016, 'STopping Over-Medication of People with learning disabilities, autism or both (STOMP)', to address this concern. STOMP is supposed to encourage psychiatrists in the United Kingdom and elsewhere to rationalise psychotropic medication use in people with intellectual disabilities. The current study aims to gather UK psychiatrists' views and experience of implementing the STOMP initiative.

METHODS

An online questionnaire was sent to all UK psychiatrists working in the field of intellectual disabilities (estimated 225). Two open-ended questions allowed participants to write comments in response to these questions in the free text boxes. One question asked about the challenges psychiatrists faced locally to implement STOMP, and the other asked for examples of successes and positive experiences from the process. The free text data were analysed using a qualitative method with the help of the NVivo 12 plus software.

RESULTS

Eighty-eight (estimated 39%) psychiatrists returned the completed questionnaire. The qualitative analysis of free-text data has shown variation within services in the experience and views of the psychiatrists. In areas with good support for STOMP implementation provided through adequate resources, psychiatrists reported satisfaction in the process with successful antipsychotic rationalisation, better local multi-disciplinary and multi-agency working, and increased awareness of STOMP issues among the stakeholders such as people with intellectual disabilities and their caregivers and multidisciplinary teams, and improved quality of life caused by reduced medication-related adverse events in people with intellectual disabilities. However, where resource utilisation is not optimum, psychiatrists seemed dissatisfied with the process with little success in medication rationalisation.

CONCLUSIONS

Whereas some psychiatrists are successful and enthusiastic about rationalising antipsychotics, others still face barriers and challenges. Much work is needed to achieve a uniformly positive outcome throughout the United Kingdom.

Psychotropic medication in pregnancy and lactation and early development of exposed children

There is still limited knowledge about alterations of blood concentrations of psychotropic drugs during pregnancy, the transfer of psychotropic drugs into breastmilk and the effects on exposed children. We investigated changes in concentrations of psychopharmacological medication during pregnancy and lactation in serum and breastmilk at different time points in a naturalistic sample of 60 mothers and observed the development of the exposed children in the first 12 months. We found a decrease in serum concentrations from the first to the second trimester of amitriptyline, duloxetine, escitalopram, quetiapine and sertraline. Citalopram stayed rather stable during pregnancy, sertraline levels interestingly increased again from the second to the third trimester. High concentration-by-dose ratios in breastmilk were found for venlafaxine as well as lamotrigine, low for quetiapine and clomipramine. Similarly, clomipramine and quetiapine showed low milk/serum-penetration ratios. Regarding the birth outcome measures in children, we found no significant differences between in utero exposed compared to nonexposed newborns. There were no significant differences in the development in the first 12 months. Psychotropic medication in the peripartum needs a balancing of risks and benefits and a continuous therapeutic drug monitoring can be a guidance for clinicians to monitor drug alteration patterns, which are likely to occur due to physiological pregnancy-associated changes in pharmacokinetics. Accordingly, therapeutic drug monitoring can optimize a medication in pregnancy and lactation with the lowest effective dose.

First-line Behavioral Health Treatment Prior to Stimulant or Alpha-2 Agonist Use for Preschoolers on Kentucky Medicaid in 2017

OBJECTIVE

We aimed to assess the degree to which the American Academy of Pediatrics' (AAP) clinical guidelines were followed when treating attention deficit/hyperactivity disorder (ADHD) in preschoolers.

METHOD

Using Medicaid claims for children 4 to 5 years of age receiving their first dose of stimulants/alpha-2 agonists in 2017 (n = 836), we determined if BH was received prior to initiation of medication. We examined predictors after controlling for confounders.

RESULTS

More than half the sample did not receive first-line BH, which did not differ by demographics. Those receiving BH prior to medication had a higher rate of receiving an ADHD diagnosis. Only three diagnoses were significant in multivariate (OR 13.8, 95% CI [1.7-115.1]) analyses.

CONCLUSION

More than half the sample did not, conservatively, meet the AAP clinical recommendations. Further research is needed to identify targets for intervention. Limitations are noted.

Impact of the COVID-19 pandemic on the consumption patterns of psychotropic drugs and predictors of limited access to medication

Background

Despite the efforts of the health system to improve access to medications during the coronavirus disease of 2019 (COVID-19) pandemic, such as online consultations, encouraging generic prescriptions, and other measures to limit the storage of medication, psychotropic patients faced significant challenges in accessing their medications.

Objectives

This study aimed (1) to compare the consumption of psychotropics before and during the pandemic, (2) to assess the association between having difficulties finding the medications and the general characteristics of the patients, and (3) to assess the predictors of these difficulties.

Design

A case-control study was performed in which 128 patients (cases) were recruited during the pandemic (July-October 2021), and 256 patients (controls) using psychotropics before the pandemic were matched for age and sex.

Methods

Data were collected using a uniform survey given to patients using psychotropics and filled out at their time and place preferences.

Results

More patients used antipsychotics and anti-anxiety medications before the pandemic, while antidepressants were used more during the pandemic. Almost half of the patients reported facing difficulties finding their medications in both time frames. Before the pandemic, these difficulties were noted per increase in age and being employed and were less faced if patients had medical assistance or lived in the north of Lebanon. However, more patients reported having difficulties accessing their medication during the pandemic, with no significant differences.

Conclusion

The consumption of psychotropic drugs was higher among cases. All patients faced challenges in accessing their medication throughout the pandemic, while older and employed patients had more limitations before the pandemic. Further investigations exploring viable solutions are recommended in order to maintain sustainable access to treatment.

Inflammation and damage-associated molecular patterns in major psychiatric disorders

BACKGROUND

Emerging evidence indicates that inflammation plays an important role as a mechanism underlying mental disorders. However, most of the research on inflammatory mechanisms focuses on serum levels of interleukins and very few studies have investigated molecules that initiate and expand innate immune pathways such as damage-associated molecular patterns (DAMPs).

OBJECTIVES

This study investigated the levels of DAMPs among patients diagnosed with major depressive disorder (MDD), bipolar disorder (BD) I and II, schizophrenia (SCZ), and generalized anxiety disorder (GAD). We quantified serum levels of heat shock proteins (HSPs) 70 and 60 and of S100 calcium-binding protein B (S100B).

METHODS

Serum levels of HSP70, HSP60, and S100B were assessed in a sample of participants with psychiatric disorders (n = 191) and a control group (CT) (n = 59) using enzyme-linked immunosorbent assay (ELISA).

RESULTS

Serum HSP70 concentrations were significantly higher in the MDD group compared to the CT, SCZ, and BD groups. The GAD group had higher concentrations of HSP70 than the SCZ group. Exploring associations with medications, lithium (p = 0.003) and clozapine (p = 0.028) were associated with lower HSP70 levels. Approximately 64% of the sample had DAMPs levels below the limits of detection indicated by the respective ELISA kit.

CONCLUSION

This was the first study to assess DAMPs levels in a transdiagnostic sample. Our preliminary findings suggest that HSP70 may be associated with MDD pathophysiology. Medications such as lithium and clozapine were associated with lower HSP70 levels in BD and SCZ groups, respectively. Therefore, it is worth mentioning that all participants were medicated and many psychotropic drugs exert an anti-inflammatory effect, possibly reducing the signs of inflammation.

Characterisation of medication side effects in patients with mostly resistant depression in a real-world setting

OBJECTIVES

This study aimed to identify factors associated with side effects of psychotropic drugs in a real-world setting enriched with treatment-resistant depression (TRD) patients.

METHODS

A total of 1410 depressed patients were treated in a naturalistic setting. Side effects were measured with the Udvalg for Kliniske Undersogelser Side Effect Rating Scale (UKU); the total score and UKU subscales were considered. Clinical-demographic variables were tested for association with side effects in univariate and then multivariate analyses.

RESULTS

Total, psychic and neurological side effects were associated with depressive symptom severity, while autonomic side effects were higher in those with somatic comorbidities and other side effects were lower in patients receiving trazodone. In multivariate analyses, depressive symptom severity was associated with psychic and total side effects, while generalised anxiety disorder (GAD) with neurological side effects and somatic comorbidities remained associated with autonomic side effects. Trazodone was associated with lower side effects and with augmentation treatments. Augmentation therapies showed opposite effects depending on response status, i.e. increased or decreased the risk of side effects in responders and non-responders/resistant patients, respectively.

CONCLUSIONS

Psychic side effects may be difficult to distinguish from depressive symptoms and factors associated with different types of side effects are heterogeneous and likely interacting.

Gene Enrichment Analysis of Astrocyte Subtypes in Psychiatric Disorders and Psychotropic Medication Datasets

Astrocytes have many important functions in the brain, but their roles in psychiatric disorders and their responses to psychotropic medications are still being elucidated. Here, we used gene enrichment analysis to assess the relationships between different astrocyte subtypes, psychiatric diseases, and psychotropic medications (antipsychotics, antidepressants and mood stabilizers). We also carried out qPCR analyses and “look-up” studies to assess the chronic effects of these drugs on astrocyte marker gene expression. Our bioinformatic analysis identified gene enrichment of different astrocyte subtypes in psychiatric disorders. The highest level of enrichment was found in schizophrenia, supporting a role for astrocytes in this disorder. We also found differential enrichment of astrocyte subtypes associated with specific biological processes, highlighting the complex responses of astrocytes under pathological conditions. Enrichment of protein phosphorylation in astrocytes and disease was confirmed by biochemical analysis. Analysis of LINCS chemical perturbagen gene signatures also found that kinase inhibitors were highly discordant with astrocyte-SCZ associated gene signatures. However, we found that common gene enrichment of different psychotropic medications and astrocyte subtypes was limited. These results were confirmed by “look-up” studies and qPCR analysis, which also reported little effect of psychotropic medications on common astrocyte marker gene expression, suggesting that astrocytes are not a primary target of these medications. Conversely, antipsychotic medication does affect astrocyte gene marker expression in postmortem schizophrenia brain tissue, supporting specific astrocyte responses in different pathological conditions. Overall, this study provides a unique view of astrocyte subtypes and the effect of medications on astrocytes in disease, which will contribute to our understanding of their role in psychiatric disorders and offers insights into targeting astrocytes therapeutically.

Health Care Consumption, Psychiatric Diagnoses, and Pharmacotherapy 1 and 2 Years Before and After Newly Diagnosed HIV: A Case-Control Study Nested in The Greater Stockholm HIV Cohort Study

OBJECTIVE

We compare individuals with newly diagnosed HIV with sex-, age-, and socioeconomic status-matched HIV-negative controls, with the aim of studying the frequency of health care visits, the types of clinics visited, registered diagnoses, and psychopharmacotherapy.

METHODS

The data were collected through the Stockholm Region administrative database (Stockholm Regional Health Care Data Warehouse) for men and women (people) living with newly diagnosed HIV (PLWH) in their medical records (930 men, 450 women) and controls. The odds ratios (ORs) with 99% confidence intervals (CIs) for psychiatric comorbidities and relevant pharmacotherapies were calculated during the 2011-2018 period.

RESULTS

Substance use disorder was higher in PLWH than in controls, before and after newly diagnosed HIV in men (OR = 1 year before 4.36 [99% CI = 2.00-9.5] and OR = 1 year after 5.16 [99% CI = 2.65-10.08]) and women (OR = 1 year before 6.05 [99% CI = 1.89-19.40] and OR = 1 year after 5.24 [99% CI = 1.69-16.32]). Health care contacts and psychiatric disorders were more common in cases than controls 1 and 2 years after diagnosis, particularly for depression in men 1 year after HIV (OR = 3.14, 99% CI = 2.11-4.67), which was not found in women (1 year OR = 0.94, 99% CI = 0.50-1.77).

CONCLUSIONS

Before newly diagnosed HIV, PLWH have the same level of psychiatric diagnoses as their controls, except for substance use disorder. Psychiatric problems are more common in PLWH than in their controls after newly diagnosed HIV.

Actionable Predictive Factors of Homelessness in a Psychiatric Population: Results from the REHABase Cohort Using a Machine Learning Approach

BACKGROUND

There is a lack of knowledge regarding the actionable key predictive factors of homelessness in psychiatric populations. Therefore, we used a machine learning model to explore the REHABase database (for rehabilitation database-n = 3416), which is a cohort of users referred to French psychosocial rehabilitation centers in France.

METHODS

First, we analyzed whether the different risk factors previously associated with homelessness in mental health were also significant risk factors in the REHABase. In the second step, we used unbiased classification and regression trees to determine the key predictors of homelessness. Post hoc analyses were performed to examine the importance of the predictors and to explore the impact of cognitive factors among the participants.

RESULTS

&nbsp;First, risk factors that were previously found to be associated with homelessness were also significant risk factors in the REHABase. Among all the variables studied with a machine learning approach, the most robust variable in terms of predictive value was the nature of the psychotropic medication (sex/sex relative mean predictor importance: 22.8, σ = 3.4). Post hoc analyses revealed that first-generation antipsychotics (15.61%; p < 0.05 FDR corrected), loxapine (16.57%; p < 0.05 FWER corrected) and hypnotics (17.56%; p < 0.05 FWER corrected) were significantly associated with homelessness. Antidepressant medication was associated with a protective effect against housing deprivation (9.21%; p < 0.05 FWER corrected).

CONCLUSIONS

Psychotropic medication was found to be an important predictor of homelessness in our REHABase cohort, particularly loxapine and hypnotics. On the other hand, the putative protective effect of antidepressants confirms the need for systematic screening of depression and anxiety in the homeless population.

Descriptive Longitudinal Analysis of Stereotypy and Corresponding Changes in Psychotropic Medication

INTRODUCTION

Psychotropic medication is often prescribed to individuals with intellectual and developmental disabilities who engage in challenging and other behavior (e.g., aggression and stereotypy, respectively), but there is limited understanding of the effects of these medications on behavior.

OBJECTIVE

Within the context of a larger study that evaluated the effects of psychotropic medication regimen changes on the presentation of challenging behavior, this study describes the presentation of stereotypic behavior of three individuals diagnosed with autism spectrum disorder.

METHODS

Stereotypy was measured during weekly, one-hour, direct observations and during the control and ignore conditions of functional analyses of challenging behavior (which were conducted following changes in psychotropic medication regimens).

RESULTS

Patterns of stereotypy varied over time, but not significantly, and at times seemed to coincide with medication changes.

DISCUSSION

Our results suggest stereotypy persists throughout adulthood; however, additional research is needed.

Psychotropic medication prescribing trends in a developmental-behavioural clinic during the COVID-19 pandemic

AIM

Psychotropic medication prescribing among children with developmental-behavioural and mental health problems appears to be rising globally. We aim to examine the effects of the COVID-19 pandemic and rapid introduction of telehealth consultations on the prescribing trends and medication change in a large paediatric public hospital developmental-behavioural outpatient service.

METHODS

Data for developmental-behavioural outpatient encounters from 23 March 2019 to 22 March 2021 were extracted from the electronic medical record; representing the 12 months following the conversion to telehealth consultations during the onset of COVID-19 pandemic and the 12 months prior to this change. Excel and Statistical Package for the Social Sciences were used to calculate percentages and logistic regression to compare psychotropic prescribing trends during both periods.

RESULTS

During the pandemic, there were a total of 3201 encounters (92.0% telehealth), compared with 2759 encounters (1.6% telehealth) during the previous year. Despite the higher number of encounters during the pandemic, the rates of encounters with psychotropic medication prescriptions reduced compared to the previous 12 months (19.8% vs. 29.3%). Prescriptions made during COVID-19 were more likely to be provided at review visits, patients ≥12 years and during consultant led encounters. The reduction in prescriptions involved both new and follow-up psychotropic medications. The majority of follow-up medication dosages were left unchanged.

CONCLUSIONS

Psychotropic prescribing rates were lower during the COVID-19 pandemic. Fewer new medications were commenced and most medication dosages were unchanged.

Psychotropic drugs intake in people aging with intellectual disability: Prevalence and predictors

Background

Psychotropic medication is frequently administered to people with intellectual disability with mental health and/or behavioural problems, instead of other non‐pharmacological interventions. This study describes the mental health and behavioural problems of people aging with intellectual disability, their psychotropic medication intake, and the factors contributing to a greater medication intake.

Method

The sample consisted of 991 people with intellectual disability over 45 years. Descriptive statistics and multinominal logistic regression were carried out.

Results

Antipsychotics were the most used psychotropic drug. Older people with mild intellectual disability living in institutions and affected by mental health and behavioural problems were more likely to take larger amounts of psychotropic medication.

Conclusions

Antipsychotics continue to be widely used by people with intellectual disability and mental and behavioural health problems, especially those in institutionalised settings. Future research should consider if medication intake could be reduced providing better supports in the community and non‐pharmacological interventions.

Psychotropic Medication Use Is Associated With Greater 1-Year Incidence of Dementia After COVID-19 Hospitalization

Background

COVID-19 has been associated with an increased risk of incident dementia (post-COVID dementia). Establishing additional risk markers may help identify at-risk individuals and guide clinical decision-making.

Methods

We investigated pre-COVID psychotropic medication use (exposure) and 1-year incidence of dementia (outcome) in 1,755 patients (≥65 years) hospitalized with COVID-19. Logistic regression models were used to examine the association, adjusting for demographic and clinical variables. For further confirmation, we applied the Least Absolute Shrinkage and Selection Operator (LASSO) regression and a machine learning (Random Forest) algorithm.

Results

One-year incidence rate of post-COVID dementia was 12.7% (N = 223). Pre-COVID psychotropic medications (OR = 2.7, 95% CI: 1.8-4.0, P < 0.001) and delirium (OR = 3.0, 95% CI: 1.9-4.6, P < 0.001) were significantly associated with greater 1-year incidence of post-COVID dementia. The association between psychotropic medications and incident dementia remained robust when the analysis was restricted to the 423 patients with at least one documented neurological or psychiatric diagnosis at the time of COVID-19 admission (OR = 3.09, 95% CI: 1.5-6.6, P = 0.002). Across different drug classes, antipsychotics (OR = 2.8, 95% CI: 1.7-4.4, P < 0.001) and mood stabilizers/anticonvulsants (OR = 2.4, 95% CI: 1.39-4.02, P = 0.001) displayed the greatest association with post-COVID dementia. The association of psychotropic medication with dementia was further confirmed with Random Forest and LASSO analysis.

Conclusion

Confirming prior studies we observed a high dementia incidence in older patients after COVID-19 hospitalization. Pre-COVID psychotropic medications were associated with higher risk of incident dementia. Psychotropic medications may be risk markers that signify neuropsychiatric symptoms during prodromal dementia, and not mutually exclusive, contribute to post-COVID dementia.

Central hypothyroidism related to antipsychotic and antidepressant medications: an observational study and literature review

OBJECTIVE

To investigate the final diagnosis and clinical outcome of patients referred to endocrinology in our district general hospital with biochemical isolated central hypothyroidism (CeH), and whether there is an association between this biochemical picture and treatment with antidepressant and antipsychotic medications.

METHODS

We performed a retrospective observational study of patients referred to endocrinology with unexplained biochemical isolated CeH over a 5-year period.

RESULTS

Of the 29 patients included in the study, 4 were found to have a partially empty or empty sella and 1 to have a bulky pituitary gland which was deemed to be an incidental radiological finding. No patients had any clinically significant pathology. On reviewing their medications, 18/29 (62%) were found to be on psychotropic medications.

CONCLUSIONS

Our study suggests a relationship between patients on psychotropic medications and biochemical isolated CeH, an association only described in a very limited amount of literature prior to this. The mechanism behind this may be suppression of TSH secretion via antagonism of the dopamine-serotoninergic pathway. Determining a correlation between psychotropic medications and isolated CeH could lead to the avoidance of further radiological investigations and unnecessary anxiety for patients. However, a larger observational study is needed to provide further evidence to support/refute our finding.

A Systematic Review of Direct Assessments to Evaluate Psychotropic Medication Effects for Children With Disabilities

To evaluate effects of psychotropic medication for children with disabilities, direct assessments may offer a valuable supplement to caregiver reports. Relative to indirect assessment, direct measures of behavior can increase objectivity and sensitivity, and some have potential to isolate distinct behavioral and learning processes. We conducted a systematic, narrative literature review to identify and describe the types and qualities of direct assessment methods that have been used to evaluate effects of non-stimulant psychotropic medication for children with disabilities. We identified 50 studies and 78 direct assessments, which we organized and described using seven assessment categories. Only one study met all three direct assessment quality indicators. We use our descriptive results to highlight research trends and gaps that warrant further study.

Stakeholders' views on the use of psychotropic medication in older people: a systematic review

Background

psychotropic medication use has been shown to increase with age and has been associated with increased risk of falls, strokes and mortality. Various guidelines, regulations and tools have been developed to reduce inappropriate prescribing, but this remains high. In order to understand the reasons for this, we aimed to systematically review healthcare professionals’, patients’ and family caregivers’ attitudes towards the use of psychotropic medication in older people.

Methods

a systematic literature search was carried out from inception to September 2020 using PUBMED, EMBASE, PsycINFO and CINAHL and hand-searching of reference lists. Included studies investigated stakeholder views on psychotropic in adults over the age of 65. Findings were thematically synthesised.

Results

overall, there was an acceptance of long-term psychotropic medication for older people both living in the community and in residential care. While healthcare professionals were aware of guidelines for the use of benzodiazepines and psychotropic medicines, they identified barriers to following them on individual, team and organisational levels. Alternative non-pharmacological approaches were not always available or accepted by patients.

Conclusion

psychotropic medicine use in older adults remains a complex issue, which needs to be addressed on a broad level. Attitudes of older people and healthcare professionals encourage long-term use. Meanwhile, various internal and external factors act as barriers to the use of non-drug alternatives in this population. In order to reduce overprescribing of psychotropics, there is a need to increase the acceptability and accessibility of alternative interventions in both care homes and the community.

Association of mental health diagnosis with race and all-cause mortality after a cancer diagnosis: Large-scale analysis of electronic health record data

BACKGROUND

Disparity in mental health care among cancer patients remains understudied.

METHODS

A large, retrospective, single tertiary-care institution cohort study was conducted based on deidentified electronic health record data of 54,852 adult cancer patients without prior mental health diagnosis (MHD) diagnosed at the University of California, San Francisco between January 2012 and September 2019. The exposure of interest was early-onset MHD with or without psychotropic medication (PM) within 12 months of cancer diagnosis and primary outcome was all-cause mortality.

RESULTS

There were 8.2% of patients who received a new MHD at a median of 197 days (interquartile range, 61-553) after incident cancer diagnosis; 31.0% received a PM prescription; and 3.7% a mental health-related visit (MHRV). There were 62.6% of patients who were non-Hispanic White (NHW), 10.8% were Asian, 9.8% were Hispanic, and 3.8% were Black. Compared with NHWs, minority cancer patients had reduced adjusted odds of MHDs, PM prescriptions, and MHRVs, particularly for generalized anxiety (Asian odds ratio [OR], 0.66, 95% CI, 0.55-0.78; Black OR, 0.60, 95% CI, 0.45-0.79; Hispanic OR, 0.72, 95% CI, 0.61-0.85) and selective serotonin-reuptake inhibitors (Asian OR, 0.43, 95% CI, 0.37-0.50; Black OR, 0.51, 95% CI, 0.40-0.61; Hispanic OR, 0.79, 95% CI, 0.70-0.89). New early MHD with PM was associated with elevated all-cause mortality (12-24 months: hazard ratio [HR], 1.43, 95% CI, 1.25-1.64) that waned by 24 to 36 months (HR, 1.18, 95% CI, 0.95-1.45).

CONCLUSIONS

New mental health diagnosis with PM was a marker of early mortality among cancer patients. Minority cancer patients were less likely to receive documentation of MHDs or treatment, which may represent missed opportunities to identify and treat cancer-related mental health conditions.

Brugada syndrome: should we be screening patients before prescribing psychotropic medication?

Brugada syndrome (BrS) presents with a characteristic electrocardiogram (ECG) and is associated with sudden cardiac death. Until now, prolongation of QTc interval and its association with Torsade de Pointe and possible fatal arrhythmia have been the focus of routine baseline ECGs before prescribing psychotropic medication. A semi-systematic literature review was conducted using PubMed. The terms 'Brugada', 'Brugada Syndrome' AND 'psychotropic' 'antipsychotic' 'antidepressant' 'mood stabilisers' 'clozapine' 'Tricyclic Antidepressants' 'Lithium' were searched. From a search that delivered over 200 articles, 82 articles were included. Those that included details around causative medication, doses of medication and where clear timeline on drug cause were included. Where clarification was needed, the manufacturer of the medication was contacted directly. Psychotropic medication can be associated with BrS, Brugada phenocopy or unmasking of BrS, in overdose or in normal doses. Our results include a table summarising a number of psychotropic overdoses that led to BrS unmasking. Routine screening for BrS in patients before prescribing psychotropic medication is a natural extension of the baseline ECG currently routinely done to rule out QTc prolongation. Psychiatrists need to invest in ensuring better skills in interpreting ECGs and work closer with cardiologists in interpreting ECGs.

Short-Term Psycho-Education for Caregivers to Reduce Overmedication of People with Intellectual Disabilities (SPECTROM): Development and Field Testing

People with intellectual disabilities (PwID) are at a higher risk of developing challenging behaviours (CB). Despite the poor evidence for the effectiveness of medications in managing CB, they are used widely among PwID (50–63%). The aims of our study were to develop a training programme, SPECTROM for support staff to help reduce overmedication in PwID and carry out field testing of SPECTROM including a process evaluation. We developed SPECTROM using the Experience-based co-design method that included four focus groups and a one-day co-design event. Twenty trainees received SPECTROM training. We used the Management of Aggression and Violence Attitudes Scale-Revised-Intellectual Disabilities (MAVAS-R-ID) and the Psychotropic knowledge questionnaire. A semi-structured interview and a feasibility questionnaire were used for process evaluation. SPECTROM website contains 14 modules, resources, and face-to-face training. MAVAS-R-ID scores showed change in staff attitude to ‘medication management’ domain was statistically significant (p < 0.05). Psychotropic knowledge questionnaire showed statistically significant post-training improvement in correct responses (p < 0.05). Process evaluation data showed that SPECTROM was acceptable, applicable, practical, and relevant to staff practice, and helped to improve self-reflection, knowledge, and support to PwID. SPECTROM is a useful training that helps to change the support staff’s attitude toward CB and improve their knowledge of psychotropic medications.

Patterns and Predictors of Healthcare Use among Adolescent and Young Adult Cancer Survivors versus a Community Comparison Group

Simple Summary

Adolescent and young adult cancer survivors face several significant physical/mental health late effects following cancer treatment. These effects may be minimized through healthcare use tailored to young survivors’ needs. Using a cross-sectional study design, we examined the healthcare use of 93 adolescent/young adult cancer survivors (aged 15–39 years), relative to a comparison group of adolescents and young adults recruited from the local community (n = 183). Our cancer survivor group reported greater use of medical and mental health services, and medications during the past six months relative to the comparison group. Our cancer survivor group also reported less psychological distress, and similar work/study participation relative to the comparison group. Survivors who were female, diagnosed with brain/solid tumors and who had finished treatment more recently reported greater healthcare use. Future research is needed to determine whether the healthcare accessed by adolescent and young adult cancer survivors is appropriate and meets their needs.

Abstract

Healthcare use (HCU) during survivorship can mitigate adolescent and young adult (AYA) cancer survivors’ (aged 15–39 years) risk of medical and psychosocial late effects, but this is understudied. We surveyed 93 Australian AYA post-treatment cancer survivors (M_age = 22.0 years, SD = 3.5; 55.9% female) and a comparison sample of 183 non-matched AYAs (M_age = 19.7, SD = 3.2; 70.5% female) on their HCU, medication use, depression/anxiety, and general functioning. Relative to our comparison AYAs, a higher proportion of our survivor group reported medical HCU (community-delivered: 65.6% versus 47.0%, p = 0.003; hospital-delivered: 31.2% versus 20.3%, p = 0.044) and mental HCU (53.8% vs. 23.5%; p < 0.0001) in the past six months. A higher proportion of our survivors reported taking medications within the past six months than our comparison AYAs (61.3% vs. 42.1%, p = 0.003) and taking more types (p < 0.001). Vitamin/supplement use was most common followed by psychotropic medications. Our survivor group reported lower depression (p = 0.001) and anxiety symptoms (p = 0.003), but similar work/study participation (p = 0.767) to our comparison AYAs. Across groups, psychological distress was associated with higher mental HCU (p = 0.001). Among survivors, those who were female, diagnosed with brain/solid tumors and who had finished treatment more recently reported greater HCU. Future research should establish whether this level of HCU meets AYAs’ survivorship needs.

Deciding to discontinue prescribed psychotropic medication: A qualitative study of service users' experiences

Many mental health service users decide to discontinue their psychotropic medication at some stage in the treatment process; however, few studies have captured these experiences. This study aimed to explore people's experiences of coming off medication. A qualitative descriptive design and individual interviews with 23 people who experienced coming off medication were employed. COREQ checklist was used. Data were analysed using inductive and deductive approaches and six major themes were developed. Findings suggest that while medication was useful for many in the short-term, the adverse effects had significant impact and contributed to the decision to come off medication. Participants also reported being driven by a questioning of the biomedical model of treatment and the belief that there were other strategies to manage their distress. Mixed experiences of support from healthcare professionals for the medication cessation process were reported. The discontinuation process was often difficult resulting in changes in mood and behaviour which for many culminated in relapse of distress, rehospitalization and return to medication. To support the process of coming off and staying off medication, participants identified a range of useful strategies but particularly highlighted the importance of peer support. Findings from this study demonstrate the importance of mental health nurses having a collaborative discussion with service users which may support safer decision-making and lessen the risk of people discontinuing medication abruptly. Finding also indicates a need for robust studies that develop and test interventions to support people who wish to discontinue psychotropic medications.

Psychiatric History and Overactive Bladder Symptom Severity in Ambulatory Urogynecological Patients

Introduction and hypothesis: A link between psychiatric comorbidities and overactive bladder symptomatology has been suggested by preclinical and clinical studies. Given this, we hypothesized that a psychiatric history and current treatment with psychotropic medications could be related to the severity of overactive bladder and incontinence symptoms in patients referred to a tertiary care urogynecological center. Methods: One hundred and twenty-seven female patients diagnosed with an overactive bladder were screened for a lifetime history of psychiatric disorders and the type and number of psychotropic medications currently taken. The overall severity of overactive bladder symptoms was assessed using the Indevus Urgency Severity Scale. The severity and impact of urinary incontinence on the quality of life were quantified with the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form. Urinary incontinence was further quantified with the aid of the Urinary Distress Inventory-6. The patients were screened for stress urinary incontinence using the Stamey Incontinence Score. Results: A psychiatric history, as well as current use of at least two psychotropic medications, was associated with increased severity of overactive bladder symptoms. A history of depression and current treatment with any selective serotonin reuptake inhibitor was associated with increased severity of stress urinary incontinence symptoms. Current treatment with other psychotropic medications, including sedative-hypnotics and drugs with anticholinergic properties was not related to the severity of overactive bladder and incontinence symptoms.

Initiation of psychotropic medication in hospitalized patients with COVID-19: Association with clinical and biological characteristics

INTRODUCTION

Inpatients with coronavirus disease 2019 (COVID-19) show a high rate of neuropsychiatric manifestations, possibly related to a higher risk of serious illness or death. Use of psychotropic medications (PMs) indicates the presence of neuropsychiatric symptoms in COVID-19 patients. So far, potential clinical predictors of use of PMs have not been much investigated. In order to extend research in this area, we aimed to investigate the prevalence of PM prescription among a sample of inpatients with COVID-19 and to find potential predictors of initiation of PMs in these individuals.

METHODS

This is a cross-sectional single-center study, conducted during the first outbreak peak in a hospital of northern Italy. Information on socio-demographic characteristics, comorbidities, routine blood test, use of potential COVID-19 treatments, and length of stay were retrieved from medical records.

RESULTS

Data were available for 151 inpatients. Forty-seven of them (31.1%) started at least one prescription of a PM. PM prescription was significantly inversely associated with lymphocyte and platelet counts. A significant association was also found for lactate dehydrogenase (LDH).

CONCLUSION

Our findings suggest that the initiation of PMs could be common among COVID-19 inpatients. Lymphocyte and platelet counts as well as LDH levels may reflect neuropsychiatric complications of COVID-19.

Direct Measures of Medication Effects: Exploring the Scientific Utility of Behavior-Analytic Assessments

The purpose of the current study was to explore the scientific utility of two behavior analytic assessments (i.e., progressive ratio and demand assessments) for psychotropic medication evaluation. For a sample of 23 children with disabilities who were prescribed medication, we conducted a series of generalizability and optimization studies to identify sources of score variance and conditions in which stable estimates of behavior can be obtained. To inform construct validity, we calculated correlations between scores from each assessment and those from a standardized behavior rating scale (Aberrant Behavior Checklist-Second Edition; ABC-2). Results offer initial support for the scientific utility of progressive ratio scores. More research is needed to evaluate sensitivity to change and construct validity of scores from these and other behavior analytic assessments.

Weight Gain and Mental Health in the Canadian Prison Population

Most inmates gain excessive bodyweight during incarceration in Canadian federal penitentiaries. It is currently unknown if the weight gain is related to participants' higher prevalence of mental illness and/or psychotropic medication use. This study examined how weight change (kg) and body mass index (BMI) change (kg/m²) of 1,420 participants were associated with mental health status and psychotropic medication use. Participants who took psychotropic medications did not gain more weight during incarceration compared to their counterparts who were not taking psychotropic medications (6.5 kg vs. 6.0 kg, p = 0.87, respectively). However, participants taking psychotropic medications were more likely to be overweight or obese, which means they already had higher BMI at the beginning of their incarceration as opposed to gaining more weight during incarceration. Weight gain of participants observed during incarceration in Canadian federal penitentiaries was not related to the higher prevalence of mental illness or psychotropic medication use.

Long-term functional stability of problem behavior exposed to psychotropic medications

Psychopharmacological and behavioral interventions are often combined in the treatment of problem behavior in people with intellectual and developmental disability (IDD). However, little is known about the interaction between medication pharmacodynamics and behavior function. A better understanding of these mechanisms could serve as the conceptual foundation for combined interventions. The current analysis is a systematic replication of Valdovinos et al. (2009). We conducted continuous functional analyses within analogue reversal and parametric analyses monitoring the impact of various dosages of primarily antipsychotic medications on problem behavior and its function. Four individuals with IDD and problem behavior who were also receiving psychotropic medications participated. Medication adjustments produced small to negligible decreases in problem behavior, and behavior function remained largely unchanged through the 14 medication adjustments evaluated. The continuous functional analysis helped to identify what could be delayed medication effects on problem behavior. The clinical and methodological implications of this replication are discussed.

Medication Adherence in Adolescents with Psychiatric Disorders

Objective: This study investigates whether adolescents' adherence to psychotropic medication is associated with demographic and socioeconomic factors, and to what extent parents' assessments of their offspring's attitudes toward treatment correspond with the adolescents' self-report. Methods: This study is part of the multicenter SEMA study (Subjective Experience and Medication Adherence in Adolescents with Psychiatric Disorders). Adolescents' subjective attitudes toward medication and their adherence were assessed using the patient and parent versions of the QATT (Questionnaire on Attitudes Toward Treatment) and the MARS (Medication Adherence Rating Scale). Furthermore, we collected socioeconomic and demographic data. Results: Of the n = 75 adolescents included in the study, n = 45 (60 %) were classified as completely adherent. Patients receiving monotherapy were more often completely adherent than those receiving a combination of different medications. There was no statistically significant association between adherence and demographic or socioeconomic factors. Consensus between adolescents and their parents regarding adolescents' attitudes toward treatment ranged from slight (κ = 0.157) to fair (κ = 0.205). Conclusion: Incomplete medication adherence in adolescents with psychiatric disorders is a common phenomenon and still poorly understood. Demographic and socioeconomic factors do not seem to be relevant in this respect. However, adolescents' subjective attitudes towards medication, which parents are presumably unable to adequately assess, warrant more careful consideration in future research.

Gender Differences in the Prevalence of Mental Health, Psychological Distress and Psychotropic Medication Consumption in Spain: A Nationwide Population-Based Study

BACKGROUND

To assess gender differences in the prevalence of self-reported mental disorders, psychological distress and psychotropic drug consumption, and to identify sociodemographic and health-related variables associated with these conditions in the male and female population (aged ≥ 18 years).

METHODS

A cross-sectional study was carried on 22,141 subjects aged 18 and over, using data from the Spanish National Health Interview Survey 2017.

RESULTS

We found an overall prevalence of mental disorders, psychological distress and psychotropic drug consumption of 13.8%, 18.3% and 13.9%, respectively. After multivariable adjustment, women showed significantly increased probabilities of 1.74-fold for mental disorders, 1.26-fold for psychological distress and 1.26-fold for psychotropic drug consumption compared to men. Variables such as gender, age, nationality, marital status, educational level, self-rated health, the presence of different chronic disorders, alcohol consumption and smoking habit were independently associated with mental disorders, psychological distress and psychotropic drug consumption. Several variables showed a differential effect on mental health status and psychotropic drug consumption according to gender.

CONCLUSIONS

Women suffer from mental disorders, experience psychological distress and consume psychotropic drugs significantly more than men in Spain. Possible explanations for these results may be related to differences in emotional processing, willingness to report diseases and even intrinsic biological traits. Screening for mental health status and psychotropic drug consumption should be considered, particularly in Spanish women, younger adults and individuals who are not married, are obese, have poor self-rated health, suffer from chronic diseases or have a smoking habit.

The Use of Antidepressants, Antipsychotics, and Stimulants in Youth Residential Care

Objectives: To assess the use of three commonly prescribed psychotropic medications in youth placed in residential care (RC). Methods: Participants were youth aged 0-20 years placed in RC institutions at least once during 2016. Data on filled prescriptions were taken from the Norwegian Prescription Database to compare the use of antidepressants, antipsychotics, and stimulants in RC with the age- and gender-adjusted general child population (GenPop) and how this co-varied with reasons for RC placement, age, and gender. Results: One thousand eight hundred fifty-six children and adolescents were identified in RC, with mean age 14 (range 0-20 years), 46% girls, 81% ≥ 13 years. Among those, 423 or 23% used any of the 3 psychotropics, which was significantly more than the 3.7% in GenPop. The prevalence ratios RC/GenPop were 6.6 for antidepressants, 17.9 for antipsychotics, and 4.4 for stimulants. The median number of days per year for the dispensed defined daily doses varied from 8.3 to 244.0 for the different antipsychotics, indicating short time use for most of the people. Polypharmacy was not frequent in RC, as only 26% used ≥2 classes of medication, but still significantly more frequent than the 10% in GenPop. Youth placed in RC for serious behavior problems had significantly higher use of stimulants than those with other placement reasons. Psychotropics were not used below age 6 years, and although the use of antidepressants and antipsychotics overall increased with age, stimulants were mostly used by 6-16-year olds. The girl/boy ratio for any psychotropic medication use in RC was 1.4 (95% confidence interval [95% CI]: 1.1-1.6), significantly higher than the corresponding ratio in GenPop: 1.0 (95% CI: 0.9-1.0). Conclusion: The present findings do not necessarily suggest an overtreatment with medication in RC. However, the frequent short-term use of antipsychotics, presumably for non-psychotic symptoms, is a concern, as it may reflect that the youth are not provided with the recommended first-line psychological treatments.

Evidence for Reduced Long-Term Potentiation-Like Visual Cortical Plasticity in Schizophrenia and Bipolar Disorder

Several lines of research suggest that impairments in long-term potentiation (LTP)-like synaptic plasticity might be a key pathophysiological mechanism in schizophrenia (SZ) and bipolar disorder type I (BDI) and II (BDII). Using modulations of visually evoked potentials (VEP) of the electroencephalogram, impaired LTP-like visual cortical plasticity has been implicated in patients with BDII, while there has been conflicting evidence in SZ, a lack of research in BDI, and mixed results regarding associations with symptom severity, mood states, and medication. We measured the VEP of patients with SZ spectrum disorders (n = 31), BDI (n = 34), BDII (n = 33), and other BD spectrum disorders (n = 2), and age-matched healthy control (HC) participants (n = 200) before and after prolonged visual stimulation. Compared to HCs, modulation of VEP component N1b, but not C1 or P1, was impaired both in patients within the SZ spectrum (χ 2 = 35.1, P = 3.1 × 10-9) and BD spectrum (χ 2 = 7.0, P = 8.2 × 10-3), including BDI (χ 2 = 6.4, P = .012), but not BDII (χ 2 = 2.2, P = .14). N1b modulation was also more severely impaired in SZ spectrum than BD spectrum patients (χ 2 = 14.2, P = 1.7 × 10-4). N1b modulation was not significantly associated with Positive and Negative Syndrome Scale (PANSS) negative or positive symptoms scores, number of psychotic episodes, Montgomery and Åsberg Depression Rating Scale (MADRS) scores, or Young Mania Rating Scale (YMRS) scores after multiple comparison correction, although a nominal association was observed between N1b modulation and PANSS negative symptoms scores among SZ spectrum patients. These results suggest that LTP-like plasticity is impaired in SZ and BD. Adding to previous genetic, pharmacological, and electrophysiological evidence, these results implicate aberrant synaptic plasticity as a mechanism underlying SZ and BD.

Do clinical psychologists have a role in clients' use of psychotropic medication? A mixed methods investigation exploring current forms of involvement

OBJECTIVES

This study aimed to explore whether clinical psychologists in the United Kingdom (UK) have a role with their clients' psychotropic medication by exploring forms of involvement undertaken, and decision-making behind involvement.

DESIGN

A mixed methods design was employed; 147 clinical psychologists took part in an online survey, and 11 respondents were interviewed, selected using intensity sampling.

METHODS

Descriptive statistics and thematic analysis were used to analyse the quantitative and qualitative data, respectively.

RESULTS

All respondents reported having some role with their clients' psychotropic medication. A thematic map diagram was created to capture the process of how clinical psychologists choose to become involved.

CONCLUSIONS

Consensus was reached in that clinical psychologists do have a role with their clients' psychotropic medication, although this varies by clinician and takes on many forms. In the light of the changing role, professional guidance would help to promote clarity and consistency.

PRACTITIONER POINTS

Clinical psychologists are regularly engaging in roles in relation to their clients' psychotropic medication use despite little guidance or training. Findings identify a range of specific roles in relation to psychotropic medication that psychologists can take including formulating the impact of psychotropic medication, supplying information to support informed consent and withdrawal, and questioning and challenging use of psychotropic medication with colleagues and prescribers. There is a need for further research and consideration around roles given movements towards prescribing rights for psychologists (by the British Psychological Society) and recent guidance published for psychological therapists on enabling conversations with clients withdrawing from or taking psychiatric drugs (Guy et al., 2019, Guidance for psychological therapists: Enabling conversations with clients taking or withdrawing from prescribed psychiatric drugs, APPG for Prescribed Drug Dependence, London, UK).

Prevalence of psychotropic and opioid prescribing among hospice beneficiaries in the United States, 2014-2016

BACKGROUND/OBJECTIVES

Psychotropic and opioid medications are routinely prescribed for symptom management in hospice, but national estimates of prescribing are lacking. Changes in Medicare hospice payment in 2014 provide the first opportunity to examine psychotropic and opioid prescribing among hospice beneficiaries, and the factors associated with use of specific medication classes.

DESIGN

Cross-sectional analysis of a 20% sample of traditional and managed Medicare with Part D enrolled in hospice, 2014-2016.

SETTING

Beneficiaries enrolled in the Medicare hospice benefit.

PARTICIPANTS

Medicare beneficiaries ≥65 newly enrolled in hospice between July 1, 2014 and December 31, 2016 (N = 554,022).

MAIN OUTCOME

Prevalence of psychotropic and opioid medication prescribing by class and factors associated with prescribing.

RESULTS

70.3% of hospice beneficiaries were prescribed a psychotropic and 63.3% were prescribed an opioid. The most common psychotropic classes prescribed were: benzodiazepines (60.6%), antipsychotics (38.3%), antidepressants (18.4%), and antiepileptics (10.2%). Lorazepam (56.4%), morphine (52.8%), and haloperidol (28.6%) were received by the most beneficiaries. Prevalence of any psychotropic and opioid prescription was highest among beneficiaries who were female (76.7%), non-Hispanic white (76.6%), and those with cancer (78.9%). Compared to white beneficiaries, non-Hispanic black beneficiaries were less likely to receive nearly every class of medication, with significantly lower odds of receiving opioids (64.1% vs 57.9%; AOR 0.75, 95% CI 0.72-0.77) and benzodiazepines (61.6% vs 52.2%; AOR 0.66, 95% CI 0.64-0.68). Differences were seen across hospice diagnosis; those with cancer were more likely to receive opioids, benzodiazepines, and antipsychotics but less likely to receive antidepressants and antiepileptics.

CONCLUSIONS

Psychotropic and opioid medications are frequently prescribed in hospice. Observed variations in prescribing across race and ethnicity may reflect disparities in prescribing as well as patient preferences for care. Further work is important to understand factors driving prescribing given limited studies surrounding medication prescribing in hospice.

Medication Use in Youth With Autism and Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Children with autism spectrum disorder (ASD) may benefit from medication to treat a diverse array of behaviors and health conditions common in this population including co-occurring conditions associated with ASD, such as attention-deficit/hyperactivity disorder (ADHD) and anxiety. However, prescribing guidelines are lacking and research providing national estimates of medication use in youth with ASD is scant. We examined a nationally representative sample of children and youth ages 6 to 17 with a current diagnosis of ASD to estimate the prevalence and correlates of psychotropic medication.

METHODS

This study used data from the 2016 and 2017 National Survey of Children's Health. We estimated unadjusted prevalence rates and used multivariable logistic regression to estimate the odds of medication use in children and youth across 3 groups: those with ASD-only, those with ASD and ADHD, and those with ADHD-only.

RESULTS

Two thirds of children ages 6 to 11 and three quarters of youth ages 12 to 17 with ASD and ADHD were taking medication, similar to children (73%) and youth with ADHD-only (70%) and more than children (13%) and youth with ASD-only (22%). There were no correlates of medication use that were consistent across group and medication type. Youth with ASD and ADHD were more likely to be taking medication for emotion, concentration, or behavior than youth with ADHD-only, and nearly half took ASD-specific medication.

CONCLUSIONS

This study adds to the literature on medication use in children and youth with ASD, presenting recent, nationally representative estimates of high prevalence of psychotropic drug use among children with ASD and ADHD.

Prevalence of psychotropic medication and factors associated with antipsychotic treatment in adults with intellectual disabilities: a cross-sectional, epidemiological study in Germany

BACKGROUND

Mental health services in people with intellectual disabilities (ID) are frequently limited to psychotropic medication (PM), especially antipsychotics. The objectives of this study were to assess the prevalence rates of PM treatment in adults with ID in Germany and to identify factors associated with antipsychotic treatment.

METHODS

This study is an epidemiological, cross-sectional study. Sampling was realised by a random selection of service-providing institutions, followed by a random selection of adults with ID within these participating institutions. Interviews were conducted with formal and informal carers of n = 197 adults with ID. Data were analysed using descriptive statistics and risk ratios.

RESULTS

The 4-week prevalence rate of PM was 53.8%. Antipsychotics were the most frequent PM (43.7%). Polypharmacy and off-label use were common. Antipsychotic treatment is associated with living in a residential home [relative risk (RR) = 2.99], not working in a sheltered workshop (RR = 1.46), autism spectrum disorder (RR = 1.89), a documented psychiatric diagnosis (RR = 1.61), psychiatric symptomatology (RR = 1.44) and (mild) challenging behaviours (RR = 4.58).

CONCLUSIONS

Further efforts are needed to provide adequate mental health care, specifically to improve PM treatment regarding amount, indication and the consideration of non-psychopharmacological treatment options.

[The prevalence of psychiatric diagnoses and psychotropic medication in icelandic nursing homes from 2003 to 2018]

INTRODUCTION

Research shows a high prevalence of mental disorders and psychotropic medication among older people, especially in nursing homes. Knowledge of this concerning issue among Icelandic nursing homes residents is limited, despite its importance for mental health policymaking. Therefore, the aim of this study was to investigate the prevalence of psychiatric diagnoses and psychotropic medication in Icelandic nursing homes, the relationship between these factors and how they have evolved from 2003 to 2018.

MATERIAL AND METHODS

The research data comes from interRAI MDS 2.0 assessments for nursing home residents in Iceland, for the period 2003-2018. The study uses the last assessment of each year (N=47,526).

RESULTS

Approximately half of the residents were diagnosed with anxiety and/or depression; 49.4% in 2003 and 54.5% in 2018. The use of psychotropic drugs increased from 66.3% to 72.5%. Antidepressants were most commonly utilized, with an increase from 47.5% to 56.2%. The use of antipsychotics drugs has remained nearly unchanged, at around 26%. Inconsistency was found between psychotropic medication and psychiatric diagnoses; on average, 18.2% of the residents took psychotropic drugs without being diagnosed and 22.3% took antipsychotics in other cases than recommended.

CONCLUSION

Age related changes influence the effect of psychotropic drugs and studies have not supported their positive long-term effects for older people who are also sensitive to associated adverse effects, especially in cases of polypharmacy. Therefore, it is important that psychotropic drugs use is based on accurate mental health assessment. To reduce psychotropic medication, other mental health interventions need to be developed.