Showing papers on "Psychotropic drug published in 1999"

Drugs and Falls in Older People: A Systematic Review and Meta‐analysis: I. Psychotropic Drugs

Abstract: OBJECTIVES: To evaluate critically the evidence linking psychotropic drugs with falls in older people. DESIGN: Fixed-effects meta-analysis. DATA SOURCES: English-language articles in MEDLINE (1966 – March 1996) indexed under accidents or accidental falls and aged or age factors; bibliographies of retrieved papers. STUDY SELECTION: Systematic evaluation of sedative/hypnotic, antidepressant, or neuroleptic use with falling in people aged 60 and older. DATA EXTRACTION: Study design, inclusion and exclusion criteria, setting, sample size, response rate, mean age, method of medication verification and fall assessment, fall definition, and the number of fallers and non-fallers taking specific classes of psychotropic drugs. RESULTS: Forty studies, none randomized controlled trials, met eligibility criteria. For one or more falls, the pooled odds ratio (95% confidence interval) was 1.73 (95%CI, 1.52-1.97) for any psychotropic use; 1.50 (95%CI, 1.25-1.79) for neuroleptic use; 1.54 (95%CI, 1.40-1.70) for sedative/hypnotic use; 1.66 (95%CI, 1.4-1.95) for any antidepressant use (mainly TCAs); 1.51 (95%CI, 1.14-2.00) for only TCA use; and 1.48 (95%CI, 1.23-1.77) for benzodiazepine use, with no difference between short and long acting benzodiazepines. For neuroleptics in psychiatric inpatients, the pooled OR was 0.41 (95%CI, 0.21-.82); for all other patients, the pooled OR was 1.66 (95%CI, 1.38-2.00). Comparing ≥1 with ≥ 2 falls, mean subject age >75 versus ≥ 75 years old, communities with >35% versus ≥35% fallers, or subject place of residence did not affect the pooled OR. Increased falls occurred in patients taking more than one psychotropic drug. CONCLUSION: There is a small, but consistent, association between the use of most classes of psychotropic drugs and falls. The evidence to date, however, is based solely on observational data, with minimal adjustment for confounders, dosage, or duration of therapy. The incidence of falls and their consequences in this population necessitate that future large randomized controlled trials of any medication in older persons should measure falls prospectively as an adverse outcome event.

The prescribing of psychotropic drugs by primary care physicians : an International collaborative study

Abstract: Psychotropic drugs play a major role in primary care management of mental disorders. This study expands the existing data on prescribing practices using data from a 15-center, primary care epidemiologic survey. Questions to be addressed include the following: Which clinical and nonclinical factors are related to the prescribing of psychotropic drugs by primary care physicians? How do prescribing patterns vary across primary care centers? At each center, primary care patients were screened using the General Health Questionnaire, and a stratified random sample completed a standardized diagnostic assessment. For each patient completing the diagnostic assessment, the treating primary care physician provided data on clinical diagnosis and medications prescribed. Study results indicated that 11.5% of all practice attenders, 51.7% of cases who received a diagnosis of mental disorders by a physician, and 27.6% of cases who received a diagnosis using the Composite International Diagnostic Interview were treated with psychotropic medication because of their psychologic problems. Anxiolytics, hypnotics, and antidepressants each accounted for approximately 20% of all prescriptions. Prescription rates increased with the prominence of psychologic complaints, severity of mental disorder, severity of social disability, female gender, age older than 40 years, lower education, unemployment, and marital separation. Rates and type of drugs also varied among specific mental disorders; 19.3% of patients with brief recurrent depression but 55.0% with agoraphobia got any psychotropic drug. Antidepressant drugs were prescribed in 7.7% of anxiety disorders compared with 31.9% of depressive disorders. There were large differences between international centers. When comparing client-type centers with clinic-type centers, overall prescription rates were similar (51.2 vs. 52.9%), but significant differences were observed with respect to psychotropic polypharmacy (12.6% client, 6.3% clinic), tranquilizer medication (24.2 client, 32.9% clinic), and antidepressant medication (17.3 client, 8.9% clinic). Psychotropic drugs have an important role in the treatment of mental disorders by general practitioners. Prescription is associated with a number of clinical but also nonclinical factors that must be recognized when guidelines for international use are to be published. Recognition of mental disorders and selection of specific drug classes are important areas in which medical practice needs improvement.

Seizure risk associated with psychotropic drugs: clinical and pharmacokinetic considerations.

Abstract: Psychiatric co-morbidity with epilepsy is common and often requires the combined use of psychotropic and antiepileptic drugs (AEDs). Antidepressants and antipsychotic agents are believed to lower the threshold for new-onset seizures and recurrent seizures in epilepsy patients. Factors that influence the risk for seizures during psychotropic drug therapy include the intrinsic convulsant potential of the drug, the drug dosage and plasma concentration, and patient-related risk factors for seizure occurrence. Available evidence supports an increased risk for seizures associated with antidepressant and antipsychotic agents in overdose and during therapeutic use of high doses of selected drugs. However, a clear differentiation in seizure risk between most antidepressants and antipsychotics used at low to moderate therapeutic doses is not often possible. Limited studies of psychotropic drug use in patients with epilepsy demonstrate that these agents usually have a positive effect on the underlying psychiatric condition without an adverse effect on seizure occurrence. Pharmacokinetic interactions between AEDs and psychotropic drugs are common. Plasma concentration monitoring is often useful for minimizing the adverse consequences of these drug-drug interactions.

Benzodiazepine use among the elderly in the community

Abstract: Benzodiazepines are the most commonly prescribed psychotropic drug in the elderly. Benzodiazepines with a long duration of action can produce marked sedation and psychomotor impairment in older people, and are associated with an increased risk of hip fracture and of motor vehicle crash. One thousand seven hundred and one individuals of 65 years and over, identified from General Practitioner lists, were interviewed using the Geriatric Mental State-AGECAT package and current psychotropic drug use was recorded. Benzodiazepines were classified as having a short or long elimination half-life. Two hundred and ninety-five (17.3%) individuals were taking a benzodiazepine, with use in females being twice that in males. Of the 295, 152 (51.5%) were taking a long acting benzodiazepine and the use of long acting anxiolytic type benzodiazepines was particularly common. Fifty-two (17.6%) benzodiazepine users were taking one or more other psychotropic drugs. A benzodiazepine was used by eight of 18 (44.4%) subjects with an anxiety disorder, 62 of 180 (34.4%) individuals with depression, and seven of 71 (9.9%) people with dementia. Four-fifths of older people on a psychotropic drug were taking a benzodiazepine, highlighting the importance of this class of drug in the elderly population. The choice of a benzodiazepine with a long duration of action, which have been shown to be associated with serious adverse events in the elderly in over one half of benzodiazepine users, is of concern. The potential for adverse effects was further accentuated by polypharmacy practices. The choice of benzodiazepine for an older person has important consequences and should be addressed in greater detail with primary care. Copyright © 1999 John Wiley & Sons, Ltd.

Alopecia Due to Psychotropic Medications

Abstract: OBJECTIVE:To review the literature and describe the incidence and nature of psychotropic drug–related alopecia to assist clinicians in their therapeutic decisions when this adverse event occurs.DATA SOURCES:A MEDLINE search (December 1966–March 1998), using each drug name and the keywords alopecia or hair loss, was conducted. A database from the Clarke Institute of Psychiatry in Toronto was also searched. Additional English-language articles were identified through the bibliography of the reviewed literature. Certain pharmaceutical companies were also consulted.STUDY SELECTION:All published case reports and review articles were considered for study evaluation.DATA EXTRACTION:When possible, details regarding psychotropic drug therapy, development of alopecia, and clinical outcomes were collected for each case.DATA SYNTHESIS:Hair loss from the scalp, eyebrows, and pubic area was identified as a possible, yet uncommon, adverse effect of most psychotropic medications. There are few effective management option...

Patient Race and Ethnicity in Primary Care Management of Child Behavior Problems: A Report From Pros and Aspn

Abstract: Background. Minority persons have less access to many specialty treatments and services, possibly because of clinician biases. It is not clear whether any such biases exist in primary care settings, especially for children with psychosocial problems. Objectives. The objective was to compare primary care recognition and treatment of pediatric psychosocial problems among African American, Hispanic American and European American patients. Design. A survey was made of parents and respective clinicians in primary care offices in two large practice-based research networks (PROS and ASPN) from 44 states, Canada, and Puerto Rico. Mixed regression analyses were employed to control for patient, clinician, and practice effects. Subjects. The subjects were 14,910 children aged 4 to 15 years seen consecutively for nonemergent care by 286 primary care clinicians in office-based practice. Measures. Measures were parents' report for sociodemographics and behavioral symptoms using the Pediatric Symptom Checklist, and clinicians' report of psychosocial problems, type, management, and severity. Results. Of the sample, 8.0% were African American youth, 9.5% were Hispanic American youth, and 82.5% were European American youth. After controlling for other factors, race and ethnicity were not associated with any differences in psychotropic drug prescribing, counseling, referral, or recognition of psychosocial problems. Clinicians reported spending slightly more time with minority patients. Conclusion. Race and ethnic status were not related to receipt of mental health services for children in primary care offices, suggesting that clinician biases may not be the primary cause of the racial differences in services noted earlier research. Improving services for minority youth may require increasing access to office-based primary care.

Counseling by primary care physicians of patients who disclose psychosocial problems.

Abstract: BACKGROUND Most descriptive studies of psychosocial counseling by US primary care physicians (PCPs) have relied on the PCPs' recollections rather than researchers' observations of actual visit content. The latter approach should yield more accurate measurement of counseling frequency and duration. METHODS Our sample consisted of 308 patients whose scores signified psychological distress on the 28-item General Health Questionnaire. Their visits to 69 community-based PCPs had been audiotaped for an earlier study of the benefits of communication skills training for PCPs. Using those tapes, we identified the disclosure of psychosocial problems by patients and subsequent counseling and psychotropic drug prescribing by their PCPs. We timed counseling and visit lengths. Effects of patient and PCP variables on visit duration and on counseling occurrence and duration were assessed using generalized estimating equations to accommodate the correlation among patients who shared PCPs. RESULTS After adjusting for the effects of the communication skills training, we found that PCPs counseled 60% of patients who disclosed psychosocial problems. Given disclosure, counseling probability was lowest for new patients (P <.001); among patients with previous visits, counseling probability was inversely related to the number of visits (P <.001). When provided, counseling had a mean duration of 5.2 minutes. Counseling was associated with a 28% (95% confidence interval, 9%-49%) increase in visit duration after adjustment for the effects of other significant variables. PCPs prescribed psychotropic medications in 30% of visits with disclosure. CONCLUSIONS PCPs treated psychosocial problems with brief counseling twice as often as with medication. Brief counseling interventions caused small but significant increases in visit durations.

Psychotropic Drug Prescription in a Psychiatric University Hospital

Abstract: A retrospective survey on drug prescription over a one-year period (1989) in 1083 patients (48.3% of whom were male) hospitalized in a psychiatric university hospital in Switzerland and a 35-day prospective study (1992) on the prescription of "as needed" (prn) medication in a closed and an open ward were carried out. Their aim was to establish a basis for a monitoring of prescription habits and for pharmacoeconomic considerations. In the retrospective study, 48.3% of the patients were male. The mean duration of hospitalization of the patients was 47.0 +/- 68.1 days (mean +/- s.d.). Only 11 out of the 1083 patients (1%) were without psychotropic medication. The mean (+/- SD) number of drugs/day the patients were prescribed was 4.6 +/- 2.8, including 3.2 +/- 1.7 psychotropic drugs. Patients suffering from schizophrenia (67 d) or from unipolar depression (67.4 d) were hospitalized for the longest periods. Antipsychotics (67.5% of the patients) were the most frequently prescribed psychotropic drugs, followed by anxiolytics (42.2%), antidepressants (28.3%), hypnotics (31.4%) and mood stabilizers (7.1%). Antiparkinsonian agents accounted for 4.6% of all prescriptions. Levomepromazine, haloperidol (30.9% of all patients) and clotiapine were the most often prescribed neuroleptics, and clozapine was administered to only 6.4% of all patients. Among the antidepressants, maprotiline (11.9% of all patients) was more frequently prescribed than the classical tricyclic antidepressant amitriptyline, while the only available SSRI fluvoxamine and MAO inhibitors were rarely used. The most frequently prescribed anxiolytics were clorazepate (28.2% of all patients), lorazepam, bromazepam, and prazepam. Among the hypnotic drugs, chloral hydrate (11.5%) was more frequently administered than the first-ranking benzodiazepine flunitrazepam (7.8%). In the prospective study, 97% and 77% of the patients (n = 55) of the closed (n = 29) and of the open ward, respectively, were prescribed "as needed" (prn) drugs. However, only 71 and 80%, respectively, of these patients finally received the drug. The frequency of prescription was 34.9% for neuroleptics, 15.1% for anxiolytic drugs, 8.2% for non-benzodiazepine hypnotics and only 2.1% for benzodiazepine hypnotics. The most frequently prescribed neuroleptic drug was clotiapine (18% of all patients), but finally, only 29% of the prescribed doses were administered. Studies of this type are biased by the fact that local habits of prescription do not allow generalisation of the findings. Such surveys should be carried out more frequently and simultaneously in different centers. Critical comparisons could help to optimize treatment.

Psychotropic drug utilization in long-term-care facilities for the elderly in Ontario, Canada.

Abstract: Objective: Despite considerable data from a number of countries regarding psychotropic utilization in long-term-care facilities for the elderly, there has been a lack of similar data from Canada. The purpose of this study was to gather prescription data from a series of institutions in Ontario and to compare the results to those of other international studies. Method: Single-day surveys were carried out in six homes for the aged, four nursing homes, two retirement homes, and a veterans' center. The results were compared to those of recent studies from other countries. Results: The data revealed considerable differences in rates of prescription between different classes of institutions and between similarly classified institutions. The prescription rate of neuroleptics ranged from 11.8% (of patients) in retirement homes to 29.8% in nursing homes. Antidepressant use ranged from 12.2% in nursing homes to 24.6% in homes for the aged, and benzodiazepine use ranged from 22.5% in nursing homes to 36.4% in retirement homes. Conclusions: The overall rate of prescription for psychotropic medications was somewhat lower than in most international studies. The rate of prescription of neuroleptics in nursing homes fell in the midrange of studies, somewhat higher than in recent studies from the United States and an earlier Italian study, but lower than in recent reports from Sweden, Austria, and Australia. The rate of neuroleptic use in homes for the aged was comparable to the rate in the U.S. studies. The overall rate of prescription of antidepressants and benzodiazepines appears to be comparable to that in recent studies from other countries.

Effects of sedation, stimulation, and placebo on cerebral blood oxygenation: a magnetic resonance neuroimaging study of psychotropic drug action.

Abstract: The effects of pharmacologic depression and stimulation of cerebral activity were investigated in seven healthy young volunteers using blood oxygenation-sensitive MRI at 2.0 T. Dynamic gradient-echo imaging (7 min) was performed before, during and after the intravenous application of 10 mg diazepam and 15 mg metamphetamine as well as of the corresponding drug placebos (isotonic saline) in a brain section covering frontotemporal gray matter, subcortical gray matter structures, and cerebellum. The MRI responses were significantly different for the two drugs applied (p = 0.01). Relative to signal strength during injection, metamphetamine elicited a signal increase of 0.97 ± 0.03% (mean ± SD, p = 0.02) within the whole section 4–5 min after injection. Similarly, both placebo conditions led to a small signal increase, i.e. 0.50 ± 0.03% (n.s.) for the metamphetamine placebo and 0.40 ± 0.07% (p = 0.03) for the diazepam placebo. Diazepam abolished this signal increase. A topographic analysis revealed the metamphetamine-induced signal increase to be more pronounced in subcortical gray matter structures (p = 0.01) and cerebellum (p = 0.02) than in frontotemporal cortical gray matter (p = 0.04). This finding is in agreement with the hypothesis that pertinent responses not only reflect global cerebral hemodynamic adjustments, but also localized perfusion changes coupled to alterations in synaptic activity. The occurrence of a placebo response is best explained by expectancy and may provide a confounding factor in the design of functional activation experiments. Copyright © 1999 John Wiley & Sons, Ltd.

Simultaneous measurement of dopamine, serotonin, their metabolites and tryptophan in mouse brain homogenates by high-performance liquid chromatography with dual coulometric detection.

Abstract: A new rapid and sensitive high-performance liquid chromatography (HPLC) method for the simultaneous determination of dopamine, 3,4-dihydroxyphenylacetic acid (DOPAC), 3-methoxytyramine, 5-hydroxytryptamine (serotonin), 5-hydroxyindoleacetic acid (5-HIAA), homovanillic acid and tryptophan has been developed and applied to mouse frontal cortex, caudate nucleus and dorsal raphe assays. A dual coulometric detector was used with detection at +0.25 and +0.55 V, which allowed the determination of tryptophan. Detection limits for all compounds (0.8-9.0 pg per injection, depending on the compounds) were useful for this application. Owing to great sensitivity of the method, the brain tissue samples can be very small, less than 2 mg. Linearity of standards was excellent (r > 0.999 in all cases). Intraday and interday precisions for samples analytes were generally acceptable (intraday assay CV 90%. Attention was paid to stability of standard and sample analytes when stored at +4 degrees C or at -70 degrees C with two different homogenizing agents (0.1 M HClO4 with 10(-7) M ascorbic acid and 0.05 M HClO4 without ascorbic acid). This simple, rapid and efficient method can be used as a basic research tool for modification of brain neurotransmitters in experimental pharmacological protocols for following psychotropic drug treatments in animals.

Treatment of anxiety during pregnancy: effects of psychotropic drug treatment on the developing fetus.

Abstract: Pregnancy is a time of great emotional change for a woman, producing increased stress and anxiety. Medication may be required for the treatment of anxiety disorders at this time. Given the fact that psychotropic drugs readily cross the placenta and could have important implications for the developing fetus, it is necessary to balance the possible effects of medication against the potential effects to both the mother and fetus if the anxiety disorder is left untreated. Despite the widespread use of psychotropic drugs such as benzodiazepines and antidepressants during pregnancy, there is a paucity of information regarding the effect of such exposure on the developing fetus. From a review of the literature it is clear that the issue of safety of psychotropic drugs during pregnancy is far from resolved. While some of the findings from animal studies are alarming, these studies cannot be directly extrapolated to humans. In addition, varying sample sizes and multiple drug exposures further complicate interpretation of human studies. Nonpharmacological treatments such as cognitive behavioural therapy should be employed whenever possible for the treatment of anxiety disorders during pregnancy. However, if medication is required pregnant women should be prescribed the lowest dosage for the minimum amount of time.

Management of and counseling for psychotropic drug-induced sexual dysfunction.

Abstract: Clinicians are increasingly faced with the need to identify, treat, and counsel patients regarding psychotropic drug-induced sexual dysfunction. Antipsychotic and antidepressant drugs have both rational mechanisms to explain their effects on sexual function and established literature documenting these effects. The agents have potential for causing decreased libido, delayed ejaculation, and anorgasmia. Management and counseling can be highly effective for patients taking these agents.

Book Review: Psychotropic Drug Handbook, 7th ed.:

Abstract: adequately, if not exhaustively, covered before the next chapter which, although entitled ‘Obstacles To Doctor–Patient Communication’ is more about the dynamics of communication with and about the patient and, as such, involves our own psychological processes. All of these chapters are enhanced by vignettes and systematically presented recommendations of dimensions to be considered, interventions to follow and frameworks for discussion. Underlying is an assumption that psychiatrists will have a coordinating role, which may not necessarily be the case. The chapter dealing with the highly charged dying child scenario is, as might be expected, the most poignant and sensitive but, nevertheless, this is not allowed to impede an objective systematic approach utilising the known principles of child development. Yet, one wonders how often child psychiatrists are involved, considering that death in childhood is comparatively rare and hospital departments of child psychiatry not numerous. The author percipiently notes that the psychiatrist’s role does not always end with the child’s death. The next chapter on HIV/AIDS is, one suspects, based on more extensive experience than that of other chapters. It leans heavily to euthanasia and narcissistic suicide, which some might have some problem in supporting. Unlike other chapters, it ends inconclusively, only pointing to the tasks and challenges ahead to which responses need to be formulated. Evaluation of requests and legal aspects lead into the essence of this book: the ethical underpinnings of our responses to requests to terminate suffering to the extent of physician-assisted suicide (PAS). The final chapter is a moral blast, arguing strongly that PAS and even lesser measures are a greater potential evil than suffering itself. The author compares these measures to a deadly virus that could infect and undermine the entire moral fabric of society. This is the only chapter without a list of references. Perhaps they are all in the bible. Four threads run through all of these chapters: (i) the need for better and more extensive palliative care (including pain control); (ii) greater appreciation of the role of the psychiatrist, in particular those in consultation–liaison; (iii) an assumed perfectibility of psychiatry in this particular area; and (iv) the dangers of undermining the moral status of the profession. M a rgaret Meade suggested that prior to Hippocrates, doctors and sorcerers were one and the same, possessing power both to kill and to heal. For the first time, the oaths specifically forbade the former, stipulating that physicians will not give a ‘deadly drug to anyone if asked for it, nor will (he) make a suggestion to this effect’. All psychiatrists, even those who never go near a hospital, could, with benefit, read the first chapter. The remainder is required reading for consultation– liaison psychiatrists and psychogeriatricians. Child psychiatrists should be ready to refer to the relevant chapter when the need arises. On PAS and euthanasia, the subject of chapter 8, the reader is directed to the clinical issues so well presented and discussed by Kelly and Varghese in this Journal [1].

Psychiatric Treatment of the Medically Ill

Abstract: Introduction Screening for Psychiatric Disorders in Medical Patients, Mark Zimmerman and Jill I. Mattia Specificity of Psychiatric Symptoms in the Medically Ill, Robert G. Robinson Epidemiology of Psychiatric Disorders in the Medically Ill, William R. Yates Specific Medical Disorders and Conditions Hypertension, Raymond Niaura and Michael G. Goldstein Psychological State, Arrhythmias, and Cardiac Mortality, Peter A. Shapiro and Steven P. Roose Noncardiac Chest Pain, Richard P. Fleet and Bernard D. Beitman Liver Disease and Transplantation, William R. Yates Renal Failure, Dialysis, and Transplantation, Norman B. Levy Endocrine Disorders, Caroline Carney Treatment of Psychiatric Disorders in Patients Infected with HIV, Glenn J. Treisman, Marc Fishman, Joseph M. Schwartz, Constantine G. Lyketsos, and Paul R. McHugh Pulmonary Disease and Lung Transplantation, Catherine L. Woodman and Joel N. Kline Cancer, Simon Wein Pregnancy and Postpartum, Michael W. O'Hara and Scott Stuart Menstrual Cycle-Associated Disorders, Susan R. Johnson Psychiatric Aspects of Cerebral Vascular Disorders, Robert G. Robinson and Sergio Paradiso Traumatic Brain Injury, Ricardo E. Jorge and Robert G. Robinson Epilepsy, Howard A. Ring Alzheimer's Disease and Other Dementias, Neal G. Ranen and Barry W. Rovner Sleep Disorders, Gabriele M. Barthlen Migraine and Other Headache Disorders, Kathleen R. Merikangas, Denise J. Stevens, and James R. Merikangas Parkinson's Disease, Sergio E. Starkstein and Gustavo Petracca Psychopharmacological Treatment in the Medically Ill Disorders Affecting Psychotropic Absorption, Metabolism, and Toxicity, Vicki L. Ellingrod Serum Level-Monitoring Strategies for Antipsychotics, Antidepressants, and Antimanic Agents, Paul J. Perry, Bruce Alexander, and Kristine A. Bever Effects of Aging on Psychotropic Efficacy and Toxicity, Susan K. Schultz and Del D. Miller Psychotropic Drug Interactions, C. Lindsay DeVane and Charles B. Nemeroff

QUALYOP project 2: monitoring the dismantling of Italian psychiatric hospitals. Psychotropic drug use in 1072 inpatients.

Abstract: Objective This study describes the use of psychotropic drugs in a sample of eight Italian psychiatric hospitals. Methods A cross-sectional approach was used to collect information about sociodemographic and clinical characteristics of the inpatient population, and about medications prescribed. Prescribing behaviour in the hospitals was compared using three indicators: the number of patients taking psychotropic drugs, the use of high doses of neuroleptics and the use of multiple neuroleptics. Results More than a thousand patients were resident in the eight hospitals on the census day, 56% of them males. Half the population had an ICD-X diagnosis of schizophrenia, one third of mental retardation. Sixty-nine percent of the sample was on neuroleptic therapy, nearly 47% on benzodiazepines and 4% on antidepressants. Twenty percent of the sample did not take any psychotropic drug on the census day. After adjustment for sociodemographic and clinical variables, setting-related variables resulted as determinants of psychotropic drug use. Conclusions These data call for continuing education in psychopharmacology towards a more rational use of drugs; longitudinal audits of clinical practice should be implemented to guide clinicians toward a more rational use of psychotropic drugs. Copyright © 1999 John Wiley & Sons, Ltd.

Introduction: A Guide for Practitioners, Professionals, and Public

Abstract: This chapter, more than any other, is written for nonmedical professionals and parents to introduce them to what may at first seem a dauntingly arcane field and to empower them to seek good information. It sets the scene for all the other chapters by introducing some basic terminology and concepts, most of which are familiar to prescribers. However, hopefully even they will benefit from a quick overview and reminder of things they know.

Resolution of Nomifensine Enantiomers on Selected Achiral and Chiral Stationary Phases Using High Performance Liquid Chromatography

Abstract: The separation of the enantiomers of nomifensine maleate, a psychotropic drug, were investigated using achiral and chiral stationary phases Three stationary phases were studied for their ability to separate the enantiomers: reversed phase cyanopropyl with a chiral mobile phase additive; inclusion (cellulose tris 3,5-dimethylphenyl carbonate (chiracel OD); and brush/pirkle type (S-tert-leucine, (R)-1-(α-naphthyl) ethylamine (Sumichiral OA-4700). Changes in mobile phase composition were studied to determine the effect of solvents on the separation of the enantiomers. Baseline separations were achieved for nomifensine enantiomers under isocratic conditions on the cyanopropyl column with 90:10 v/v 0.1% triethylamine-acetonitrile pH 4.0 (adjusted by trifluoroacetic acid) containing 10 mM β-cyclodextrin, on a Chiracel OD column using hexane-absolute methanol (96:4 v/v), and on a Sumichiral OA-4700.column using hexane-dichloroethane-absolute ethanol-trifluoroacetic acid (100:12.5:8.5:0.1v/v/v/v). The fl...

PSYCHIATRIC GENETICS '99 The Challenges of Psychopharmacogenetics

Abstract: Residing at the intersection of two relatively young fields—psychopharmacology and pharmacogenetics— psychopharmacogenetics is only now becoming recognized as a biomedical discipline in its own right. The introduction of chlorpromazine, in 1952, for the treatment of psychotic disorders, may be considered to mark the birth of psychopharmacology. Since that time, a wide array of psychotropic drugs have been applied to the treatment of various psychiatric conditions, including anxiety disorders and such mood disorders as depression and mania. Clinical experience quickly accumulated, indicating that these drugs are of variable usefulness. Stark interindividual differences in outcome and side effects are distressingly common for this group of therapeutic drugs. Early on, and continuing to this day, psychiatrists have relied on clinical experience and, not infrequently, guesswork to predict the outcome of prescribing a standard dosage of a psychotropic drug. Increasingly, however, evidence—which is often anecdotal but which is sometimes based on the results of family and twin studies—has suggested that genetic factors underlie (1) the observed interindividual and interethnic or racial differences in psychopharmacological response (Smith and Mendoza 1996; Frackiewicz et al. 1997; Varner et al. 1998) and (2) the concordant responses, among relatives, to antidepressant therapy (Franchini et al. 1998). Thus, perhaps to their own surprise, psychiatrists have found themselves concerned about familial patterns of drug kinetics and about polymorphisms in genes for receptors or enzymes, although both of these issues have traditionally been the province of pharmacogeneticists. As originally defined by Vogel (1959), pharmacogenetics is the study of the heritable differences in the metabolism and activity of exogenous agents such as drugs

Gender, Ethnic, and Geographic Variations in Psychotropic Drug Use Among Children Enrolled in Medicaid

Abstract: This study examines variations in psychotropic drug use among children enrolled in Medicaid during 1995 in two midwestern states. A dataset was created from Kansas Medicaid prescription reimbursement claims and enrollment files that included age, gender, ethnicity, diagnoses, and drugs prescribed for each of the 5,574 children under age 20 years who received at least one psychotropic drug prescription in 1995. A similar database composed of information on 41,031 children from another midwestern state was used for comparisons between the two states. We found that boys were far more likely to receive psychotropic drug prescriptions than were girls. The overall ratio of male to female psychotropic drug users is highest among younger children and nearly equal among older adolescents. While African-American and Hispanic children represented 23% and 12%, respectively, of all children enrolled in Medicaid, they accounted for only 12% and 3.5% of psychotropic drug users, respectively. The striking differences in psychotropic drug use found suggest that patient gender may influence diagnosis and treatment in a way that physiological differences alone cannot account for. Ethnic disparities found here indicate possible access problems or underdiagnoses for minority children. Future efforts to improve the mental health of young people must include attempts to identify the causes of these disparities.

Gerontopsychiatric competence is in demand. The current psychopharmacologic treatment practice in homes for the aged and nursing homes

Abstract: OBJECTIVE: A growing proportion of residents of residential and nursing homes is mentally ill and subject to intensive pharmacotherapy. This study presents data on the use of psychotropic drugs use in residential and nursing homes for the elderly in the new Lander. METHOD: The psychotropic drug use of 560 residents of 4 old-people's homes in Leipzig (Germany) was reviewed and analysed descriptively. RESULTS: Half of the population of residential and nursing homes receives psychotropic drug treatment, a substantial part with 2 or more drugs a day. Middle- and long-acting benzodiazepines were prescribed strikingly often and used for long-term treatment. Antidepressants, taken regularly by 3.6% of the nursing homes residents and 2.6% of the residential home residents, are considered to be under-used. The introduction of new substances (e.g. atypical neuroleptics, SSRI's) which might be more appropriate in vulnerable and multimorbide elderly persons was found to be delayed. CONCLUSIONS: The treatment of mental disorders in residential and nursing homes lags far behind the "state of the art" and demonstrates the need for gerontopsychiatric input into institutional care for the elderly.

Psychotropic Drug Prescription for Chronic Psychiatric Patients in a Long-Stay Care Facility

Abstract: SUMMARY Despite some methodological shortcomings, audits of prescription practice repeated at appropriate intervals may be useful in revealing discrepancies between recommended guidelines for psychotropic drug administration and actual clinical practice. The authors conducted a survey of psychopharmacotherapy of 158 chronic, mostly schizophrenic, patients treated in a long-stay care rehabilitation facility in Hong Kong. In keeping with guidelines widely accepted in the literature, patients, were found to be maintained on a median daily dose of 300 mg chlorpromazine equivalent (CPZeg) of antipsychotic medication. About one-fifth of the patients, particularly those with relatively late-onset schizophrenic illness, did not need any psychotropic medication. Aspects of pharmacotherapy identified as requiring more attention included polypharmacy, especially the co-administration of more than one antipsychotic drag, the underutilization of depot antipsychotics, prolonged treatment with the antiparkinsonian drug benzhexol and the frequent use of multiple divided daily doses of antipsychotic agents. Key words: quality assurance, antipsychotic drugs, antiparkinsonian drugs, prescribing pattern, psychiatric rehabilitation INTRODUCTION Controlled clinical trials have shown that low or moderate doses of antipsychotic drugs, i.e. 300 to 700 mg of CPZ or its equivalent, are adequate for most patients in the treatment of acute episodes of schizophrenia (Rifkin et al., 1991; Smith, 1994). In the majority of cases, high-dose antipsychotic medication appears to offer no advantage over the standard dose regime (Baldessarini et al, 1988; Thomson, 1994) However, optimal antipsychotic dosage for long tens treatment of chronic schizophrenic patients is less clear (Johnson, 1985). Recent dose reduction studies in chronic schizophrenia have proven that more than half of the patients can be maintained on minimal doses (100-300 mg CPZeq) without noticeable deterioration in their clinical condition (Faraone et al., 1989; Smith, 1994; Gilbert et al., 1995). However, most pharmaco-epidemiological surveys have also revealed that actual clinical practice fails to conform to recent psychopharmacological guidelines (Michel & Kolakowska, 1981; Clark & Holden, 1987). Such disparitis in prescribing practice also exist in Hong Kong. A local survey found trot the mean antipsychotic dose for acutely ill schizophrenic patients treated in a general hospital psychiatric unit was 589 mg CPZ equivalent daily (Chiu et al., 1992) while chronic schizophrenic patients in a large mental hospital received a mean dose of 1049 mg CPZeq of antipsychotic meditation (Chiu et al., 1991). Patients in a long-stay rehabilitation facility were taking a surprisingly high mean dose of 698 mg CPZeq (Ungvari et al, 1996). All three local surveys detected prescribing practices characterized by polypharmacy, prolonged administration of anticholinergic antiparkinsonian agents and use of multiple divided doses of antipsychotics, although such prescription patterns are discouraged by contemporary textbooks and review articles (e.g. Baldessarini et al., 1988, Potkin et al., 1993, Kane, 1995). There are a number of clinical benefits to using cross-sectional surveys. First, while limited in accuracy and generalizability, such surveys are easy to carry out and Indicate a trend of prescribing habits which may reveal discrepancies between standard recommendations and actual clinical practice in a particular setting. Second, repeated at regular intervals, cross-sectional surveys may reveal harmful prescription trends in a given setting and facilitate a closer scrutiny of psychopharmacological treatment habits of individual teams. Finally, they may serve as one of the global indicators of quality of care. Surveys which provide indicators of rational pharmacotherapy are particularly important in the rehabilitation of chronic patients where the emphasis is usually placed on the psychosocial aspects of rehabilitation Rational pharmacotherapy enhances the likelihood of successful rehabilitation for the chronic patients by providing optimal, albeit not absolute, symptom control while reducing side effects, improving drug compliance, reducing drug expenditure and saving nursing time. …

Psychotropic drug prescribing: first the good news.

Abstract: Despite improvements there is still a need for skill development in psychiatry

Genotoxicity Evaluation of Haloperidol on Human Lymphocytes in vitro

Abstract: Haloperidol, a butyrophenone antipshchotic drug, wax evaluated for its cytogenetic effects in vitro on human lymphocytes. Peripheral blood cultures were set up from three normal healthy donors for ...

Communication and Teamwork: Studies of the Impact on Quality of Drug Use in Swedish Nursing Homes

Abstract: This thesis examines factors that affect the quality of drug-use practices in Swedish nursing homes.The analysis comprises six consecutive studies. Data from the first four studies come from a randomizedcontrolled trial conducted in 1994-1995 with the primary aim of assessing the impact of regularmultidisciplinary team interventions on the quantity and quality of drug prescribing in 36 nursing homes. Facilities in the experimental group participated in an outreach program designed to influence drug use through improved teamwork among physicians, pharmacists, nurses, and nurse's assistants. The data for the last two studies come from a follow-up study in the same sample of nursing homes.Baseline results showed extensive psychotropic drug prescribing, with the most commonly prescribeddrugs being hypnotics (40%), anxiolytics (40%), and antipsychotics (38%). After 12 months of team meetings in nursing homes in the experimental group, there was a significant decrease in the prescribing of inappropriate drugs, as defined by recommendations from the Swedish Medical Product Agency.Pharmacists documented the nature of drug-related problems discussed during the meetings, as well as staff member assessments of resident outcomes. The most common drug-related problems were unclear indications and the appropriate choice of drugs. Nineteen percent of changes in drug therapy had a beneficial effect on the resident's reported clinical status while 47% of changes resulted in no observable changes in clinical outcome. Eight percent of the changes were considered to have had a negative effect on the resident. In these situations, the previous therapy was restored. The remaining 26% were too complicated to evaluate; it was not possible for nursing staff to assess whether a behavioral change was a result of the change in drug therapy.Quality indicators based on published guidelines and recommendations were developed to measure quality of drug use. Using the facility as the unit of analysis, there was a great variation among facilities in the quality of drug use. Resident characteristics (age, sex, diagnosis) did not contribute to variation among facilities in the 1995 study; rather, facilities with multidisciplinary teams and/or a staff: resident ratio above the median, were found to have higher quality of drug use.To assess the long-term effects of the multidisciplinary team intervention, a follow-up study on druguse was conducted in 1998. In addition, nurses in the study's 36 nursing homes were interviewed regarding the quality of their communication with physicians.Three factors accounted for the major part of the variation in the quality of drug use in the follow-upstudy: Whether or not the homes received the experimental intervention; the perceived quality of nursephysician communication; and the proportion of residents with behavioral symptoms.In summary, this thesis provides convincing evidence that the level of drug use in Swedish nursinghomes is high, and the choice of drugs for use in the nursing home population is often inappropriate. Further, clinical characteristics of residents-explain some, but not all, of the large variation in the quality of drug use among facilities. Factors associated with higher quality of drug use include higher perceived quality of nurse-physician communication, and exposure to the structured multidisciplinary team intervention.