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Biomedical subjects

Carl Salzman

Publications and source records attributed to Carl Salzman.

18 recordsLinked to original sources
PubMed2006

Racial disparities in access after regulatory surveillance of benzodiazepines.

BACKGROUND: We examined the effects of a prescription-monitoring program on benzodiazepine access among Medicaid enrollees living in neighborhoods of different racial composition. METHODS: We used interrupted time series and logistic regression to analyze data from noninstitutionalized persons aged 18 years or older (N = 124 867) enrolled continuously in New York Medicaid 12 months before and 24 months and 7 years after initiation of the program. We used census data to identify the racial composition of the neighborhoods. Outcome measures were nonproblematic use (short term, within dosing guidelines), potentially problematic use (>120 days' use or more than twice the recommended dose), and pharmacy hopping (filling prescriptions for the same benzodiazepine in different pharmacies within 7 days). RESULTS: There was a sudden, sustained reduction in benzodiazepine use in all the neighborhoods after the program's introduction. Despite the lowest rates of baseline use, enrollees in predominantly (> or = 75%) black neighborhoods experienced the highest rates of discontinuation after introduction of the program. This difference remained 7 years after policy initiation. Compared with white participants, black participants were more likely to discontinue nonproblematic (odds ratio, 1.78; 95% confidence interval, 1.47-2.17) and potentially problematic (odds ratio, 1.77; 95% confidence interval, 1.45-2.17) benzodiazepine use, after adjusting for sex, eligibility status, neighborhood poverty, and baseline use. The program almost completely eliminated pharmacy hopping in all racial groups, although less among white participants (82.6%) vs black participants (88.7%). CONCLUSIONS: A systematic benzodiazepine prescription-monitoring program reduced inappropriate prescribing, with a stronger effect in predominantly black neighborhoods despite lower baseline use. The policy may have resulted in an unintended decrease in nonproblematic use that disproportionately affects black populations.

Adult↗
PubMed2004

A retrospective data analysis of the impact of the New York triplicate prescription program on benzodiazepine use in medicaid patients with chronic psychiatric and neurologic disorders.

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.

Adult↗
PubMed2004

A controlled study of the effects of state surveillance on indicators of problematic and non-problematic benzodiazepine use in a Medicaid population.

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.

Adult↗
PubMed2004

Late-life anxiety disorders.

The prevalence, natural course, risk profile, and treatment of anxiety disorders in the elderly are remarkably understudied. Anxiety disorders are less prevalent in the elderly than in younger adults, but rates of subsyndromal anxiety disorders in elderly persons are nearly as high as in their younger cohorts. The most common late-life anxiety disorders are mixed anxiety-depression and generalized anxiety disorder. Though the benzodiazepines are widely used in this population and are considered relatively safe given appropriate dosing and safety monitoring, important liabilities remain with the use of these agents. Antidepressants also are widely used in elderly patients, but there are no randomized controlled anxiety disorder treatment trials in this population. Gabapentin and low-dose atypical antipsychotics are beginning to be used and studies of the atypical antipsychotics are ongoing. Until studies are completed, treatment of late-life anxiety will continue to be guided by extrapolating data from the general adult population. Psychopharmacology Bulletin. 2004;38(Suppl 1): 25-30.

Antidepressive Agents↗
PubMed2003

Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life.

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.

Age Factors↗
PubMed2003

Schizophrenia in late life.

Antipsychotics, whether conventional or atypical, are the primary class of medications for the treatment of late-life psychosis. Although the efficacy of neuroleptics in controlling agitation and psychosis associated with late-life dementia has been established, evidence for their efficacy in treating core symptoms of late-life schizophrenia other than behavioral dyscontrol is just emerging. More controlled clinical trials are needed. The available data suggest that atypical neuroleptics are therapeutically efficacious, with a more favorable side-effect profile than conventional neuroleptics. This literature further suggests the importance of low therapeutic doses and careful attention to the emergence of side effects. Future studies must distinguish between patients with true schizophrenic disorder and patients with psychosis secondary to dementia, affective illness, or organic impairment. Patients must be characterized further as having EOS versus LOS because these disorders may differ in symptom profile, course, and response to treatment. There is also a need in future studies to separate out the results of treatment of patients with EOS who have been severely ill for most of their lives from those whose course has been less devastating. Within these two groups, treatment response, effective dose ranges, and sensitivity to side effects can be scrutinized more carefully.

Adult↗
PubMed2003

Are benzodiazepines still the medication of choice for patients with panic disorder with or without agoraphobia?

OBJECTIVE: Recently, pharmacological treatment guidelines for panic disorder have changed as newer treatment options have become available. The authors examined how the use of psychotropic drugs has shifted over the course of 10 years to determine if prescribing patterns have changed to reflect these revised treatment guidelines. METHOD: A total of 443 patients with panic disorder were enrolled in the Harvard/Brown Anxiety Research Project, a prospective longitudinal study of anxiety disorders. These patients were interviewed over the course of 10 years to examine their use of psychotropic medications. RESULTS: Despite efforts aimed at increasing the use of selective serotonin reuptake inhibitors (SSRIs) in patients with panic disorder (e.g., APA's practice guideline for panic disorder, Food and Drug Administration approval of particular SSRIs for the treatment of panic disorder), only a modest increase in their use was found. Treatment patterns for psychotropic drugs appear to have remained stable over the past decade, with benzodiazepines being the most commonly used medication for panic disorder. In comparison, SSRI use throughout the follow-up period has remained low. Patients using an SSRI did not have a more favorable clinical course than those using a benzodiazepine, nor were there significantly better rates of remission in patients using SSRIs and benzodiazepines concomitantly. CONCLUSIONS: These results highlight a gap between pharmacological treatment guidelines and actual delivery of care in that recommendations to use SSRIs to treat panic disorder are not being followed. Factors potentially associated with promoting and ignoring treatment recommendations are discussed.

Adult↗
PubMed2003

Lack of relationship between long-term use of benzodiazepines and escalation to high dosages.

OBJECTIVE: The objective of this study was to determine whether long-term benzodiazepine use is associated with dose escalation. METHODS: 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). RESULTS: 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. CONCLUSION: The results of this study did not support the hypothesis that long-term use of benzodiazepines frequently results in notable dose escalation.

Adolescent↗
PubMed2003

Open-label study of mirtazapine orally disintegrating tablets in depressed patients in the nursing home.

OBJECTIVE: To evaluate the efficacy and tolerability of mirtazapine orally disintegrating tablets in depressed, elderly nursing home residents, under naturalistic study conditions. METHODS: In this open-label 12-week study, mirtazapine orally disintegrating tablets (15-45 mg/day) were administered to patients > or =70 years old with physician-diagnosed depression and a Mini-Mental State Examination (MMSE) score > or =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. RESULTS: 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 (p < 0.0001). 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. CONCLUSIONS: 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.

Administration, Oral↗
PubMed2002

Drug and ECT treatment of depression in the elderly, 1996-2001: a literature review.

A computer-based literature search of all antidepressant and electroconvulsive therapy (ECT) treatment studies published between 1995 and September 2001 was conducted. In addition, a review of published chapters, review articles, and metaanalyses was also conducted. Articles were categorized into those reporting comparative studies, those in which the therapeutic agent was not compared with another, articles about ECT, and review articles. These recent publications support the conclusions from prior reviews that antidepressants and ECT are effective and safe treatments for depressed elderly patients. Differences in efficacy and side effects appear to be slight among the various types of antidepressants. Research studies of depressed elderly increased markedly since 1995 compared with all previous years although more studies are still necessary.

Aged↗
PubMed2002

A randomized, placebo-controlled trial of paroxetine in nursing home residents with non-major depression.

Depression is common across a broad spectrum of severity among nursing home residents. Previous research has demonstrated the effectiveness of antidepressants in nursing home residents with major depression, but it is not known whether antidepressants are helpful in residents with less severe forms of depression. We conducted a randomized double-blind placebo-controlled 8-week trial comparing paroxetine and placebo in very old nursing home residents with non-major depression. The main outcome measure was the primary nurse's Clinical Impression of Change (CGI-C). Additional outcome measures were improvement on the interview-derived Hamilton Depression Rating Scale (HDRS) and Cornell Scale for Depression (CS) scores. Twenty-four subjects with a mean age of 87.9 were enrolled and twenty subjects completed the trial. Placebo response was high, and when all subjects were considered, there were no differences in improvement between the paroxetine and placebo groups. Two subjects that received paroxetine developed delirium, and subjects that received paroxetine were more likely to experience a decrease in Mini Mental State Exam scores (P =.03). There were no differences in serum anticholinergic activity between groups. In a subgroup analysis of 15 subjects with higher baseline HDRS and CS scores, there was a trend toward greater improvement in the paroxetine group in an outcome measure that combined the CGI-C and interview-based measures (P =.06). Paroxetine is not clearly superior to placebo in this small study of very old nursing home residents with non-major depression, and there is a risk of adverse cognitive effects. Because of the high placebo response and the trend towards improvement in the more severely ill patients, it is possible that a larger study would have demonstrated a significant therapeutic effect for paroxetine as compared with placebo. The study also illustrates the discordance between patient and caregiver ratings, and the difficulties in studying very elderly patients with mood disorders.

Aged↗
PubMed2002

Depression in the elderly.

Depression is prevalent in the elderly and associated with increased morbidity and mortality. Diagnosis can be complicated by the presence of concomitant medical and/or psychiatric disorders, and it is important to exclude a number of factors, such as neurological disease, hormonal causes, chronic illness, or substance abuse, particularly alcohol. Although comorbid medical illness may contribute to depressive illness, depressive disorders are not a consequence of aging. Most classes of antidepressants that are effective in adult patients are effective in the elderly and, in general, they have shown comparable efficacy in terms of response rates. However, antidepressants vary in terms of their tolerability profiles, and treatment of the elderly is complicated by their sensitivity to medication side effects and the potential for serious adverse events, such as falling or delirium. A correct dosing strategy is particularly important for the elderly, whose treatment should usually start at low doses of antidepressants and increase slowly. It is possible to successfully treat elderly patients with depressive disorder, and antidepressant therapy should be selected on the basis of prior response to treatment, the adverse-event profile, and the potential for drug-drug interactions. Treatment should also take into account the likelihood of achieving and maintaining remission of symptoms in order to restore the patient to a baseline level of functioning appropriate for their age.

Aged↗
PubMedDate not supplied

Atypical uses of atypical antipsychotics.

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.

Antipsychotic Agents↗
PubMedDate not supplied

Atypical antipsychotics in elderly patients with dementia or schizophrenia: review of recent literature.

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.

Aged↗
PubMedDate not supplied

The limited role of expert guidelines in teaching psychopharmacology.

OBJECTIVE: To consider the limited usefulness of expert guidelines for teaching psychopharmacology. METHOD: Potential problems using expert guidelines for teaching psychopharmacology are reviewed. RESULTS: 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. CONCLUSION: 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.

Algorithms↗
PubMedDate not supplied

New uses for lithium and anticonvulsants.

Lithium and several anticonvulsant medications play an important role in the treatment of bipolar mood disorder. Clinical observations and open clinical trials are beginning to suggest additional therapeutic roles for these drugs. The largest number of reports indicate a monotherapy antidepressant effect for lithium and for lamotrigine. There is also strong evidence for lithium's role in augmenting antidepressant therapy, with reports also suggesting an augmenting role for divalproex and for lamotrigine. The potential usefulness of these medications for 21 other conditions has been reported in the literature, primarily from small case series or open-label, uncontrolled trials.

Anticonvulsants↗