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Jeanine A Driesenaar,1 Peter AGM De Smet,2,3 Rolf van Hulten,4,5 Litje Hu,1 Sandra van Dulmen1,6,7 1NIVEL, Netherlands institute for health services research, Utrecht, the Netherlands; 2Department of Clinical Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands; 3IQ Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands; 4Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands; 5Department of Pharmacotherapy and Pharmaceutical Care, University of Groningen, Groningen, the Netherlands; 6Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands; 7Faculty of Health Sciences, University College of Southeast Norway, Drammen, Norway Background: Pharmaceutical care is one of the major tasks of pharmacists, which aims to improve patient outcomes. Counseling patients with asthma or chronic obstructive pulmonary disease about their use of inhaled corticosteroids (ICS) might enhance medication adherence and symptom control. Therefore, effective pharmacist–patient communication is very important. In this regard, both affective communication, for handling emotions, and instrumental communication, for exchanging biomedical and lifestyle information, are relevant. Until now, only few studies have explored pharmacist–patient communication, and further insight is needed in this regard. The aim of this study is to investigate how pharmacists and pharmacy technicians communicate about ICS with patients with asthma and/or chronic obstructive pulmonary disease, what topics are discussed by them, and whether pharmacists and pharmacy technicians differ in their communication during counseling sessions. Methods: Patients aged ≥18 years who had used ICS for at least 1 year and filled at least two ICS prescriptions in the preceding year were recruited through 12 pharmacies. Participants had one counseling session with a pharmacist or a pharmacy technician, which was video-recorded. The process and content of the provider–patient communication were analyzed using the Roter interaction analysis system, adapted to the pharmaceutical setting. Results: A total of 169 sessions were recorded and analyzed. The communication appeared largely instrumental. Lifestyle, psychosocial issues, and ICS adherence were not discussed in detail. The pharmacists had longer conversations and more affective talk than the pharmacy technicians. Conclusion: Pharmacists and pharmacy technicians may need to pay more attention to ICS adherence, lifestyle, and psychosocial topics. They differed in their communication; the pharmacists exhibited more affective behavior and discussed medical and therapeutic issues more extensively compared to the pharmacy technicians. Educational courses for pharmacists and pharmacy technicians could focus more on the discussion of adherence, lifestyle, and psychosocial topics with patients. Keywords: community pharmacy, communication, inhaled corticosteroids, pharmacist–patient interaction, Roter interaction analysis system

MNA Van Steenis,1 JA Driesenaar,2 JM Bensing,2,3 R Van Hulten,4 PC Souverein,4 L Van Dijk,2,4 PAGM De Smet,5 AM Van Dulmen2,6,71Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands; 2NIVEL (Netherlands institute for health services research), Utrecht, The Netherlands; 3Department of Psychology, Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, The Netherlands; 4Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands; 5IQ Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; 6Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; 7Department of Health Sciences, Buskerud University College, Drammen, NorwayBackground: Beliefs play a crucial role in medication adherence. Interestingly, the relationship between beliefs and adherence varies when different adherence measures are used. How adherence, in turn, is related to asthma symptoms is still unclear. Our aim was to investigate the relationship between beliefs (ie, necessities and concerns) about inhaled corticosteroids (ICS) and subjectively as well as objectively measure adherence and the agreement between these measures. Further, the relationship between adherence and asthma symptoms was examined.Methods: A total of 280 patients aged 18–80 years who filled at least two ICS prescriptions in the preceding year were recruited to complete a questionnaire. The questionnaire included the Beliefs about Medicines Questionnaire to assess necessity beliefs and concerns about ICS, four questions about ICS use to measure self-reported adherence, and the Asthma Control Questionnaire to assess asthma symptoms. Proportion of days covered was used to determine pharmacy refill adherence.Results: Data from 93 patients with asthma were analyzed. Necessities were positively related to self-reported adherence (P = 0.01). No other associations were found between beliefs and subjective or objective adherence. There was no correlation between self-reported and refill adherence. Participants were significantly (P < 0.001) less adherent according to self-report data (24.4%) than according to pharmacy data (57.8%). No relationship was found between adherence and asthma symptoms.Conclusion: Higher necessities are associated with higher self-reported adherence, suggesting that it could be more important to focus on necessities than on concerns in an attempt to improve adherence. Self-reported and refill adherence measurements cannot be used interchangeably. No relationship between adherence and asthma symptoms was found.Keywords: asthma, inhaled corticosteroids, adherence, medication beliefs, asthma symptoms

To assess experiences related to antidepressant use reported to an internet-based medicine reporting system and to compare the nature of the side effects reported by patients with those reported by health care professionals (HCPs). All reports submitted from May 2004 to May 2005 to an internet-based medicine reporting system in The Netherlands related to the use of antidepressants were analysed. Spontaneous reports of adverse drug reactions on antidepressants from HCPs received by The Netherlands Pharmacovigilance Centre Lareb from May 2004 to May 2005 were included for comparison. Of the 2232 individuals who submitted a report to the internet-based medicine reporting system, 258 submitted a report on antidepressants. Of these, 92 individuals (36%) reported on effectiveness, 40 (16%) of whom reported on ineffectiveness, and 217 (84%) submitted a report on side effects, with 202 (78%) reporting a total of 630 side effects that were experienced as negative. Fourteen individuals (5%) reported a practical issue and four (2%) reported a reimbursement issue. Of all 630 side effects reported, 48% resulted in the patient discontinuing the antidepressant therapy; of these 29% did not inform their HCP. Of all the side effects reported, 52% were perceived as “very negative”. In comparison to the side effects reported by HCPs, patients more often reported apathy, excessive sweating, ineffectiveness, somnolence, insomnia, sexual problems and weight increase. Patients report the ineffectiveness and side effects of antidepressant therapy as negative and leading to discontinuation of the therapy. Patients and HCPs differ in the nature of the reported side effects. Patient experiences should be included in the evaluation of antidepressant treatment in clinical practice. [ABSTRACT FROM AUTHOR]

Background Patient centred communication can improve pharmaceutical care, but is not well described for pharmacists. Aim of the review To provide a comprehensive and accessible overview of the concept of patient centred communication for the pharmacy practice. Method A scoping review and thematic analysis was undertaken to synthesize the extracted data and present it in a model. Results Literature search and selection resulted in eighteen articles. Thematic analysis of the extracted data led to five categories regarding patient centred communication. Two categories refer to phases of a pharmaceutical consultation: (1) shared problem defining and (2) shared decision making; three refer to underlying concepts and assumptions about patient centredness regarding (3) the patient, (4) the pharmacist and (5) the therapeutic relation. The categories were modelled in the so called Utrecht's Model for Patient centred communication in the Pharmacy. Conclusion Although there might be barriers to implement patient centred communication in the pharmacy, the concept of patient centred communication as described in the literature is relevant for the pharmacy practice.

Objectives: To compare pharmacists' and pharmacy technicians' perceptions of patients' beliefs regarding inhaled corticosteroids (ICS) with those of patients and to compare the ICS beliefs of pharmacists and technicians with those of patients with asthma., Methods: 1269 community pharmacies were approached to fill out an online questionnaire; 1952 patients were sent a questionnaire by post. Beliefs (i.e., necessity and concerns) regarding ICS were measured using (an adapted version of) the Beliefs about Medicines Questionnaire (BMQ-specific). Pharmacists and technicians were instructed to fill out the BMQ for themselves, and to fill it out in the way they thought most of their patients would complete it., Results: 136 pharmacists, 90 pharmacy technicians and 161 patients with asthma completed the questionnaire. Pharmacists and technicians thought patients had more concerns about ICS than patients themselves reported (p < 0.0001). They also thought that patients had stronger beliefs in their personal need for ICS than patients reported (p < 0.01). Pharmacists reported lower levels of concerns than patients (p < 0.05) and both providers attributed a higher level of necessity to ICS than patients did (p < 0.0001)., Conclusion: Pharmacists and technicians overestimate the personal need for treatment as well as the concerns patients with asthma have regarding ICS. They also have, to some extent, stronger positive beliefs about ICS than patients. If pharmacists and technicians expect that patients share their positive views about ICS, they might be less likely to elicit and address patients' doubts and concerns about ICS, which might be relevant for effective ICS treatment and subsequent patient outcomes.

The aim of this study was to examine cue-responding behavior at the pharmacy while counseling about inhaled corticosteroids (ICS) in relation to medication adherence and medication beliefs. Patients with asthma aged ≥18 years using ICS were recruited from 12 pharmacies. Counseling sessions were video-recorded. Patients' emotional and informational cues and pharmacists' and pharmacy technicians' cue-responding behaviors were coded using an expanded version of the Medical Interview Aural Rating Scale. The Beliefs about Medicines Questionnaire assessed patients' ICS concern and necessity beliefs. Self-reported ICS adherence was measured by four questions. During the 86 sessions, patients expressed on average 2.3, mostly informational, cues (70.8%). In 26.7% of the sessions, no cues were expressed. Pharmacists' and technicians' responses to emotional cues (59.3%) were mostly inadequate, and to informational cues mostly appropriate (63.6%). Providing inappropriate information (20.3%) was related to higher concerns post session (p < .05), and cue exploration to higher self-reported adherence at 3 months (p < .05). Apparently, providers' responses to patients' cues might have therapeutic value. In addition, patients might need to be encouraged to ask questions and express their concerns.

Introduction: Older people often use medications with anticholinergic or sedative side effects which increase the risk of falling and worsen cognitive impairment. The Drug Burden Index (DBI) is a measure of the burden of anticholinergic and sedative medications. Medication reviews are typically done by a pharmacist in collaboration with a general practitioner to optimise the medication use and reduce these adverse drug events. We will evaluate whether a Multidisciplinary Multistep Medication Review (3MR) is an effective intervention to reduce a patient's DBI., Methods: A randomised controlled trial including 160 patients from 15 community pharmacies will be conducted. Per pharmacy, 1 pharmacist will perform a structured 3MR in close collaboration with the general practitioner, including the objective to reduce the DBI., Analysis: Primary outcome--the difference in proportion of patients having a decrease in DBI ≥ 0.5 in the intervention and control groups at follow-up. Secondary outcomes--anticholinergic and sedative side effects, falls, cognitive function, activities of daily living, quality of life, hospital admission, and mortality., Ethics and Dissemination: The burden of patients will be kept at a minimum. The 3MR can be considered as usual care by the pharmacist and general practitioner. Medical specialists will be consulted, if necessary. The intervention is specifically aimed at older community-dwelling patients in an attempt to optimise prescribing, in particular, to reduce medication with anticholinergic and sedative properties. Study results will be published in peer-reviewed journals and will be distributed through information channels targeting professionals., Trial Registration Number: NCT02317666; Pre-results., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: To analyze information and communication in the community pharmacy when patients collect a first dispensing for chronic medication., Methods: In 3 pharmacies in the South-West of the Netherlands, counter-based communication with patients receiving a first dispensing for chronic medication was observed and audiotaped. Each contact was analyzed by two observers using an observation checklist. An 11-item questionnaire was given to the patients., Results: 72 Patients were included. Only pharmacy technicians provided information. Average contact lasted approximately 2min. A computer checklist to support information giving was closely followed. Interactions were structured with introduction and closure. Mostly, information was given without exploring needs of the patient. Questioning showed open-ended questions (26%); check-questions and questions asking feedback (57%). A mean general score given was 5.8 (range 1-9). Of 46 responders who filled in a questionnaire, the majority felt that information was useful, clear and understandable., Conclusion: Our results show a concise and efficient way of information giving, closely related to a computer checklist. Technicians dominate the interaction. They ask few questions. Patients are satisfied about provided information and the contact., Practice Implications: We suggest a more patient-centered way of communication to increase patients' participation and to meet patients' needs for information., (Copyright © 2011. Published by Elsevier Ireland Ltd.)

Background: Monocyte recruitment into the vessel wall is a crucial initial step in vascular repair, arteriogenesis and atherogenesis. Two distinct human monocyte subpopulations can be classified according to their CD14/16 surface expression, namely CD14++CD16-monocytes (CD16-mo) and CD14+CD16+ monocytes (CD16+mo). We investigated different functional properties of the two monocyte subsets., Methods: CD16-/CD16+mo were isolated from human blood by an immunological selection. We assessed monocyte chemokinesis, chemotaxis, adhesion and Vascular-Endothelial Growth Factor (VEGF) receptor expression. Furthermore, generation of reactive oxygen species (ROS) as well as expression of antioxidant enzymes was investigated., Results: Chemokinesis of CD16+mo was decreased compared to CD16-mo (p<0.01). Likewise, adhesion capacity of CD16+mo was weaker (p<0.05). CD16+mo chemotaxis towards the angiogenic ligands vascular endothelial growth factor-A (VEGF-A) and placenta growth factor-1 (PlGF-1) was reduced compared to CD16-mo. VEGFR-1 is the receptor for VEGF-A and PlGF-1 on monocytes. VEGFR-1 protein expression was lower in CD16+mo than in CD16-mo (p<0.05). The impaired VEGF-A- and PlGF-1-induced CD16+mo chemotaxis might therefore be attributed to the reduced VEGFR-1 expression. CD16+mo exhibited less spontaneous ROS production than CD16-mo. Additionally, the antioxidant enzyme manganese superoxide dismutase was expressed at higher levels in CD16+mo (p<0.05); this might partly explain the higher oxidative resistance of CD16+mo., Conclusion: These novel functional differences between CD16-mo and CD16+mo may predict different functional roles of both monocyte subsets in vascular repair, arteriogenesis and atherogenesis., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Patients' perceptions are important to consider when trying to understand why patients often do not follow prescriptions for antidepressant treatment. This study aimed to investigate the influence of patients' perceptions and illness severity at the start on antidepressant-medication-taking behaviour., Methods: Eighteen community pharmacies in the Netherlands participated in this 6-month follow-up study. One hundred and ten patients presenting a first antidepressant prescription, prescribed by a general practitioner (GP), were included. A questionnaire was completed at inclusion, after 6 and 26 weeks., Key Findings: Of all 110 patients, eight (7.3%) did not initiate drug taking, 32 (29.1%) discontinued use, six (5.5%) switched to different antidepressant medication, and 64 (58.2%) continued on the same antidepressant during follow-up. Compared to continuers, non-initiators had lower belief scores for impact of illness (P = 0.044), perceived norm GP (P < 0.001), intention to take medication (P < 0.001), and attitude towards medication (P = 0.004). Furthermore, non-initiators were less severely depressed (P = 0.024). Discontinuers and continuers did not differ in illness severity at inclusion. However, discontinuers more often reported a non-specific reason for use, such as fatigue and sleeping problems (P = 0.014). Compared to continuers, switchers had higher illness severity scores at inclusion (depression, P = 0.041; anxiety, P = 0.050). During follow-up depression and anxiety severity improved for all treatment groups and reached the same level of severity at 6 months., Conclusions: Patients' illness and treatment perceptions and illness severity influence their decisions about antidepressant drug taking. Patients' care could be improved by eliciting patients' beliefs about illness and treatment and assessing illness severity before prescribing.

Background: Pharmacists are increasingly acknowledging their responsibility to inform and counsel patients. However, it is unclear how these tasks are implemented and whether patients' needs are being fulfilled., Objective: To examine patients' perceptions of information received at the start of selective serotonin-reuptake inhibitor (SSRI) treatment, aiming to identify (1) information needs and (2) the potential role of the community pharmacist as information provider., Methods: A qualitative descriptive study comprising semi-structured telephone interviews was carried out with patients who had recently started a new course of SSRI treatment. Patients were recruited through 6 Dutch community pharmacies. The interviews were guided by the following topics: type of information obtained, unmet information needs, preferred information provider, and the role of the pharmacist., Results: Forty-one patients took part in an interview. Information needs varied widely among patients; overall, patients felt that they would benefit from information tailored to their needs. Many patients required more concrete and practical information on adverse effects and delayed onset of action than was provided. In addition, an explanation of the term dependency in the context of SSRI use and a discussion of the necessity for use and believed harms of long-term treatment were important to patients. Regardless of patients' needs, the role of the pharmacist was generally perceived as limited, and patients identified several pharmacy-related barriers to improved communication, including the timing of information (mainly restricted to first-time dispensing), lack of time and privacy, lack of empathy and a protocol-driven way of providing information, and inexperience of pharmacy technicians., Conclusions: Patients starting treatment with antidepressants may benefit from information tailored to their personal needs. Along with the prescribing physician, community pharmacists could have an important role in informing and counseling patients.

Background: The question whether patients actually start drug taking after having received a first antidepressant prescription is often overlooked., Aim: To determine the incidence of patients who do not fill or fill only a single antidepressant prescription at the pharmacy, and to identify associated patient characteristics., Design of Study: Retrospective study linking a general practice to a pharmacy dispensing database., Setting: General practice in the Netherlands., Study Population: patients who received a first-time antidepressant prescription from a GP. Three patient groups were identified: patients who did not fill the prescription (non-fillers); patients who filled only a single prescription (single Rx-fillers); and patients who filled at least two consecutive prescriptions. Non-fillers and single Rx-fillers were combined into a group of decliners., Results: Of all 965 patients, 41 (4.2%) did not fill the prescription, and 229 (23.7%) filled only a single prescription. Patients who consulted their GP for a non-specific indication, rather than for depression, anxiety, panic, or obsessive-compulsive disorder, were almost three times more likely (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.8 to 3.9) to decline treatment. Further, the risk of declining was almost fivefold higher (OR = 4.8, 95% CI = 2.1 to 11.3) in non-Western immigrants, and almost twofold higher (OR = 1.8, 95% CI = 1.2 to 2.8) in patients >60 years of age., Conclusion: Over one in four patients who receive a first-time antidepressant prescription decline treatment; they either do not initiate drug taking or do not persist with antidepressant use for longer than 2 weeks.

Background: New drugs are cornerstones of clinical practice. However, when included in practice in an erratic fashion, there is valid concern about uncertain risk-benefit for patients and increased healthcare expenditures. In several countries, general practitioners (GPs) and pharmacists work closely together to ensure proper use of new drugs in clinical practice., Objective: To estimate the effect of pharmacotherapy audit meetings (PTAMs) between GPs and community pharmacists on prescribing of newly marketed drugs by GPs., Methods: We conducted an observational study of new drug prescribing in a cohort of 103 GPs, working in 59 practices, from 1999 until 2003. The main outcome measures were the decisions to start therapy with a new drug or with an existing older drug from the same therapeutic category within the first 6 months after market introduction. Multilevel modeling was used for analyses., Results: Overall, in 6.1% of the decisions to start drug therapy, GPs chose the drug that was most recently introduced into the market. The GPs attending low-quality PTAMs made 1861 decisions to start therapy; in 112 (6.0%) of those decisions, a new drug was preferred over an older alternative. GPs participating in high-quality PTAMs preferred a new drug in only 3.4% of the 3138 decisions made. Compared with GPs participating in PTAMs on the highest quality level (level 4), GPS attending level 1 or level 2 PTAMs were more than twice as likely to start therapy with new drugs than with older drugs (OR 2.24; 95% CI 1.04 to 4.81 vs OR 2.31; 95% CI 1.30 to 4.09, respectively)., Conclusions: PTAMs may be an effective way to control early prescribing of new drugs in general practice. For PTAMs to be effective, it is vital that GPs and pharmacists set common goals on how to optimize pharmacotherapy. This concordance should be reflected in PTAMs that result in concrete decisions with auditing of GP prescribing behavior. Pharmacists should play an active role in organizing PTAMs to increase their influence on drug prescribing.

Background: In the Netherlands, community pharmacists and general practitioners (GPs) collaborate in pharmacotherapy audit meetings (PTAMs) to optimize pharmacotherapy., Objective: To identify associations between the quality level of PTAMs and characteristics of pharmacists., Methods: We used a cross-sectional questionnaire design in a Dutch general practice and community pharmacy setting to estimate the contribution of pharmacists to the quality level of PTAMs. The questionnaire was sent to 123 community pharmacies working closely with 104 GP practices. The outcome variable was the quality level of PTAMs. The questionnaire provided information on 4 topics that were used as independent variables: characteristics of the PTAMs, provision of pharmacotherapy activities, characteristics of the pharmacists, and characteristics of the pharmacies., Results: In total, 109 (88.6%) pharmacists completed the questionnaire, with 103 participating in 62 different PTAMs. Seventeen pharmacists participated in level 1 PTAMs (lowest level), 57 in level 2, 21 in level 3, and 8 in PTAMs at the highest level. The multinomial logistic regression identified only one significant association: pharmacists who participated in the highest quality level reported that they undertake initiatives in PTAMs (OR 2.98; 95% CI 1.07 to 8.26) more frequently compared with pharmacists participating on the lowest level., Conclusions: In light of existing evidence, the role of pharmacists in PTAMs seems to be important. Pharmacists should create a distinct profile of their expertise, allowing them to professionalize PTAMs by undertaking more initiatives. PTAMs offer pharmacists a great opportunity to become integral members of the prescribing process.

Objective: The health-related quality of life (HRQOL) of initial benzodiazepine users was measured over time. Furthermore, benzodiazepine usage characteristics as determinants of change in mental and physical health status of the benzodiazepine users were examined., Methods: In the only pharmacy of a Dutch community of 13,500 and during four months from November 1994, all patients with a benzodiazepine prescription and no history of benzodiazepine use over a period of 12 months before inclusion, were invited to participate. A total of 106 initial benzodiazepine users were matched for age and gender. In a six-month follow-up study, HRQOL was measured with the RAND-36. Consequently, in a nested case control design, determinants of change in mental and physical functioning over the six-month period were analysed using the Mental Component Summary and the Physical Component Summary., Results: At baseline, initial benzodiazepine users showed a lower HRQOL as compared to reference subjects. After six-month follow-up, benzodiazepine users presented an absolute increase in HRQOL, while the reference subjects maintained a stable HRQOL. Diazepam and the male gender were associated with an increase in physical functioning over time. Younger age, a lower daily dose (DDD < 0.75) and a period of use between 16 and 60 days were associated with better mental functioning over time., Conclusion: This study is one of the first to associate improvement in HRQOL over time of starting benzodiazepine users with specific usage characteristics, such as limited duration of use and a low dosage.

Prolonged benzodiazepine use is a widespread phenomenon in medical practice. In the present article, we argue that psychological models may contribute to our understanding of benzodiazepine use. This study examined variables derived from the theory of planned behaviour and the health belief model in relation to the length of benzodiazepine use. Data were collected from a sample of all benzodiazepine users with a request for this medicine in the only pharmacy in a Dutch community (N=467). Determinants of the length of benzodiazepine use were analysed separately for inexperienced and experienced users using structural equation modelling (SEM) analyses. For both groups, results showed that the intention to use benzodiazepines was a predictor of length of use. Attitudes towards benzodiazepine use had an indirect influence on length of use, through intentions. Furthermore, a positive attitude toward using benzodiazepines was related to the perceived norm of the prescriber. Experienced users were more inclined to consume benzodiazepines when they had less control over drug taking. In this group, the belief that benzodiazepine use leads to dependence was associated with less control over drug taking and a high intention to use the drug. In addition, older experienced users reported a higher intention to use the drug. For inexperienced users, the perceived attitude of the prescriber towards use of the medicine was a strong determinant. Finally, results of SEM-analyses showed that the model accounted for far more variance in behaviour for experienced users (67%), than for inexperienced users (18%).

Objective: The aim of the study was to identify initial usage predictors for prolonged benzodiazepine use., Methods: An 8-year pharmacy data-based study (1983-1992) was carried out on a retrospective cohort of 425 initial benzodiazepine users. The setting was the only pharmacy in a community of 13,500 people., Results: Among the 425 initial users, 36% had a single initial exposure year, 50% had two to seven exposure years, and 14% had benzodiazepine use during all 8 years of follow-up. Prolonged use over more years was associated with an initial high number of prescriptions, elderly patients and initial use of hypnotics. Two patterns of irregular prolonged use were investigated: increase in use was associated with a shorter length of the first usage period and switching to another benodiazepine during the first 90 days; relapses of use were associated with a shorter length of first usage period and initial use of an anxiolytic. Gender and initial dosage were not associated with prolonged use at all., Conclusion: During the first 90 days after initiation of benzodiazepine use, a number of determinants of prolonged benzodiazepine use were visible. The prescribers of these drugs and the pharmacists should advise rational use not only at the start but also at the moment of the first repeat prescription in order to prevent needless prolonged use and dependence.

Background: There is much concern about the widespread long-term use of benzodiazepines. Utilisation data can give a foundation for interventions for appropriate use., Objective: To compare long-term usage patterns of benzodiazepines in a Dutch and a Swedish community in different periods., Methods: Eight-year follow-up patterns of use were investigated with respect to the characteristics of those who continued use over the whole follow-up period. In the Dutch community of 13,500, the data of a cohort of 1358 benzodiazepine users were analysed during the years 1984-1991; in the Swedish community of 20,000 people, a cohort of 2038 benzodiazepine users was followed from 1976., Results: At the end of the follow-up period, 32.9% of the Dutch cohort and 33% of the Swedish cohort had continued use of benzodiazepines. The two overall survival curves showed similar patterns. Stratification for age, gender, previous versus initial use and heavy versus non-heavy use showed comparable proportions of patients continuing benzodiazepine use over time., Conclusion: The parallels in the results of two cohorts in different countries and different periods are striking and give support to the idea to stimulate interventions to reduce long-term benzodiazepine use.

Objective: To examine attitudes and beliefs associated with changes in the intention to use benzodiazepines during the six-month period after first benzodiazepine use., Design: Population-based 6-month follow-up with 3 measurement points (baseline, 2 weeks after inclusion, 6 months after inclusion)., Setting: Starting or initial benzodiazepine users were included during a period of 4 months from November 1994 in the only pharmacy of a Dutch community of 13,500 people., Measures: Variables proposed by the Model of Planned Behaviour and the Health Belief Model. Drug exposure data from automated pharmacy records., Results: At baseline, the intention to use benzodiazepines was primarily predicted by the perceived norm of the general practitioner regarding benzodiazepine use, and by the participants' own attitudes. After fourteen days, the determinants of change in the intention to use benzodiazepines were the initially perceived norm of the general practitioner and the change in the severity of participants' illnesses. After six months, the change in the severity of the illness and the perceived health benefits of benzodiazepines at the time of inclusion were the main determinants of the change in the intention to use benzodiazepines between the second and third measurement point. The intention to use benzodiazepines showed a decrease during follow-up. The three intention measures were significant predictors of actual benzodiazepine use during the year following baseline assessment., Conclusion: The study sheds light on interesting determinants of decrease or increase in the intention to use during the six-month period after first benzodiazepine use.

The relationship between characteristics of benzodiazepine exposure and health-status was examined in order to investigate risk profiles of benzodiazepine users. In the only pharmacy of a Dutch community of 13,500 inhabitants, all current benzodiazepine users that presented with a benzodiazepine prescription in November 1994 were invited to participate. On the basis of the RAND-36 questionnaire, summary scores for both physical and mental health were calculated, the Physical Component Summary (PCS) and the Mental Component Summary (MCS). After dichotomization with a cut-off point indicating seriously impaired health and after the combination of the PCS and MCS, four different categories of health status could be identified. We used logistic regression to study the relation between these four different groups with respect to benzodiazepine exposure. In total a group of 360 current benzodiazepine users was studied. Results showed that almost one-third of the participants had no significant impaired health; this group was further classified as reference group. We classified three other groups: one with physical problems (31%), one with mental problems (18%), and one with a combination of the two (22%). Multivariate analysis showed differences in risk factors for an impaired health status. The group with impaired physical health was associated with self-reported indication for muscle relaxation, hypnotic use, and a high CDS (Chronic Disease Score). The group with impaired mental health was associated with more frequent consulting of a mental health care specialist and with a low sense of self-efficacy. The group with both impaired physical as well as mental health was associated with a higher incidence of widowhood, a lower sense of self-efficacy, a high CDS, using benzodiazepines more than prescribed, and reporting depression as reason for their benzodiazepine use. In particular, two groups need critical examination: a group of apparently healthy users with long-term benzodiazepine use; and a frail group with impaired physical and mental health and using a higher dose than prescribed. Patient counseling and management of these four groups can be tailored to the specific needs of each group.

The association between patterns of use of benzodiazepines and chronic somatic morbidity was examined by applying the Chronic Disease Score (CDS). In the only pharmacy in a Dutch community, 6921 patients with data available covering a 10-year period (1983-1992) were included. In 1992, two-thirds of the patients had a CDS of 0, indicating no chronic morbidity. Patients with chronic morbidity showed a twofold risk of a history of benzodiazepine use. Within the group of benzodiazepine users, longer exposure to benzodiazepines as well as a history of different benzodiazepines were associated with a higher risk of chronic morbidity. Duration of episodes of use and daily dose were not found to be significantly associated with chronic disease. A pattern of increased benzodiazepine use showed a higher risk of chronic morbidity compared with benzodiazepine users with a stable use. Moreover, a history of benzodiazepine use was found to predict a sharp increase in chronic morbidity. We found a clear association between previous and actual use of benzodiazepines and chronic somatic disease. Benzodiazepine use may be induced by sleeping difficulties and anxiety problems caused by the chronic disease., (Copyright 1999 John Wiley & Sons, Ltd.)

Only a few longitudinal studies have addressed benzodiazepine use over time. We therefore conducted a 10-year follow-up study (1983-1992) on usage patterns of benzodiazepines in a Dutch community of 13 500 people. Use decreased during the time of the study. Twelve (1983) to ten (1992) percent of the inhabitants was a recipient at least once a year of a benzodiazepine prescription. The use by gender showed more women using more prescriptions as men. Women were not prescribed more DDDs per prescription as men. Individual benzodiazepines showed differences in use by gender. Use increased with age among both women and men. Most of the users were 55 years or older. One out of three patients was either an incidental user (1-30 days use in one calendar year), a regular (31-180 days), or a long term user (more than 180 days). The use of long half-life hypnotics decreased, the use of the short half-life ones showed an increase. Behind a stable overall trend we found strong fluctuations in use of individual benzodiazepines.