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Background:Benzodiazepines (BZs) and selective serotonin reuptake inhibitors (SSRIs) are effective in the pharmacologic treatment of panic disorder (PD). However, treatment guidelines favor SSRIs over BZs based on the belief that BZs are associated with more adverse effects than SSRIs. This belief, however, is currently supported only by opinion and anecdotes.Aim:The aim of this review and meta-analysis was to determine if there truly is evidence that BZs cause more adverse effects than SSRIs in acute PD treatment.Methods:We systematically searched Web of Science, PubMed, Cochrane Central Register of Controlled Trials, and clinical trials register databases. Short randomized clinical trials of a minimum of four weeks and a maximum of 12 weeks that studied SSRIs or BZs compared to placebo in acute PD treatment were included in a meta-analysis. The primary outcome was all-cause adverse event rate in participants who received SSRIs, BZs, or placebo.Results:Overall, the meta-analysis showed that SSRIs cause more adverse events than BZs in short-term PD treatment. Specifically, SSRI treatment was a risk factor for diaphoresis, fatigue, nausea, diarrhea, and insomnia, whereas BZ treatment was a risk factor for memory problems, constipation, and dry mouth. Both classes of drugs were associated with somnolence. SSRIs were associated with abnormal ejaculation, while BZs were associated with libido reduction. BZs were protective against tachycardia, diaphoresis, fatigue, and insomnia.Conclusion:Randomized, blinded studies comparing SSRIs and BZs for the short-term treatment of PD should be performed. Clinical guidelines based on incontrovertible evidence are needed.

Objectives To investigate the relation between the risk of Alzheimer’s disease and exposure to benzodiazepines started at least five years before, considering both the dose-response relation and prodromes (anxiety, depression, insomnia) possibly linked with treatment. Design Case-control study. Setting The Quebec health insurance program database (RAMQ). Participants 1796 people with a first diagnosis of Alzheimer’s disease and followed up for at least six years before were matched with 7184 controls on sex, age group, and duration of follow-up. Both groups were randomly sampled from older people (age >66) living in the community in 2000-09. Main outcome measure The association between Alzheimer’s disease and benzodiazepine use started at least five years before diagnosis was assessed by using multivariable conditional logistic regression. Ever exposure to benzodiazepines was first considered and then categorised according to the cumulative dose expressed as prescribed daily doses (1-90, 91-180, >180) and the drug elimination half life. Results Benzodiazepine ever use was associated with an increased risk of Alzheimer’s disease (adjusted odds ratio 1.51, 95% confidence interval 1.36 to 1.69; further adjustment on anxiety, depression, and insomnia did not markedly alter this result: 1.43, 1.28 to 1.60). No association was found for a cumulative dose 180 prescribed daily doses) and with the drug half life (1.43 (1.27 to 1.61) for short acting drugs and 1.70 (1.46 to 1.98) for long acting ones). Conclusion Benzodiazepine use is associated with an increased risk of Alzheimer’s disease. The stronger association observed for long term exposures reinforces the suspicion of a possible direct association, even if benzodiazepine use might also be an early marker of a condition associated with an increased risk of dementia. Unwarranted long term use of these drugs should be considered as a public health concern.

Objective:This study examined the association between a Medicaid prior-authorization policy for second-generation antipsychotic and anticonvulsant agents and medication discontinuation and health service use by patients with bipolar disorder. Methods:A pre-post design with a historical comparison group was used to analyze Maine Medicaid and Medicare claims data. A total of 946 newly treated patients were identified during the eight-month policy (July 2003–February 2004), and a comparison group of 1,014 was identified from the prepolicy period (July 2002–February 2003). Patients were stratified by number of visits to community mental health centers (CMHCs) before medication initiation (proxy for illness severity): CMHC attenders, at least two visits; nonattenders, fewer than two. Changes in rates of medication discontinuation and outpatient, emergency room, and hospital visits were estimated. Results:Compared with nonattenders, at baseline CMHC attenders had substantially higher rates of comorbid mental di...

Atypical antipsychotic drugs have been used off label in clinical practice for treatment of serious dementia-associated agitation and aggression. Following reports of cerebrovascular adverse events associated with the use of atypical antipsychotics in elderly patients with dementia, the U.S. Food and Drug Administration (FDA) issued black box warnings for several atypical antipsychotics titled "Cerebrovascular Adverse Events, Including Stroke, in Elderly Patients With Dementia." Subsequently, the FDA initiated a metaanalysis of safety data from 17 registration trials across 6 antipsychotic drugs (5 atypical antipsychotics and haloperidol). In 2005, the FDA issued a black box warning regarding increased risk of mortality associated with the use of atypical antipsychotic drugs in this patient population.Geriatric mental health experts participating in a 2006 consensus conference (Bethesda, Md., June 28-29) reviewed evidence on the safety and efficacy of antipsychotics, as well as nonpharmacologic approaches, in treating dementia-related symptoms of agitation and aggression. EVIDENCE/CONSENSUS PROCESS: The participants concluded that, while problems in clinical trial designs may have been one of the contributors to the failure to find a signal of drug efficacy, the findings related to drug safety should be taken seriously by clinicians in assessing the potential risks and benefits of treatment in a frail population, and in advising families about treatment. Information provided to patients and family members should be documented in the patient's chart. Drugs should be used only when nonpharmacologic approaches have failed to adequately control behavioral disruption. Participants also agreed that there is a need for an FDA-approved medication for the treatment of severe, persistent, or recurrent dementia-related symptoms of agitation and aggression (even in the absence of psychosis) that are unresponsive to nonpharmacologic intervention.This article outlines methodological enhancements to better evaluate treatment approaches in future registration trials and provides an algorithm for improving the treatment of these patients in nursing home and non-nursing home settings.

Anticonvulsants are being used clinically as monotherapy and adjuncts in mental illnesses other than affective disorders. This review focuses on the literature for anticonvulsants and lithium in substance use disorders, anxiety disorders, and schizophrenia. Given the abuse potential and other difficulties with prescribing benzodiazepines for alcohol and benzodiazepine withdrawal, anticonvulsants have been considered as an alternative. Promising therapeutic effects have been demonstrated in many of the anxiety disorders, with the greatest number of trials and positive results in posttraumatic stress disorder. Although anticonvulsant and lithium augmentation for schizophrenia is common in practice and has been studied in double-blind, randomized, controlled trials, the sum of the evidence has been inconclusive.

Background Treatment studies of depression in residential care are limited. Reports of predictors of response are rare. In the largest nursing home prospective antidepressant trial reported, we examined predictors of response. Methods This was a 12-week open-label study of mirtazapine orally disintegrating tablets performed in 30 US nursing homes. Subjects were men and women aged ≥70, with a Mini Mental State Exam (MMSE) score ≥10, who had a depressive disorder that required antidepressant treatment. Mirtazapine was started at 15 mg at bedtime, and adjusted to 15–45 mg/day. A 16-item Hamilton Depression Rating Scale was used to assess depression at baseline, weeks 2, 4, 8, and 12 or early termination. Results One hundred and twenty-four patients received at least one dose of study drug and of these, 119 had at least one post-drug assessment. Mean age was 82.9 years and 72% were female. Response rates at 12 weeks were 47% on the HAMD and 54% on the CGI. Age, sex, MMSE score, medical burden, history of prior depression, and baseline HAMD severity were not significantly associated with HAMD response (≥50% improvement) and in most cases correlations were trivial

Atypical antipsychotic drugs are primarily indicated for the treatment of psychotic disorders such as schizophrenia and schizoaffective disorder. Recently, they have also been used for mood stabilization. This article reviews other, potentially therapeutically useful indications for these medications. In most cases, the evidence supporting these new uses is limited but provocative, and involves only case reports. It has not yet been determined whether the usefulness of atypical antipsychotics for nonpsychotic disorders outweighs their potential to cause serious side effects.

To consider the limited usefulness of expert guidelines for teaching psychopharmacology.Potential problems using expert guidelines for teaching psychopharmacology are reviewed.Expert guidelines are an important contribution to the growth of evidence-based psychiatry. As such, they may also be used to teach fundamentals of psychopharmacology. Their use as teaching materials may be limited by their reliance on Diagnostic and Statistical manual of Mental Disorders (DSM) diagnoses, especially for patients with unclear or complicated diagnosing pictures. Biases may also exist in their construction and the data from which they are derived. Other problems include overemphasis on newly released medications and the potential for teaching a "cookbook" approach to psychopharmacology treatment, limiting the development of the "art" of psychopharmacology practice.Although expert guidelines may be a useful tool for teaching psychopharmacology, they also may limit the teaching of psychopharmacology. Comprehensive psychopharmacology training programs that use expert guidelines as teaching tools should emphasize critical reading of clinical trials literature and teaching the use of all psychotropic drugs. Training in the art of psychopharmacology including, nonpharmacological aspects of drug treatment, should also be included.

The objective of this study was to determine whether long-term benzodiazepine use is associated with dose escalation.The authors examined changes in dose and the frequency of dose escalation among new and continuing (at least two years) recipients of benzodiazepines identified from a database containing drug-dispensing and health care use data for all New Jersey Medicaid patients for 39 months. Independent variables included age; Medicaid eligibility category; gender; race or ethnicity; neighborhood socioeconomic variables; chronic illnesses, such as schizophrenia, bipolar illness, panic disorder, and seizure disorder; and predominant benzodiazepine received. Logistic regression analyses were conducted to determine the association between the independent variables and escalation to a high dosage (at least 20 diazepam milligram equivalents [DMEs] per day for elderly patients and at least 40 DMEs per day for younger patients).A total of 2,440 patients were identified, comprising 460 new and 1,980 continuing recipients. Seventy-one percent of continuing recipients had a permanent disability. Among all groups of continuing recipients, the median daily dosage remained constant at 10 DMEs during two years of continuous use. No clinically or statistically significant changes in dosage were observed over time. The incidence of escalation to a high dosage was 1.6 percent. Subgroups with a higher risk of dose escalation included antidepressant recipients and patients who filled duplicate prescriptions for benzodiazepines at different pharmacies within seven days. Elderly and disabled persons had a lower risk of dose escalation than younger patients.The results of this study did not support the hypothesis that long-term use of benzodiazepines frequently results in notable dose escalation.

This commentary focuses on psychopharmacology teachers and their teaching. The authors offer broadly based pedagogic suggestions on how to deliver evidence-based and neurobiologically informed prescribing information to clinicians at all levels of experience. They argue that teaching essential psychopharmacology knowledge and practice must be up-to-date, accurate, and consistent with the reality of an individual patient’s life experience and beliefs. They stress that educators must teach that nonpsychopharmacological factors in a patient’s life may be as relevant to the treatment setting as the actual pharmacological basis of psychotropic drug therapeutics.

Quetiapine is an atypical antipsychotic agent that does not appear to increase patient risk for treatment-emergent extrapyramidal symptoms (EPS) or anticholinergic symptoms. Previous studies of quetiapine use in elderly patients with schizophrenia and other psychoses examined short-term administration (or = 12 weeks). Given the growing elderly population, the commensurate increase in elderly patients with psychoses, and the expected increase in disease treatment-years, the effect of long-term quetiapine administration in older patients is of considerable interest.This study assesses the long-term tolerability, safety, and clinical benefit of quetiapine in elderly patients with psychosis.Elderly patients (or = 65 years of age) with psychotic disorders, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, participated in this 52-week, open-label, multicenter trial. Investigators increased (and later adjusted) daily doses of quetiapine on the basis of clinical response and tolerability, and assessed safety and efficacy. Efficacy assessments were made using the 18-item Brief Psychiatric Rating Scale (BPRS), Clinical Global Impressions (CGI), Simpson-Angus Scale, and the Abnormal Involuntary Movement Scale (AIMS). For patients who withdrew before week 52, analyses were performed using observed data and the last observation carried forward.One hundred eighty-four patients with psychotic disorders (98 women and 86 men) with a mean age of 76.1 years entered the trial. Seventy-two percent had psychotic disorders due to general medical conditions such as Alzheimer's disease, and 28% had other psychotic disorders, most commonly schizophrenia. Overall, 89 (48%) patients completed treatment through 52 weeks. Median total daily dose was 137.5 mg. Reasons, for withdrawal included lack of efficacy (19%), adverse events or intercurrent illness (15%), failure to return for follow-up (13%), protocol noncompliance (3%), and diminished need for treatment (2%). Somnolence (31%), dizziness (17%), and postural hypotension (15%) were common adverse events, but they rarely resulted in withdrawal from therapy. EPS-related adverse events occurred in 13% of patients. At end point (week 52), mean total score on the Simpson-Angus Scale had decreased from baseline by 1.8 points, whereas changes in AIMS scores were negligible. No clinically important effects were reported relative to mean changes in hematologic, thyroid function, or hepatic function variables. Quetiapine treatment appeared to have no associated cardiovascular adverse outcomes despite cardiovascular comorbidities and unrestricted use of concomitant cardiovascular medications. Significant decreases in BPRS total score (n = 170, P0.001) and CGI Severity of Illness item score (n = 177, P0.002) were seen at end point (observed data and last observation carried forward). Decreases ofor = 20% in mean BPRS total score were observed in 83 (49%) patients.These results provide preliminary information to clinicians regarding tolerability, safety, and clinical improvement with quetiapine in elderly patients with psychotic symptoms, and support controlled studies of quetiapine in this patient population.

Benzodiazepines have been used in the United States for more than three decades as treatment for anxiety, panic, and disturbed sleep. l e 2 Nonpsychiatric physicians commonly prescribe them for brief periods as part of acute medical treatments; psychiatrists administer them more often on a prolonged or even chronic basis. Although benzodiazepines are members of the sedativehypnotic class of psychotropic drugs, they are among the safest medications known; they have virtually no lethal potential when taken alone, and few meaningful interactions when taken together with other drugs. Compared with previously available sedativehypnotic agents, they represent a major pharmacological advance in the treatment of anxiety.3 As with the barbiturates and with meprobamate before them, controversy has swirled around the use of benzodiazepines since their introduction, and it shows no sign of abating.'g The controversy is focused on three concerns: the potential for abuse, especially as a consequence of therapeutic use; the advisability of long-term use, in light of dependence and withdrapal symptoms; and side effects, particularly cognitive impairment. Conflicting opinions regarding these concerns (summarized in Table 1) leave patients and clinicians bewildered when they must decide whether a benzodiazepine is appropriate for therapeutic purposes.

(1995). Resistant Depression in the Very Old—A Role for Maintenance ECT? Harvard Review of Psychiatry: Vol. 3, No. 3, pp. 152-155.

Most studies of the elderly use age 65 as the definition of the onset of old age, and most studies of the pharmacologic treatment of depression in the elderly focus on patients between the ages of 60 and 70. Very few patients over the age of 75 have been specifically studied, and virtually none over the age of 80. Data for this review of treatment of depressed patients over the age of 75 were derived from a larger review prepared for a 1992 NIMH consensus development conference on the diagnosis and treatment of depression in late life. Available studies were divided into three categories: 1) mixed-age studies that include subjects over 75 (n = 18); 2) mixed-age reports of patients having a mean age of 75 or older (n = 13); and 3) reports including only patients with minimum age of 75 years or older (>n = 5). Data are available from only 171 identifiable patients over the age of 75. Consequently, available data for patients in this very old age category are too limited for reliable or valid treatment recommendations to be made; further research is necessary.

Benzodiazepines are widely prescribed drugs. Most patients are prescribed benzodiazepines for short periods of time for anxiolytic or hypnotic purposes. However, some benzodiazepines are also used for extended periods at high doses to treat panic and agoraphobic disorders. When chronically prescribed benzodiazepines are discontinued, a predictable pattern of discontinuance symptoms may develop, indicating physiological dependence. Benzodiazepines also produce a variety of side effects including sedation, reduced coordination, and impaired cognition, which are primarily related to dose and duration of treatment. Benzodiazepines are commonly used by polysubstance abusers but their abuse as recreational drugs when taken alone is rare, and high-dose treatment for panic and agoraphobic symptoms does not lead to abuse. Prescribing guidelines are offered.

In a controlled study, benzodiazepine treatment was gradually discontinued from a group of elderly nursing home residents. In comparison with similar residents who continued on benzodiazepines, measures of memory and cognitive functioning showed significant improvement following discontinuance. There was no associated increase in anxiety, agitation, or sleeplessness. These data are consistent with previous observations suggesting that benzodiazepines impair cognitive function in the elderly and further indicate that such impairment is reversible upon benzodiazepine discontinuance.

Nonbarbiturate hypnotics• •? .[B] [C] [C]All cause respiratorydepression and increase sedation Alldecreaseantipsychotic serumlevels Hypotension ingarecommendation by the Food and DrugAdministration in Novem ber 1989 that its use be curtailed due to the incidence of eosinophilia myalgia syndrome. As in the past, because of space limitations references cannot be in cluded here but will be provided by the authors on request. Reprints are also available on request.

The most common complaints of older adults concern their difficulty initiating or maintaining sleep, which results in insufficient sleep and an increased risk of falls, difficulty with concentration and memory, and overall decreased quality of life. Difficulties sleeping are not, however, an inevitable part of aging. Rather, the sleep complaints are often comorbid with medical and psychiatric illness, associated with the medications used to treat those illnesses, or the result of circadian rhythm changes or other sleep disorders. Health care professionals specializing in geriatrics need to learn to recognize the different causes of sleep disturbances in this population and to initiate appropriate treatment. Nonpharmacological treatment techniques are discussed; pharmacological treatments are discussed in a companion article.

Disturbed sleep is common in the elderly, who, as a group, take a disproportionately large number of hypnotic medications. Benzodiazepine hypnotics, as well as the newer benzodiazepine receptor agonists, are the primary treatments for these late-life sleep disorders and are effective and safe when used within recommended prescribing guidelines. The elderly also receive other psychiatric medications to induce sleep, although these are off-label uses not well supported by research literature. There is also no literature support for the use of over-the-counter sleep preparations, although both melatonin and a melatonin receptor agonist appear to be moderately effective and safe. Prescribing guidelines for the elderly continue to emphasize short-term, low-dose use, with short-half-life medications. Hypnotic drugs should be used in conjunction with nonmedication treatments, including appropriate sleep hygiene practice, and treatment of other medical or psychiatric causes of disturbed sleep.

How do we best teach clinical psychopharmacology to trainees and clinicians, so they not only increase their knowledge base, but even more importantly also learn to practice the most informed, evidence-based practice possible? This article attempts to answer this elusive question by compiling the individual and combined wisdom of 5 expert psychopharmacology teachers, each of whom draws on years of their own experiences as master educators. The topics covered include teaching clinical psychopharmacological competence in adult psychiatry residency training and in issues specific to both pediatric and geriatric populations, teaching physicians to improve clinical outcomes through continuing medical education, and new developments in adult-centered pedagogy and assessment. Although the focus of this article is on practical pearls found useful in teaching psychiatric residents and practicing physicians, the lessons learned are applicable to other groups of learners such as medical students, other trainees, and nonmedical clinicians. Our goal is to help educators produce competent psychopharmacology clinicians schooled in the latest evidence, capable of keeping up with new knowledge as it becomes available, and practicing both the art and science of expert clinical care.

In elderly persons, antipsychotic drugs are clinically prescribed off-label for a number of disorders outside of their Food and Drug Administration (FDA)-approved indications (schizophrenia and bipolar disorder). The largest number of antipsychotic prescriptions in older adults is for behavioral disturbances associated with dementia. In April 2005, the FDA, based on a meta-analysis of 17 double-blind randomized placebo-controlled trials among elderly people with dementia, determined that atypical antipsychotics were associated with a significantly (1.6-1.7 times) greater mortality risk compared with placebo, and asked that drug manufacturers add a 'black box' warning to prescribing information for these drugs. Most deaths were due to either cardiac or infectious causes, the two most common immediate causes of death in dementia in general. Clinicians, patients, and caregivers are left with unclear choices of treatment for dementia patients with psychosis and/or severe agitation. Not only are psychosis and agitation common in persons with dementia but they also frequently cause considerable caregiver distress and hasten institutionalization of patients. At the same time, there is a paucity of evidence-based treatment alternatives to antipsychotics for this population. Thus, there is insufficient evidence to suggest that psychotropics other than antipsychotics represent an overall effective and safe, let alone better, treatment choice for psychosis or agitation in dementia; currently no such treatment has been approved by the FDA for these symptoms. Similarly, the data on the efficacy of specific psychosocial treatments in patients with dementia are limited and inconclusive. The goal of this White Paper is to review relevant issues and make clinical and research recommendations regarding the treatment of elderly dementia patients with psychosis and/or agitation. The role of shared decision making and caution in using pharmacotherapy for these patients is stressed.

Drs. Torous, Stern, Padmanabhan, Keshavan and Perez are to be congratulated for defining and describing a psychiatric resident training program to encourage neuroscience learning. As these authors eloquently describe, specific knowledge of brain function is beginning to clarify our understanding of some, if not many, psychiatric disorders. The authors are careful to point out that our expanding neuroscience information base has not yet yielded reliable and always reproducible clinical treatment results, but the emerging data are encouraging. As the authors indicate, we now understand specific functions of many brain anatomical sites, their inter-site circuitry, their genetic origin, as well as the microcircuitry that is necessary for the extraordinary communication between neuronal pathways throughout the brain. The authors then provide a clinical example of neuroscience teaching using a clinical example: the neurological basis of symptoms of a depressed patient and the application of this information to suggest new and more specific therapeutic approaches. I was particularly taken by the analogy of impaired brain circuitry with an urban traffic jam that may have many causes: dysfunctional traffic signals (circuit nodes), street and highway construction (pathways), impaired road materials (neurotransmitters), and planning (genes). Together, dysfunction in these areas can bring traffic to a standstill, somewhat like some psychiatric disorders. Other traffic problems may contribute to broken restraints and traffic guidelines leading to wild and disorganized driving and potential mayhem. But here is where the analogy may become simplistic and potentially misleading, as is, I believe, the forecast of neuroscience based treatment that will finally bring about development of more effective psychiatric treatments. Automobile traffic may be halted by many different

Atypical antipsychotics have become a common pharmacologic option for the treatment of various psychiatric and behavioral symptoms in older adults, although these medications have been officially approved by the U.S. Food and Drug Administration for use only in schizophrenia and bipolar disorder. Despite the widespread use of these agents, there is a relative shortage of rigorously conducted trials. This review focuses on recently published randomized, blinded, controlled trials involving the use of atypical antipsychotics in elderly patients with dementia (n = 9) or schizophrenia (n = 3), with some discussion of published large, open-label studies and a few unpublished controlled trials. In general, the studies of patients with dementia reported modest efficacy of atypical antipsychotics when compared to placebo and conventional antipsychotics. In addition, an advantage in terms of motor side effects was consistently noted with atypical antipsychotics when compared to conventional antipsychotics. The studies have also shown, however, a greater risk of mortality and adverse cerebrovascular events with several of these agents than with placebo in individuals with dementia. There are insufficient data comparing atypical antipsychotics to one another. In the trials involving elderly persons with schizophrenia, atypical antipsychotics were associated with significant improvements in psychopathology; differences in efficacy among atypical antipsychotics were unclear. A careful consideration of the risk-benefit ratio of atypical antipsychotics, as well as that of available alternative treatments, is needed for each individual elderly patient. Clinical judgment, caution, and consent should be the watchwords in this area of psychopharmacology.

Objective: Benzodiazepines (BZs) are safe, effective drugs for treating anxiety, sleep, bipolar, and convulsive disorders, but concern is often expressed about their overuse and potential for abuse. We evaluated the effects of physician surveillance through a Triplicate Prescription Program (TPP) on problematic and non-problematic BZ use. Method: This study uses interrupted time series analyses of BZ use in the New York (intervention) and New Jersey (control) Medicaid programs for 12 months before and 24 months after the New York BZ TPP. The regulation required NY physicians to order BZs on triplicate prescription forms with one copy forwarded by pharmacies to a state surveillance unit. Study participants were community-dwelling persons over age 18 continuously enrolled between January 1988 and December 1990 in New York ( n = 125,837) or New Jersey Medicaid ( n = 139,405). Results: During the baseline year, 20.2% of New York and 19.3% of New Jersey cohort members received at least one BZ prescription. After the TPP, there was a sudden, sustained reduction in BZ use of 54.8% (95% CI = [51.4%, 58.3%]) in New York with no changes in New Jersey. Significantly greater reductions were experienced by young women, and persons living in zip codes that were urban, predominantly Black, or with a high density of poor households. Increases in potential substitute medications were modest. At baseline, nearly 60% of BZ recipients had no evidence of potentially problematic use. Despite a somewhat greater likelihood of discontinuation of BZ therapy among those with potentially problematic use, the largest impact of the TPP was a substantially greater relative reduction in access to BZs among non-problematic users. Conclusions: State-mandated physician surveillance dramatically reduces BZ use with limited substitution of alternative drugs, lowers rates of possible abuse, but may severely limit non-problematic BZ use.

The aging of the world’s population has resulted in a new demographic phenomenon: a significant increase in the percentage of elderly compared with the general population. Between 1960 and 1990, the general population in the U.S. increased by less than 50%, while those over 65 increased by almost 100%, and those over 85 years of age increased by almost 250% (1).

To evaluate the efficacy and tolerability of mirtazapine orally disintegrating tablets in depressed, elderly nursing home residents, under naturalistic study conditions.In this open-label 12-week study, mirtazapine orally disintegrating tablets (15-45 mg/day) were administered to patientsor =70 years old with physician-diagnosed depression and a Mini-Mental State Examination (MMSE) scoreor =10. Patients with medical comorbidities, cognitive impairment and/or concomitant medications were enrolled if they met study inclusion criteria and had illnesses and/or medication dosages that were considered stable. Assessments were performed at baseline by physicians and at days 14, 28, 56, and 84 (or early termination) by physicians or nurse coordinators using the Clinical Global Impression (CGI) scale, the 16-item Hamilton Rating Scale for depression (Ham-D-16 (the standard 17-item scale minus item 14)), and the Cornell Scale for Depression in Dementia (CSDD). Tolerability was evaluated based on treatment-emergent adverse events.A total of 119 patients in the intent-to-treat (ITT) group were treated with mirtazapine orally disintegrating tablets (mean daily dose: 19.4 mg) and evaluated for efficacy. At endpoint, 54% of patients in the ITT group showed CGI-I response (defined as a CGI-I score of 1 or 2 ('very much' or 'much' improved) and 47% were Ham-D-16 responders (defined as decrease from baseline of at least 50% in Ham-D-16 total score). CSDD mean scores and Ham-D-16 mean total scores demonstrated a progressive decrease from baseline to trial completion. The decrease in Ham-D scores from baseline to day 84 was statistically significant (p0.0001). Mean changes from baseline to day 84 were -6.6 +/- 6.9 (CSDD score) and -7.9 +/- 7.4 (Ham-D-16 total score). Ham-D Factor I, Factor VI and item 1 scores also decreased. Fourteen of 124 patients in the all-subjects-treated (AST) group (11.3%) discontinued prematurely due to adverse events. The most frequently occurring adverse events were urinary tract infection (19%), accidental injury (18%), fall (18%), somnolence (12%), and upper respiratory infection (12%). Mean body weight increased by 0.7 +/- 2.25 kg (1.54 +/- 5 lb) from baseline to day 28, and by 1.3 +/- 3.36 kg (2.86 +/- 7.4 lb) from baseline to day 84.The results suggest that mirtazapine orally disintegrating tablets provide antidepressant efficacy and are a relatively well-tolerated treatment for depression in this patient population of elderly nursing home residents with medical and cognitive comorbidities.

Background: Benzodiazepines are treatment mainstays for several disorders, but there is often concern about dependency and addiction. In January 1989, New York implemented regulations requiring physicians to order benzodiazepines using state-monitored triplicate prescription forms. Objective: The purpose of this study was to assess the effects of the triplicate prescription program (TPP) on changes in use of benzodiazepines and other psychoactive drugs in clinically vulnerable Medicaid populations. Methods: Using an interrupted time series with comparison series design, psychoactive medication use was examined in the New York (intervention) and New Jersey (control) Medicaid programs before and after implementation of the New York benzodiazepine TPP among community-dwelling Medicaid beneficiaries aged ≥19 years continuously enrolled from January 1988 through December 1990 in New York or New Jersey with diagnoses of schizophrenia, schizophreniform disorder, schizoaffective disorder, schizoid personality disorder, or schizotypal personality disorder; bipolar disorder; epilepsy; and/or panic disorder, agoraphobia without history of panic disorder, social phobia, or specific phobia. Results: A total of 125,837 New York and 139,405 New Jersey Medicaid beneficiaries were continuously enrolled and met the study inclusion criteria. Of these, there were 6054 Medicaid enrollees in New York and 6875 enrollees in New Jersey who were clinically vulnerable patients with ≥1 of the specified diagnoses. New York Medicaid patients with any of these diagnoses experienced a −48.1% relative change (95% CI, −50.0% to −46.2%) in benzodiazepine use at 6 months after TPP implementation, with no decline in use in New Jersey patients. The largest reduction in benzodiazepine use was seen among patients with seizure disorder (−59.9% at 6 months; 95% CI, −63.9% to −55.9%). Although use of substitute drugs increased slightly in New York after the TPP, it did not offset reductions in benzodiazepine use. The effects of TPP were sustained for 7 years of follow-up and had the greatest impact on nonproblematic benzodiazepine use. Conclusions: During the time period studied in this analysis, the New York TPP reduced benzodiazepine use among chronically ill patients for whom these agents represent effective treatment. Our findings suggest that many patients previously receiving benzodiazepines did not receive any pharmacologic intervention.

Objectives To review progress made during the past decade in late-life mood disorders and to identify areas of unmet need in health care delivery and research. Participants The Consensus Development Panel consisted of experts in late-life mood disorders, geriatrics, primary care, mental health and aging policy research, and advocacy. Evidence (1) Literature reviews addressing risk factors, prevention, diagnosis, treatment, and delivery of services and (2) opinions and experiences of primary care and mental health care providers, policy analysts, and advocates. Consensus Process The Consensus Development Panel listened to presentations and participated in discussions. Workgroups considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed and edited to incorporate input from the entire Consensus Development Panel. Conclusions Despite the availability of safe and efficacious treatments, mood disorders remain a significant health care issue for the elderly and are associated with disability, functional decline, diminished quality of life, mortality from comorbid medical conditions or suicide, demands on caregivers, and increased service utilization. Discriminatory coverage and reimbursement policies for mental health care are a challenge for the elderly, especially those with modest incomes, and for clinicians. Minorities are particularly underserved. Access to mental health care services for most elderly individuals is inadequate, and coordination of services is lacking. There is an immediate need for collaboration among patients, families, researchers, clinicians, governmental agencies, and third-party payers to improve diagnosis, treatment, and delivery of services for elderly persons with mood disorders.