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PubMed1979

The use of minor tranquilizers in a community mental health center.

A study of 306 adult psychiatric outpatients visiting a CMHC during one month revealed that 55 per cent of those patients received a psychotropic medication and 45 per cent of the medication recipients used a minor tranquilizer as all or part of their treatment regimen. The most common diagnosis for patients receiving minor tranquilizers was depressive neurosis. The tranquilizers were prescribed in relatively high doses, and 57 of the 77 patients who recieved them had taken the drugs continuously for at least six months. The study also revealed that polypharmacy was widely practiced. The authors' suggestions for improving the quality of pharmacotherapy in a CMHC include instituting peer review of prescribing and recordkeeping practices and monitoring the effectiveness of medications through the application of quantitative mood scales at regular intervals.

Adult↗

PubMed1983

The impact of psychopharmacology education on prescribing practices.

The authors describe a pharmacology education program on the psychiatry service of a Veterans Administration medical center. The program, directed by a clinical pharmacist, includes weekly lectures to medical students and weekly psychopharmacology review rounds for psychiatric residents that are also attended by staff psychiatrists. To determine the impact of the psychopharmacology review rounds on prescribing practices, the authors conducted a retrospective chart review of psychopharmacologic treatment methods before and after the rounds were instituted. The review compared prescribing practices in the two periods and focused particularly on changes in practices related to multiple daily dosages, polypharmacy, prophylactic anticholinergics, and drug use in alcohol withdrawal. The review demonstrated that the teaching effort resulted in a use of psychotropic medications that was more in line with recommendations in the literature.

Adult↗

PubMed1992

A single-case-study method for treating resistiveness in patients with Alzheimer's disease.

A single-case-study approach was used to identify the best medication for treating resistiveness to care in patients with moderately advanced dementia. The double-blind research design incorporated three medications, placebo washout periods, multiple baselines, frequent ratings by nurses of patients' resistiveness, and visual and statistical analysis of results to find the optimal drug, one that provided a stable response at a low dose. Six patients completed the trials. Thiothixene was more effective than oxazepam and diphenhydramine. Important features of the design were its avoidance of polypharmacy and high doses and its use of frequent ratings (each nursing shift) of patients' resistiveness. Although the single-case-study method is labor intensive, it can be beneficial when adapted for clinical use.

Aged↗

PubMed1994

Psychiatric treatment of older African Americans.

Older black Americans are increasingly seen in mental health settings, although prevalence rates of many psychiatric disorders in this group are unknown because black Americans are underrepresented in epidemiologic studies. Improved treatment of this population requires an understanding of the biopsychosocial context of their lives, including historic events that have affected them and the influence of African values emphasizing community and family. Risk factors for mental disorders among older black Americans include multiple medical problems and resulting polypharmacy as well as stressors such as living in high-crime areas. The author suggests using a reminiscence approach in initial interviews to learn the elder's personal history and to identify his or her coping capacities and important relationships and resources. Group psychotherapy can be effective with other elderly persons. Pharmacologic interventions should be used cautiously.

Black or African American↗

PubMed1996

The value of consultation-liaison interventions to the general hospital.

Changes in health care funding have greatly enhanced the value of consultation-liaison services to their parent hospitals. This paper reviews representative studies showing that consultation-liaison interventions improve patient care, enhance patients' satisfaction with treatment, and reduce polypharmacy, adverse drug reactions, and subsequent hospitalizations. Reductions in costs of hospitalization realized by consultation-liaison interventions are also described, including average reductions in hospital stays of one to one and a half days, upgrades in diagnosis-related group (DRG) codes, and timely patient transfers to inpatient medical-psychiatric units or inpatient psychiatric facilities. These data suggest that consultation-liaison services will become increasingly important over the next few years.

Combined Modality Therapy↗

PubMed1997

The impact of OBRA-87 on psychotropic drug prescribing in skilled nursing facilities.

OBJECTIVES: This study examined the impact of regulations established by the Omnibus Budget Reconciliation Act of 1987 (OBRA-87) on prescriptions for psychotropic drugs, and on research on their use in nursing homes. METHODS: Data were collected on drugs prescribed for residents of 39 skilled nursing facilities over the four-year period from 1989 to 1992, bracketing the implementation of OBRA-87 in the fall of 1990. Changes in prescribing patterns were analyzed by drug class, specific target medications and doses, number of drugs prescribed, and multidrug combinations. To determine the effect of OBRA-87 on research, peer-reviewed journals were searched for the number and content of publications on psychotropic drug use in skilled nursing facilities between 1980 and 1996. RESULTS: The number of prescriptions for antipsychotics, sedative antihistamines, and sedative-hypnotics decreased significantly, while prescribing of anxiolytics increased. Qualitative, but not quantitative, shifts occurred in prescriptions for antidepressant drugs, the most frequently used psychotropic medications in all years. Rates of psychotropic polypharmacy remained stable. The number of data-based publications on psychotropic drug use in nursing homes increased after implementation of OBRA-87, but few were related to the effectiveness of drug treatment. CONCLUSIONS: Implementation of OBRA-87's nursing home regulations was associated with reductions in use of drugs specifically targeted by this legislation and was a potent stimulus to research, an unanticipated benefit of legislative action. Increased use of anxiolytics, persistent prescribing of anticholinergic antidepressants, enthusiastic adoption of new agents despite a limited research database involving frail patients, and the paucity of new studies reporting data on clinical effectiveness suggest a need for targeted research on treatment outcomes to improve the care of this population.

Aged↗

PubMed1997

The changing role of the psychiatrist in board-and-care homes.

The role of the psychiatrist in board-and-care homes has been changing dramatically since a job description was published in 1989. The role has become more complex as a result of advances in psychopharmacology, the trend toward polypharmacy regimens, the necessity to evaluate the interaction potentials of drug combinations, and the emergence of more sophisticated treatment algorithms. Broad social trends have added to the complexity of board-and-care treatment, such as the tendency to release more severely disturbed patients from long-term-care facilities because of the increasing costs associated with institutionalization. However, treatment of these patients will continue to be expensive because of the higher costs of new drugs and of using medication combinations. Continued high-cost treatment will increase pressure to control costs by managed care companies, third-party payers, and government agencies. Although this paper describes the effects of these trends on board-and-care psychiatrists, they are also relevant to psychiatrists in general and to other practitioners.

Cost Control↗

PubMed1975

Septicaemia.

Septicaemia still presents a major diagnostic and therapeutic challenge to the clinician. Most cases are hospital-acquiredand the reasons for their increasing prevalence are discussed, with reference to predisposing factors and opportunistic infections. The pathology and bacteriology of proven cases (positive blood cultures) in 1974 in a modern children's and maternity hospital complex are presented. Gram-positive and Gram-negative varieties are compared and the molecular biology and mechansims of endo- and exotoxaemia described. Successful therapy demands correct choice of antibiotic and the development of shock requires skilled supportive measures. For the former a rational scheme is outlined and a plea is made for collection of data for this purpose. Polypharmacy is deprecated and either an aminoglycoside or a cephalosporin forms the mainstay of therapy. The emergence of Bacteroids sp. in cases of abdominal and puerperal sepsis necessitates addition of a lincomycin or metronidazole. Superinfection with systemic candidiasis requires 5-fluorocytosine.

Cefazolin↗

PubMed1981

Clinical use of minoxidil (Loniten).

The powerful peripheral vasodilator minoxidil, in a dose of 5-40 mg daily, controlled the previously refractory blood pressure in 45 out of 47 patients for periods up to fifty-seven months. The majority of the previous polypharmacy was withdrawn, leaving most of the patients taking a beta-blocking drug, minoxidil and a diuretic. Severe sodium retention leading to congestive cardiac failure necessitated the withdrawal of the drug in 3 patients. In one patient the drug was discontinued because of postural hypotension, and it was withdrawn in 2 female patients because of hirsutism. Five patients were removed from the trial as they were started on chronic maintenance haemodialysis or received a renal transplant. Significant glucose intolerance developed in one patient, requiring the addition of an oral hypoglycaemic agent. The 4 deaths that occurred were not directly related to treatment. Following the oral administration of 5 mg minoxidil, an obvious reduction in both the systolic and diastolic pressure was seen in two hours.

Adolescent↗

PubMedDate not supplied

Illicit anabolic steroid use in athletes. A case series analysis.

Because of recent anabolic steroid abuse scandals at all levels of athletic competition ranging from high school sports to the 1988 Olympics in Seoul, Korea, the investigators closely examined the anabolic steroid use histories of 20 competitive and noncompetitive weight lifters. Steroid efficacy studies only examine the anabolic effects of individual drugs. However, these 20 steroid users consistently practiced polypharmacy. During steroid use cycles lasting between 7 and 14 weeks, athletes commonly used two or three oral agents and two long-acting injectable products. Dosages of oral preparations tended to be similar to those used in efficacy studies, whereas dosages of the long-acting injectable agents were approximately three to eight times greater than those used in controlled studies. Subjects reported significant increases in body weight and strength. In addition, mental status changes were reported that included symptoms of depression, hostility, aggression, and paranoia. Based on the pattern of anabolic steroid use currently being practiced in the United States, it is apparent that past efficacy and toxicology studies are of limited value in delineating the benefits and hazards of these drugs.

Adolescent↗

PubMed2004

Major depression and mental health care utilization in Canada: 1994 to 2000.

BACKGROUND: Major depression makes an important contribution to disease burden in Canada. In principle, the burden of major depression can be reduced by the provision of treatment within the health care system. In a previous data analysis, the National Population Health Survey (NPHS) reported an increase in antidepressant (AD) use between 1994 and 1998. In this paper, the analysis is extended to 2000, and additional aspects of health care utilization are described. METHODS: The NPHS provides a unique source of longitudinal data concerning major depression and its treatment in Canada. In this survey, probable cases of major depression were identified using a brief predictive instrument; health care utilization was evaluated using additional survey items; and the latest data release from Statistics Canada (that is, 2000) was used to make weighted estimates of the frequency of health care utilization in relation to major depression status. RESULTS: The use of ADs has continued to escalate. These increases have been largest in men and in persons aged under 35 years. There has been an increase in polypharmacy: in 2000, almost 9% of persons taking an AD reported taking more than 1 AD medication-a tripling since 1994. The frequency of consultations with alternative practitioners has also grown. Although the overall proportion of persons with major depression who report consulting with health professionals about their mental health has not increased, the number of persons with major depressive disorder reporting 6 or more visits to nurses, social workers, and psychologists may have. CONCLUSION: The provision of AD treatment continues to expand in Canada. This probably represents a changing pattern of practice, because the frequency of professional consultation has not increased. More detailed data are required to evaluate the extent to which treatment needs are being met.

Adult↗

PubMed1986

A role for catecholamines in the pathogenesis of neuroleptic malignant syndrome.

The authors present a case report in which an agitated response to antidepressants preceded the neuroleptic malignant syndrome (NMS). In a review of 64 cases of NMS in the literature, they found that 80% were described as agitated prior to the development of the syndrome. Polypharmacy was common. A review of the literature on theories of pathogenesis involving sympathetic amines other than dopamine is presented to explain this phenomena. It is suggested that these toxic reactions to medication can be interpreted as resulting from a relative NE/DA excess, in which antidepressants increase the numerator, while neuroleptics functionally decrease the denominator. It is recommended that where an agitated response to antidepressants is observed, neuroleptics should be used only with considerable caution.

Akathisia, Drug-Induced↗

PubMed1989

Tricyclic antidepressants: contemporary issues for therapeutic practice.

The clinical pharmacology of tricyclic antidepressants is reviewed, with an emphasis on recent findings. These medications have become the treatment of choice for the majority of depressed patients. Their efficacy is limited by lack of vigor and precision in dosage. Pharmacokinetic aspects are addressed which affect the rationale for selective use and interpretation of plasma concentration monitoring. These include nonlinearity, active metabolites, plasma protein binding and age effects. Specific indications for therapeutic drug monitoring occur with patients who fail to respond, those at risk because of age, medical condition or polypharmacy, and to check compliance. Integration of knowledge concerning pharmacokinetics and plasma levels with clinical response will aid in making appropriate pharmacotherapeutic decisions.

Antidepressive Agents, Tricyclic↗

PubMed1990

[Who are the patients treated in an outpatient clinic with high dosage neuroleptics?].

The use of high doses of neuroleptics (NL) in treatment of chronic psychosis is a controversial subject in the literature. In this context, it is surprising to note the lack of objective data about the prevalence and the consequences concerning this mode of prescription when treating people suffering from severe mental disorders. This study describes the clientele exposed to high doses of NL from an outpatient clinic of a psychiatric hospital. The equivalent of 18 mg or more of haloperidol per day was used as the high dose criterion. Overall, we observed the use of NL in all diagnostic categories and the frequent use of polypharmacy in patients treated with NL. Among the 435 patients receiving NL, 26.4% had high dose prescriptions (two men for every woman). Most of these high dose NL subjects had a diagnosis of schizophrenic disorder (87.9%). Fifty-one of them had been receiving high doses for six months or more and 39 of them agreed to meet our research team. The mean age of these subjects was 37.2 years and the mean dose was 63.5 mg haloperidol equivalent/day. Thirty-five subjects were diagnosed as chronic schizophrenic disorder and four as schizo-affective disorder. Nineteen patients had tardive dyskinesia. In two out of three cases the high dose prescription began during hospitalization and the main reason was presence of severe psychotic symptoms. Significant positive correlations were found between parkinsonian symptoms and negative symptoms of schizophrenia as well as psychosocial dysfunctions on 39 subjects. These findings support the hypothesis that the use of high doses of NL contribute to the negative symptoms and the psychosocial dysfunctions. The implications of these findings relating to assessment and treatment of schizophrenic outpatients are discussed.

Adult↗

PubMed1998

The use of psychotropic medication in preschoolers: indications, safety, and efficacy.

OBJECTIVE: To review the indications, safety and efficacy of psychotropic medications used in preschoolers. METHODS: Proprietary prescription-use databases indicate that practitioners are prescribing psychotropic medications for preschool patients at an increasing rate. A Medline search was conducted using drug exposure for children below the age of 6 years to identify efficacy and safety reports of these agents in the preschool age-group. RESULTS: The search yielded 22 reports that mention exposure to medications, including maternal exposure, accidental overdose, and adverse events in preschool children. Safety issues highlight the age-specific vulnerabilities of this age-group, including hepatotoxicity from valproic acid, among others. In addition, the prominence of adverse-event responses in this age group may be related to polypharmacy not seen in school-age children or adolescents. Less than a dozen controlled efficacy studies of psychotropic agents were identified for children in the preschool age-group. These are limited by the small numbers of subjects in the reports. Only 2 disorders described in the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV), attention-deficit hyperactivity disorder (ADHD) and autistic disorder, are mentioned. The Food and Drug Administration (FDA) approved psychotropic medications for preschoolers but limited their use to medical purposes, not psychiatric, with the exception of use for ADHD. CONCLUSION: Because data about psychotropic drug safety and efficacy in adults have not been extended to children, new psychopharmacological research is required before clinicians can use these agents to treat psychiatric disorders in the preschool age-group.

Age Factors↗

PubMed2000

Safety and tolerability of topiramate in children.

Three double-blind, randomized, placebo-controlled studies of topiramate that include children have been published and prospective but unblinded and retrospective reviews have been reported providing information regarding topiramate's safety and tolerability. These studies indicate that side effects tend to occur early in treatment with topiramate, especially in children receiving polypharmacy. Two classes of adverse events are commonly reported: central nervous system and anorexia/weight loss. Central nervous system effects include somnolence, difficulties with concentration, and behavior changes. Tolerance to these effects seems to develop in most children. When it occurs, weight loss has been noted in the first 12 to 18 months, after which normal weight gain resumes, without long-term impact on growth. As opposed to the experience in adults, aphasia and word-finding difficulties are not commonly seen, and parasthesiae are not reported by children. Renal calculi are rare. Life-threatening idiosyncratic reactions have not been attributed to topiramate. While metabolic acidosis has been reported, no other clinically significant laboratory abnormalities have been associated with the use of topiramate in children.

Anticonvulsants↗

PubMed2006

Behavioral and emotional problems in children with epilepsy.

The principal purpose of this study was to assess behavioral and emotional problems in children with epilepsy to investigate if specific behavioral and emotional problems are associated with specific medical epilepsy-related factors. The Child Behavior Checklist (CBCL) was used to assess parent-reported behavioral and emotional problems in 108 5- to 18-year-old children with various epilepsy syndromes. Specific medical epilepsy-related factors, such as etiology, age at onset, seizure symptoms, prognosis, seizure frequency, electroencephalography (EEG), and anticonvulsive therapy, were recorded during a regular follow-up examination in our pediatric outpatient epilepsy clinic, and 22.2% of our patients showed moderate to severe behavioral or emotional problems as measured by the Child Behavior Checklist total score. Higher Child Behavior Checklist scores were associated with such specific medical epilepsy-related factors as etiology, age at onset, and polypharmacy. Higher scores on the Social Problem scale were associated with symptomatic epilepsy syndromes and an earlier age at onset. Higher scores on the Social Problems, Attention Problems, and Aggressive Behavior scales were associated with anticonvulsive polytherapy. There were no statistically significant associations between the Child Behavior Checklist scores and seizure symptoms and frequency and EEG at the time of evaluation. The demonstrated frequency of behavioral and emotional problems in children with epilepsy suggests the necessity to address psychosocial issues during the course of clinical treatment.

Adolescent↗

PubMed1997

Meeting the challenge of epilepsy in persons with multiple handicaps.

Epilepsy occurs in more than 30% of persons with mental retardation and up to 50% of those with multiple handicaps living in institutional settings. Treatment of epilepsy in this population presents many unique challenges. Through careful adherence to basic principles of diagnosis, classification, and antiepileptic drug use, as many as 80% of individuals can be successfully managed with one- or two-drug therapy and enjoy positive outcomes in the areas of community integration and increased independence. Rational polypharmacy with the newer anticonvulsant drugs offers additional opportunity for improving outcomes for these individuals, especially with the use of felbamate and lamotrigine, where broad-spectrum efficacy and positive impact on psychosocial functioning is being demonstrated. Further systematic study of new drugs in this population is clearly warranted.

Adolescent↗