This study examined antidepressant use among 3,226 elderly patients receiving home healthcare. Over one-third of patients were taking antidepressants, including 29.15% without a documented depression diagnosis. Blacks used antidepressants less than whites even after controlling for other factors. Increased antidepressant use was associated with younger age, more disabilities, use of other psychotropics like benzodiazepines, and higher overall medication counts. The high rates of antidepressant use without depression raise questions about appropriate prescribing in this vulnerable population.
ABSTRACT- Background: The occurrence of psychiatric disorders is more in the prisoners than in general population. Co-morbidity is seen to be an important and complex entity in clinical assessment of mental state competence (diminished mental capacity, temporary insanity and insanity) in the offenders at the time of the offence. It has a great role in determining all possible options in future treatment of violent offenders. Aim: This research article is focused on the co-morbid psychiatric diagnoses and the treatment outcomes in the mentally ill prisoners referred to the tertiary care mental health facility. Materials and Method: Total 100 mentally ill prisoners referred to the tertiary care psychiatric hospital during the study period (Jan 2015 - Dec 2015) was the sample size. It was a prospective study and the sampling method was of the purposive type. Results: Besides their primary diagnosis, the referred prisoners had more than one co-morbid psychiatric diagnosis in 46% of the cases. The most frequent co-occurring conditions were learning disabilities, personality disorders, and substance use disorders. The outcomes for the psychiatric conditions were positive as patients responded well to the line of management. Conclusion: The study provides valuable data to understand the mental health needs and the treatment gaps in this population so as to plan adequate services to tackle these issues. Key-words- Mentally ill prisoners, Psychiatric co-morbidities, Treatment outcomes, Substance use disorders, Personality disorders
Protective factors against suicidal acts in major depression:Reasons for living, Journal Club Presentation in the Dept of Psychiatric Nursing, Kothamangalam
Depresi dan bunuh diri sebagai masalah kesehatan mental yang lazim untuk pasien hemodialisis. Tujuan: Para penulis meneliti faktor-faktor demografi dan psikologis yang terkait dengan depresi pada pasien hemodialisis dan dijelaskan hubungan antara depresi, kecemasan, kelelahan, kualitas kesehatan yang berhubungan hidup yang buruk, dan meningkatkan risiko bunuh diri.
ABSTRACT- Background: The occurrence of psychiatric disorders is more in the prisoners than in general population. Co-morbidity is seen to be an important and complex entity in clinical assessment of mental state competence (diminished mental capacity, temporary insanity and insanity) in the offenders at the time of the offence. It has a great role in determining all possible options in future treatment of violent offenders. Aim: This research article is focused on the co-morbid psychiatric diagnoses and the treatment outcomes in the mentally ill prisoners referred to the tertiary care mental health facility. Materials and Method: Total 100 mentally ill prisoners referred to the tertiary care psychiatric hospital during the study period (Jan 2015 - Dec 2015) was the sample size. It was a prospective study and the sampling method was of the purposive type. Results: Besides their primary diagnosis, the referred prisoners had more than one co-morbid psychiatric diagnosis in 46% of the cases. The most frequent co-occurring conditions were learning disabilities, personality disorders, and substance use disorders. The outcomes for the psychiatric conditions were positive as patients responded well to the line of management. Conclusion: The study provides valuable data to understand the mental health needs and the treatment gaps in this population so as to plan adequate services to tackle these issues. Key-words- Mentally ill prisoners, Psychiatric co-morbidities, Treatment outcomes, Substance use disorders, Personality disorders
Protective factors against suicidal acts in major depression:Reasons for living, Journal Club Presentation in the Dept of Psychiatric Nursing, Kothamangalam
Depresi dan bunuh diri sebagai masalah kesehatan mental yang lazim untuk pasien hemodialisis. Tujuan: Para penulis meneliti faktor-faktor demografi dan psikologis yang terkait dengan depresi pada pasien hemodialisis dan dijelaskan hubungan antara depresi, kecemasan, kelelahan, kualitas kesehatan yang berhubungan hidup yang buruk, dan meningkatkan risiko bunuh diri.
Efficacy of individualized homeopathic treatment and fluoxetine for moderate ...home
his study is the first trial of classical homeopathy that will evaluate the efficacy of homeopathic
individualized treatment using C-potencies versus placebo or fluoxetine in peri- and postmenopausal women with
moderate to severe depression. It is an attempt to deal with the obstacles of homeopathic research due to the
need for individual prescriptions in one of the most common psychiatric diseases.
QUALITY OF LIFE AS A PREDICTOR OF POST OPERATIVE OUTCOME FOLLOWING REVASCULAR...Shantonu Kumar Ghosh
World Health Organization (WHO) defines quality of life as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.8
QOL encompasses the concept of health-related quality of life (HRQOL) and other domains such as environment, family and work. HRQOL is the extent to which one’s usual or expected physical, emotional and social well-being is affected by a medical condition or its treatment.9
For patients suffering from peripheral arterial disease (PAD), quality of life (QoL) has become as important as medical outcome end points, such as mortality and morbidity, to evaluate the effect of disease and treatment.10
Carle Palliative Care Journal Club for 7/3/18Mike Aref
Journal club review of "Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial" by D. Hui et. al. in JAMA. 2017 Sep 19;318(11):1047-1056.
Exploring the Relationship between the Platelet Indices and Psychosocial Morb...CrimsonPublishersGGS
Exploring the Relationship between the Platelet Indices and Psychosocial Morbidity in Elderly Patients at a Rural Medical College Hospital by Sunil Kumar in Geriatrics studies Journal
Identifying Significant Antipsychotic-Related Side Effects in Patients on a Community Psychiatric Rehabilitation Unit-A Feasibility Study of The Glasgow Antipsychotic Side-Effect Scale (GASS) by Ahmed Saeed Yahya* in crimson publishers: Journal of Physical Medicine and Rehabilitation
Antipsychotic side-effects are common and are an important determinant of non-adherence and consequent relapse. Most rating scales for the identification of these are lengthy and complicated. This report reviews the medical literature on the Glasgow antipsychotic side-effect scale (GASS)-a brief and validated rating scale to measure the unwanted effects of antipsychotics. We administered the GASS to fourteen in-patients in a United Kingdom-based Community Psychiatric Rehabilitation Unit. The objective was to establish the utility of the GASS in this setting and to make recommendations on how this tool could be used in clinical practice to improve adherence to antipsychotic medication.
https://crimsonpublishers.com/epmr/fulltext/EPMR.000529.php
For more Open access journals in Crimson Publishers
Please click on: https://crimsonpublishers.com/
For more articles in Examines in Physical Medicine & Rehabilitation
Please click on: https://crimsonpublishers.com/epmr/
Để xem full tài liệu Xin vui long liên hệ page để được hỗ trợ
: https://www.facebook.com/thuvienluanvan01
HOẶC
https://www.facebook.com/garmentspace/
https://www.facebook.com/thuvienluanvan01
https://www.facebook.com/thuvienluanvan01
tai lieu tong hop, thu vien luan van, luan van tong hop, do an chuyen nganh
Knowledge and Perceptions Related to Hypertension, Lifestyle Behavior Modific...iosrjce
IOSR Journal of Nursing and health Science is ambitious to disseminate information and experience in education, practice and investigation between medicine, nursing and all the sciences involved in health care. Nursing & Health Sciences focuses on the international exchange of knowledge in nursing and health sciences. The journal publishes peer-reviewed papers on original research, education and clinical practice.
By encouraging scholars from around the world to share their knowledge and expertise, the journal aims to provide the reader with a deeper understanding of the lived experience of nursing and health sciences and the opportunity to enrich their own area of practice. The journal publishes original papers, reviews, special and general articles, case management etc.
Case # 29- The depressed man who thought he was out of options. .docxannandleola
Case # 29- The depressed man who thought he was out of options.
Depression has become a common mental disorder in our elderly population. This has caused a global concern for occur, geriatric patients, as depression often results in a significant burden for families as well as communities. Elderly people who suffer from depression may have an inferior baseline and record for medical assessments than those individuals without depression. Despite consistent evidence of the effectiveness of antidepressants for many with depression,
3
particularly those with more severe depression, remission rates are disappointingly low. An AHRQ-sponsored report found that only 46% of patients experienced remission from depression during 6 to 12 weeks of treatment with second-generation antidepressants. One major reason for this issue is non-adherence to medications and treatment plans. Studies have shown that patients' age, race and ethnicity are consistently associated with predictions of outcomes. (Rossom et al., 2016).
This case study involves a 69-year old man whose chief complaint is unremitting, chronic depression. After several years of medications and treatments, he feels hopeless for a recovery from his chronic depression. This assignments seeks to explore his family and social support systems, diagnostic testing, differential diagnosis and pharmacologic treatment options for this patient.
Questions for the client
How have you been sleeping lately?
How many times in the last week have you had feelings of hopelessness?
Are you having thoughts of harming yourself? Do you have a plan?
These questions are an important yet simple place to start when treating patients. Sleep disturbances plague much of the world's population and have shown to be a major indicator for mental health issues. Changes in sleep neurophysiology are often observed in depressive patients, and impaired sleep is, in many cases, the chief complaint of depression (Armitage, 2007). Depressed patients with sleep disturbance are likely to present more severe symptoms and difficulties in treatment. In addition, persistent insomnia is the most common residual symptom in depressed patients and is considered a vital predictor of depression relapse and may contribute to unpleasant clinical outcomes (Hinkelmann et al., 20120. Questions involving feelings of hopelessness and suicidal ideations with or without a plan relate to issues of patient safety. Across psychiatric disorders, hopelessness is associated with suicidal ideation and behavior. A meta-analysis of 166 longitudinal studies (sample size not reported) found that hopelessness was associated with an increased risk of ideation (Ribeiro, Huang, Fox, & Franklin, 2018).
Family and social support system
Family and social support systems are imperative for any patient in recovery. If the patient is agreeable to discussions with family members, then a discussion with his wife would be helpful. Researc.
Efficacy of individualized homeopathic treatment and fluoxetine for moderate ...home
his study is the first trial of classical homeopathy that will evaluate the efficacy of homeopathic
individualized treatment using C-potencies versus placebo or fluoxetine in peri- and postmenopausal women with
moderate to severe depression. It is an attempt to deal with the obstacles of homeopathic research due to the
need for individual prescriptions in one of the most common psychiatric diseases.
QUALITY OF LIFE AS A PREDICTOR OF POST OPERATIVE OUTCOME FOLLOWING REVASCULAR...Shantonu Kumar Ghosh
World Health Organization (WHO) defines quality of life as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.8
QOL encompasses the concept of health-related quality of life (HRQOL) and other domains such as environment, family and work. HRQOL is the extent to which one’s usual or expected physical, emotional and social well-being is affected by a medical condition or its treatment.9
For patients suffering from peripheral arterial disease (PAD), quality of life (QoL) has become as important as medical outcome end points, such as mortality and morbidity, to evaluate the effect of disease and treatment.10
Carle Palliative Care Journal Club for 7/3/18Mike Aref
Journal club review of "Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial" by D. Hui et. al. in JAMA. 2017 Sep 19;318(11):1047-1056.
Exploring the Relationship between the Platelet Indices and Psychosocial Morb...CrimsonPublishersGGS
Exploring the Relationship between the Platelet Indices and Psychosocial Morbidity in Elderly Patients at a Rural Medical College Hospital by Sunil Kumar in Geriatrics studies Journal
Identifying Significant Antipsychotic-Related Side Effects in Patients on a Community Psychiatric Rehabilitation Unit-A Feasibility Study of The Glasgow Antipsychotic Side-Effect Scale (GASS) by Ahmed Saeed Yahya* in crimson publishers: Journal of Physical Medicine and Rehabilitation
Antipsychotic side-effects are common and are an important determinant of non-adherence and consequent relapse. Most rating scales for the identification of these are lengthy and complicated. This report reviews the medical literature on the Glasgow antipsychotic side-effect scale (GASS)-a brief and validated rating scale to measure the unwanted effects of antipsychotics. We administered the GASS to fourteen in-patients in a United Kingdom-based Community Psychiatric Rehabilitation Unit. The objective was to establish the utility of the GASS in this setting and to make recommendations on how this tool could be used in clinical practice to improve adherence to antipsychotic medication.
https://crimsonpublishers.com/epmr/fulltext/EPMR.000529.php
For more Open access journals in Crimson Publishers
Please click on: https://crimsonpublishers.com/
For more articles in Examines in Physical Medicine & Rehabilitation
Please click on: https://crimsonpublishers.com/epmr/
Để xem full tài liệu Xin vui long liên hệ page để được hỗ trợ
: https://www.facebook.com/thuvienluanvan01
HOẶC
https://www.facebook.com/garmentspace/
https://www.facebook.com/thuvienluanvan01
https://www.facebook.com/thuvienluanvan01
tai lieu tong hop, thu vien luan van, luan van tong hop, do an chuyen nganh
Knowledge and Perceptions Related to Hypertension, Lifestyle Behavior Modific...iosrjce
IOSR Journal of Nursing and health Science is ambitious to disseminate information and experience in education, practice and investigation between medicine, nursing and all the sciences involved in health care. Nursing & Health Sciences focuses on the international exchange of knowledge in nursing and health sciences. The journal publishes peer-reviewed papers on original research, education and clinical practice.
By encouraging scholars from around the world to share their knowledge and expertise, the journal aims to provide the reader with a deeper understanding of the lived experience of nursing and health sciences and the opportunity to enrich their own area of practice. The journal publishes original papers, reviews, special and general articles, case management etc.
Case # 29- The depressed man who thought he was out of options. .docxannandleola
Case # 29- The depressed man who thought he was out of options.
Depression has become a common mental disorder in our elderly population. This has caused a global concern for occur, geriatric patients, as depression often results in a significant burden for families as well as communities. Elderly people who suffer from depression may have an inferior baseline and record for medical assessments than those individuals without depression. Despite consistent evidence of the effectiveness of antidepressants for many with depression,
3
particularly those with more severe depression, remission rates are disappointingly low. An AHRQ-sponsored report found that only 46% of patients experienced remission from depression during 6 to 12 weeks of treatment with second-generation antidepressants. One major reason for this issue is non-adherence to medications and treatment plans. Studies have shown that patients' age, race and ethnicity are consistently associated with predictions of outcomes. (Rossom et al., 2016).
This case study involves a 69-year old man whose chief complaint is unremitting, chronic depression. After several years of medications and treatments, he feels hopeless for a recovery from his chronic depression. This assignments seeks to explore his family and social support systems, diagnostic testing, differential diagnosis and pharmacologic treatment options for this patient.
Questions for the client
How have you been sleeping lately?
How many times in the last week have you had feelings of hopelessness?
Are you having thoughts of harming yourself? Do you have a plan?
These questions are an important yet simple place to start when treating patients. Sleep disturbances plague much of the world's population and have shown to be a major indicator for mental health issues. Changes in sleep neurophysiology are often observed in depressive patients, and impaired sleep is, in many cases, the chief complaint of depression (Armitage, 2007). Depressed patients with sleep disturbance are likely to present more severe symptoms and difficulties in treatment. In addition, persistent insomnia is the most common residual symptom in depressed patients and is considered a vital predictor of depression relapse and may contribute to unpleasant clinical outcomes (Hinkelmann et al., 20120. Questions involving feelings of hopelessness and suicidal ideations with or without a plan relate to issues of patient safety. Across psychiatric disorders, hopelessness is associated with suicidal ideation and behavior. A meta-analysis of 166 longitudinal studies (sample size not reported) found that hopelessness was associated with an increased risk of ideation (Ribeiro, Huang, Fox, & Franklin, 2018).
Family and social support system
Family and social support systems are imperative for any patient in recovery. If the patient is agreeable to discussions with family members, then a discussion with his wife would be helpful. Researc.
Original ArticleDesign and implementation of a randomized.docxgerardkortney
Original Article
Design and implementation of a randomized
trial evaluating systematic care for bipolar
disorder
Abundant evidence demonstrates that treatments
for bipolar disorder can reduce the severity of
mood symptoms and improve daily functioning.
Specific pharmacotherapies have been proven effi-
cacious in the acute management of mania and
depression (1, 2) as well as in the prevention of
recurrence (1). For lithium, more intensive treat-
ment has been shown to improve both long-term
clinical outcomes and psychosocial functioning.
Promising evidence also supports the efficacy of
several disease-specific psychosocial interventions
for bipolar disorder (3, 4).
Unfortunately, treatments provided in everyday
practice fall far short of those proven in clinical
Simon GE, Ludman E, Unützer J, Bauer MS. Design and implementation
of a randomized trial evaluating systematic care for bipolar disorder.
Bipolar Disord 2002: 4: 226–236. ª Blackwell Munksgaard, 2002
Objectives: Everyday care of bipolar disorder typically falls short of
evidence-based practice. This report describes the design and
implementation of a randomized trial evaluating a systematic program to
improve quality and continuity of care for bipolar disorder.
Methods: Computerized records of a large health plan were used to
identify all patients treated for bipolar disorder. Following a baseline
diagnostic assessment, eligible and consenting patients were randomly
assigned to either continued usual care or a multifaceted intervention
program including: development of a collaborative treatment plan,
monthly telephone monitoring by a dedicated nurse care manager,
feedback of monitoring results and algorithm-based medication
recommendations to treating mental health providers, as-needed outreach
and care coordination, and a structured psychoeducational group
program (the Life Goals Program by Bauer and McBride) delivered by the
nurse care manager. Blinded assessments of clinical outcomes, functional
outcomes, and treatment process were conducted every 3 months for
24 months.
Results: A total of 441 patients (64% of those eligible) consented to
participate and 43% of enrolled patients met criteria for current major
depressive episode, manic episode, or hypomanic episode. An additional
39% reported significant subthreshold symptoms, and 18% reported
minimal or no current mood symptoms. Of patients assigned to the
intervention program, 94% participated in telephone monitoring and 70%
attended at least one group session.
Conclusions: In a population-based sample of patients treated for bipolar
disorder, approximately two-thirds agreed to participate in a randomized
trial comparing alternative treatment strategies. Nearly all patients
accepted regular telephone monitoring and over two-thirds joined a
structured group program. Future reports will describe clinical
effectiveness and cost-effectiveness of the intervention program compared
with usual care.
Gregory E Simona, Evette
Lud.
Hospital and Community Psychiatry October 1989 Vol. 40 No. 10 .docxwellesleyterresa
Hospital and Community Psychiatry October 1989 Vol. 40 No. 10 1025
dictive Behaviors. Edited by Donovan
DM, Marlart GA. New York, Guilford,
1988
35. Grant I, Reed R: Neuropsychology of
alcohol and drug abuse, in Substance
Abuse and Psychology. Edited by Alter-
man A!. NewYork, Plenum, 1985
36. Vardy MM, Kay SR: LSD psychosis or
LSD-induced schizophrenia? A multi-
method inquiry. Archives of General
Psychiatry 40:877-883, 1983
37. Castellani 5, Petnie WM, Ellinwood E:
Drug-induced psychosis: neurobiologi-
cal mechanisms, in Substance Abuse and
Psychology. Edited by Alterman A!.
New York, Plenum, 1985
38. McLellan AT, Woody GE, O’Brien CP:
Development ofpsychiatnic disorders in
drug abusers. New England Journal of
Medicine 301:1310-1314, 1979
39. Ellinwood E, Duarte-Escalante 0:
Chronic methamphetamine intoxication
in three species ofexperimental animals,
in Current Concepts on Amphetamine
Abuse. Edited by Ellinwood E, Cohen S.
Rockville, Md, National Institute of
Mental Health, 1972
40. BeIIDS: The experimental reproduction
of amphetamine psychosis. Archives of
General Psychiatry 30:35-40, 1973
41. Alterman A!: Substance abuse in psychi-
atnic patients, in Substance Abuse and
Psychology. Edited by Alterman A!.
New York, Plenum, 1985
42. Kendler KS: A twin study of individuals
with both schizophrenia and alcoholism.
BritishJournal ofPsychiatry 147:48-53,
1985
43. Hesselbrock MN, Hesselbrock VM,
Tennen H, et al: Methodological con-
sidenations in the assessment of depres-
sion in alcoholics. Journal of Consulting
and Clinical Psychology 51:399-405,
1983
44. HimmelhochJM, Hill 5, Steunberg B, et
al: Lithium, alcoholism, and psychiatric
diagnosis. Journal of Psychiatric Treat-
ment and Evaluation 5:83-88, 1983
45. Mayfield D: Substance abuse in theaffec-
sive disorders, in Substance Abuse and
Psychology. Edited by Alterman A!.
New York, Plenum, 1985
46. Schuckit MA: The importance of family
history ofaffective disorder in agroup of
young men. Journal of Nervous and
MentalDisease 170:530-535, 1982
47. Robertson MJ: Mental disorder among
homeless persons in the United States:
an overview of recent empirical liters-
tare. Administration in Mental Health
14:14-27, 1986
48. Blashfield BK Propositions regarding
the use of cluster analysis in clinical re-
search.JournalofConsultingand Clinical
Psychology 48:456-459, 1980
49. Blashfield RK, Money LC:The classifica-
tion of depression through cluster anal-
ysis. Comprehensive Psychiatry 20:516-
527, 1979
50. OverallJE, Hollister LE, Johnson M, et
al: Nosology ofdepression and differen-
tial response to drugs. JAMA 195:946-
948, 1966
51. Spitzer RL, Williams JBW: Having a
dream: a research study for DSM-IV.
Archives ofGeneral Psychiatry 45:871-
874, 1988
Treatment of Patients With
Psychiatric and Psychoactive
Substance Abuse Disorders
Fred C. Osher, M.D.
Lial L. Kofoed, M.D.
The treatment ofindividuals with
coexisting psychoactive substance
abuse and severepsy ...
Background: Behavioral health conditions are prevalent among patients in inpatient medical settings and when not adequately treated contribute to diminished treatment outcomes and quality of life. Substantial evidence has demonstrated the effectiveness of psychological interventions in addressing behavioral health conditions in a range of settings but, to a lesser extent with psychologically-based interventions delivered in inpatient medical settings. Purpose: The purpose of this paper is to increase attention on psychological interventions being delivered to patients across a broad spectrum of medical specialties in inpatient medical settings to support the implementation of interventions to address increasing patient needs. Methods: This selected, brief review of the literature sought to describe published psychologically-based interventions delivered in inpatient medical settings. A search for studies catalogued on PubMed from 2007 to 2016 was examined and studies were included in the review if they were delivered within inpatient medical settings. Two reviewers independently assessed relevant studies for criteria. Results: A total of ten articles met the inclusion criteria with interventions targeting outcomes across four primary domains: 1) pain and fatigue; 2) cognition; 3) affective/emotional and; 4) self-harm. Several articles support interventions grounded in Cognitive-Behavioral Therapy and brief psychological interventions. Most studies reported favorable outcomes for the interventions relative to controls. Conclusions: Psychologically-based interventions, especially those that integrate components of cognitive-behavioral therapy and a multidisciplinary approach, can be implemented in inpatient medical settings and may promote improved patient outcomes. However, the quality of this evidence requires formal assessment, requiring more comprehensive reviews are needed to replicate findings and clarify effectiveness of interventions.
Integrated Care Model: Interventions and Strategies for Addressing Co-Morbidities in Early Recovery by Dr. Alkesh Patel, M.D., M.R.O. Addiction Psychiatrist and Assistant Clinical Professor Icahn School of Medicine at Mount Sinai, NYC.
Copyright 2016 American Medical Association. All rights reserv.docxmelvinjrobinson2199
Copyright 2016 American Medical Association. All rights reserved.
Intensive vs Standard Blood Pressure Control
and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years
A Randomized Clinical Trial
Jeff D. Williamson, MD, MHS; Mark A. Supiano, MD; William B. Applegate, MD, MPH; Dan R. Berlowitz, MD; Ruth C. Campbell, MD, MSPH;
Glenn M. Chertow, MD; Larry J. Fine, MD; William E. Haley, MD; Amret T. Hawfield, MD; Joachim H. Ix, MD, MAS; Dalane W. Kitzman, MD;
John B. Kostis, MD; Marie A. Krousel-Wood, MD; Lenore J. Launer, PhD; Suzanne Oparil, MD; Carlos J. Rodriguez, MD, MPH;
Christianne L. Roumie, MD, MPH; Ronald I. Shorr, MD, MS; Kaycee M. Sink, MD, MAS; Virginia G. Wadley, PhD; Paul K. Whelton, MD;
Jeffrey Whittle, MD; Nancy F. Woolard; Jackson T. Wright Jr, MD, PhD; Nicholas M. Pajewski, PhD; for the SPRINT Research Group
IMPORTANCE The appropriate treatment target for systolic blood pressure (SBP) in older
patients with hypertension remains uncertain.
OBJECTIVE To evaluate the effects of intensive (<120 mm Hg) compared with standard
(<140 mm Hg) SBP targets in persons aged 75 years or older with hypertension
but without diabetes.
DESIGN, SETTING, AND PARTICIPANTS A multicenter, randomized clinical trial of patients aged
75 years or older who participated in the Systolic Blood Pressure Intervention Trial (SPRINT).
Recruitment began on October 20, 2010, and follow-up ended on August 20, 2015.
INTERVENTIONS Participants were randomized to an SBP target of less than 120 mm Hg
(intensive treatment group, n = 1317) or an SBP target of less than 140 mm Hg (standard
treatment group, n = 1319).
MAIN OUTCOMES AND MEASURES The primary cardiovascular disease outcome was a
composite of nonfatal myocardial infarction, acute coronary syndrome not resulting in a
myocardial infarction, nonfatal stroke, nonfatal acute decompensated heart failure, and death
from cardiovascular causes. All-cause mortality was a secondary outcome.
RESULTS Among 2636 participants (mean age, 79.9 years; 37.9% women), 2510 (95.2%)
provided complete follow-up data. At a median follow-up of 3.14 years, there was a
significantly lower rate of the primary composite outcome (102 events in the intensive
treatment group vs 148 events in the standard treatment group; hazard ratio [HR], 0.66
[95% CI, 0.51-0.85]) and all-cause mortality (73 deaths vs 107 deaths, respectively; HR, 0.67
[95% CI, 0.49-0.91]). The overall rate of serious adverse events was not different between
treatment groups (48.4% in the intensive treatment group vs 48.3% in the standard
treatment group; HR, 0.99 [95% CI, 0.89-1.11]). Absolute rates of hypotension were 2.4% in
the intensive treatment group vs 1.4% in the standard treatment group (HR, 1.71 [95% CI,
0.97-3.09]), 3.0% vs 2.4%, respectively, for syncope (HR, 1.23 [95% CI, 0.76-2.00]), 4.0% vs
2.7% for electrolyte abnormalities (HR, 1.51 [95% CI, 0.99-2.33]), 5.5% vs 4.0% for acute
kidney injury (HR, 1.41 [95% CI, 0.98-2.04]), and 4.9% vs 5.5% for inj.
Copyright 2016 American Medical Association. All rights reserv.docxbobbywlane695641
Copyright 2016 American Medical Association. All rights reserved.
Intensive vs Standard Blood Pressure Control
and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years
A Randomized Clinical Trial
Jeff D. Williamson, MD, MHS; Mark A. Supiano, MD; William B. Applegate, MD, MPH; Dan R. Berlowitz, MD; Ruth C. Campbell, MD, MSPH;
Glenn M. Chertow, MD; Larry J. Fine, MD; William E. Haley, MD; Amret T. Hawfield, MD; Joachim H. Ix, MD, MAS; Dalane W. Kitzman, MD;
John B. Kostis, MD; Marie A. Krousel-Wood, MD; Lenore J. Launer, PhD; Suzanne Oparil, MD; Carlos J. Rodriguez, MD, MPH;
Christianne L. Roumie, MD, MPH; Ronald I. Shorr, MD, MS; Kaycee M. Sink, MD, MAS; Virginia G. Wadley, PhD; Paul K. Whelton, MD;
Jeffrey Whittle, MD; Nancy F. Woolard; Jackson T. Wright Jr, MD, PhD; Nicholas M. Pajewski, PhD; for the SPRINT Research Group
IMPORTANCE The appropriate treatment target for systolic blood pressure (SBP) in older
patients with hypertension remains uncertain.
OBJECTIVE To evaluate the effects of intensive (<120 mm Hg) compared with standard
(<140 mm Hg) SBP targets in persons aged 75 years or older with hypertension
but without diabetes.
DESIGN, SETTING, AND PARTICIPANTS A multicenter, randomized clinical trial of patients aged
75 years or older who participated in the Systolic Blood Pressure Intervention Trial (SPRINT).
Recruitment began on October 20, 2010, and follow-up ended on August 20, 2015.
INTERVENTIONS Participants were randomized to an SBP target of less than 120 mm Hg
(intensive treatment group, n = 1317) or an SBP target of less than 140 mm Hg (standard
treatment group, n = 1319).
MAIN OUTCOMES AND MEASURES The primary cardiovascular disease outcome was a
composite of nonfatal myocardial infarction, acute coronary syndrome not resulting in a
myocardial infarction, nonfatal stroke, nonfatal acute decompensated heart failure, and death
from cardiovascular causes. All-cause mortality was a secondary outcome.
RESULTS Among 2636 participants (mean age, 79.9 years; 37.9% women), 2510 (95.2%)
provided complete follow-up data. At a median follow-up of 3.14 years, there was a
significantly lower rate of the primary composite outcome (102 events in the intensive
treatment group vs 148 events in the standard treatment group; hazard ratio [HR], 0.66
[95% CI, 0.51-0.85]) and all-cause mortality (73 deaths vs 107 deaths, respectively; HR, 0.67
[95% CI, 0.49-0.91]). The overall rate of serious adverse events was not different between
treatment groups (48.4% in the intensive treatment group vs 48.3% in the standard
treatment group; HR, 0.99 [95% CI, 0.89-1.11]). Absolute rates of hypotension were 2.4% in
the intensive treatment group vs 1.4% in the standard treatment group (HR, 1.71 [95% CI,
0.97-3.09]), 3.0% vs 2.4%, respectively, for syncope (HR, 1.23 [95% CI, 0.76-2.00]), 4.0% vs
2.7% for electrolyte abnormalities (HR, 1.51 [95% CI, 0.99-2.33]), 5.5% vs 4.0% for acute
kidney injury (HR, 1.41 [95% CI, 0.98-2.04]), and 4.9% vs 5.5% for inj.
Trends in Psychotropic Medication Costsfor Children and Adol.docxwillcoxjanay
Trends in Psychotropic Medication Costs
for Children and Adolescents, 1997-2000
Andrés Martin, MD, MPH; Douglas Leslie, PhD
Objective: To examine trends in psychotropic medi-
cation utilization and costs for children and adolescents
between January 1, 1997, and December 31, 2000.
Methods: Pharmacy claims were analyzed for mental
health users 17 years and younger (N = 83 039) from a
national database covering 1.74 million privately in-
sured youths. Utilization rates and costs for dispensed
medications were compared across psychotropic drug cat-
egories and individual agents over time.
Results: Overall use of psychotropic drugs increased from
59.5% of mental health outpatients in 1997 (a 1-year
prevalence of 28.7 per 1000) to 62.3% in 2000 (33.7 per
1000), a 4.7% increase. The largest changes in utiliza-
tion were seen for atypical antipsychotics (138.4%), atypi-
cal antidepressants (42.8%), and selective serotonin re-
uptake inhibitors (18.8%). The average prescription price
increased by 17.6% ($7.90 per prescription), a change
in turn attributed to a shift toward costlier medications
within the same category (55.1% of the increase, or $4.35)
and to pure inflation (44.9% of the increase, or $3.55;
P for trend �.001 for all comparisons). Almost half
(46.7%) of the $2.7 million gross sales differential was
accounted for by only 3 of the 39 drugs identified (am-
phetamine compound, risperidone, and sertraline), and
75% was accounted for by 7 drugs (the previous 3 and
bupropion, paroxetine, venlafaxine, and citalopram).
Conclusions: Psychotropic drug expenditure increases
during the late 1990s resulted from more youths being
prescribed drugs, a preference for newer and costlier medi-
cations, and the net effects of inflation. The impact of man-
aged care and pharmaceutical marketing effects on these
trends warrants further study.
Arch Pediatr Adolesc Med. 2003;157:997-1004
T
HE USE of psychotropic
medications in children has
become a highly visible is-
sue, receiving regular at-
tention from academics (for
a recent summary, see Jensen et al1), poli-
cymakers,2,3 and the lay press alike.4-6 In
contrast to the controversial and at times
charged reactions that the topic can en-
gender, reliable national estimates of the
extent of pediatric use of psychotropic
drugs have only recently started to be-
come available.7-9 Previous studies10,11 have
documented that most psychotropic medi-
cations are not prescribed by mental health
specialists but rather by general practi-
tioners, a pattern that is certainly appli-
cable to stimulants, the most widely used
psychotropic drug class for children: in
1995, pediatricians prescribed 50% of
stimulants, family practitioners 20%, and
psychiatrists only 13%.8
The financial implications of pediat-
ric pharmacotherapy have gone largely un-
examined, an important shortcoming given
that in the US expenditures for prescrip-
tion drugs have continued to be the fastest
growing component of health care across
a ...
2. This study used data from the 2007 National Home and Hospice Care Survey (NHHCS) to
estimate rates of AD use in HHC patients and identify demographic, functional, and clinical
factors associated with AD use in this vulnerable patient population.
METHODS
Sample and Measures
The NHHCS sampled HHC patients who were scheduled for assessment interviews. Patient
data were collected through agency interviews and medical records. Our sample included
HHC patients aged 65 years or older; receiving Medicare postacute care for medical and
surgical reasons. We excluded hospice patients because of their different medical and
service needs.6
We classified medications as psychotropic if approved for psychiatric disorders treatment.
ADs included selective serotonin reuptake inhibitor, serotonin-norepinephrine reuptake
inhibitor, tricyclic antidepressant, and “Others,” which included bupropion, mirtazapine.
We classified psychotropic medications besides ADs into antipsychotics, including
phenothiazene antipsychotics, atypical antipsychotics, and miscellaneous antipsychotics;
mood stabilizers including lithium, valproate, lamotrigine, and carbamazepine; and other
psychotropic medications (other psychotropics) including benzodiazepines, miscellaneous
anxiolytics, sedatives, and hypnotics.
The NHHCS reported International Classification of Disease, 9th Revision, diagnoses (1
primary and up to 15 secondary) per patient. Diagnoses were included as part of the
physician referral. Among bipolar patients, only patients who had a depression episode were
included, and were grouped with the depressed. Medical comorbidity was represented by the
sum of International Classification of Diseases, Ninth Revision, Clinical Modification
categories and functional status was measured as total activities of daily living (ADL)
impairments. Sociodemographic factors included age, gender, race, Hispanic ethnicity,
marital status (married, divorced, single—never married), and living arrangements (lives
alone, lives with spouse, lives with other family members/children/parents, or nonfamily
members).
Statistical Analysis
We used a survey data analytic procedure (SAS Institute Inc., Cary, NC), which adjusted for
variance estimation using Taylor series. Rao-Scott χ2 for weighted survey data was used to
test categorical variables. Student's t-tests were conducted for continuous variables. A
multivariate logistic regression with AD use as the dependent variable included factors
significantly associated with AD use (p < 0.10) in the bivariate analysis.
RESULTS
Sample Characteristics
Analyses included 3,226 patients, representing 1,003,390 national patients. The study
population was predominately women (68.37%), average age 80.11 years (range: 65–100,
CI = 79.65–80.57). The sample included whites (82.45%), blacks (14.98%), Asians (1.62%),
Pacific Islanders, and American Indians (0.95% combined). Hispanic participants were
8.15%. Patients were primarily widowed (46.45%) or married (38.68%). Most patients lived
alone (35.09%) or with a spouse (32.00%).
The most common psychiatric diagnoses were depression (6.76%), dementia (4.00%), and
anxiety (3.18%). Psychotic disorders comprised the smallest portion of the overall sample
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3. (0.29%), and neither dementia, anxiety nor psychotic disorders were associated with AD
use. Total number of psychiatric disorders ranged from 0 to 3 with a mean of 0.14 (CI =
0.12–0.17). Number of nonpsychiatric conditions ranged from 0 to 9 per patient with a mean
of 2.17 (2.09–2.25). Mean number of ADL impairments was 2.85 (CI = 2.76–2.94). Overall,
33.50% of patients used ADs and 3.40% were taking more than one AD. Among patients
taking ADs, the most commonly used was selective serotonin reuptake inhibitors (65.14%),
followed by tricyclic antidepressants (14.67%), serotonin-norepinephrine reuptake inhibitors
(11.34%), and other ADs (22.41%). The most common group of psychotropic medications,
besides ADs, was other psychotropics (30.15%). A small fraction received antipsychotics or
mood stabilizers. The total mean number of prescriptions was 10.67 (CI = 10.39–10.96) and
total mean number of nonpsychotropic medications was 11.09 (CI = 10.77–11.41)
suggesting that patients were taking medications without a reported prescription.
Factors Associated With AD Use
AD use was higher among patients with depression than those without (70.34% versus
28.71%). Sociodemographic factors that were significantly correlated with AD used
included black race with white (OR = 0.38, CI = 0.24–0.59) and younger age (t-test = –4.12,
df = 1, p < 0.0001). Clinical correlates included depression (OR = 5.45, CI = 3.20–9.30),
total psychiatric and nonpsychiatric disorders (t-test = 5.83, df = 1, p < 0.0001; t-test = 2.43,
df = 1, p = 0.01, respectively), and number of ADL impairments (t-test = 2.77, df = 1, p =
0.005) (mean number ADL impairments; AD users versus non-AD users: 3.03, SE = 0.07
and 2.75, SE = 0.05). AD use was associated with other psychotropic use (3.56, CI = 2.69–
4.72). Total number of prescriptions was higher among AD users (AD users 12.92, SE =
0.26 versus non-AD users 9.49, SE = 0.15). Total number of psychotropic medications and
nonpsychotropic medications were associated with AD use (t-test = 8.91, df = 1, p < 0.0001;
t-test = 7.23, df = 1, p < 0.0001, respectively).
The multivariate logistic regression found that black race and advanced age remained
significantly inversely associated with AD use. Other significant factors included
depression, ADL impairments, use of antipsychotrics and other psychotropics, and the total
number of nonpsychotropic medications (Table 1).
CONCLUSIONS
The major finding was that more than one-third of geriatric HHC patient used ADs. Use of
ADs varied systematically be sociodemographic and clinical factors even after controlling
for depression diagnoses. Among the subset with a chart diagnosis of depression, about 70%
were taking ADs. In contrast, earlier findings in the geriatric HHC population reported that
only 22% of patients who met a research depression diagnosis1 were receiving an AD. Rates
of AD use were also high (28.71%) among patients without a depression diagnosis. Whether
the high use of ADs among patients without a depression diagnosis represented the under-
reporting of depression, the initiation of ADs for past depressions that were not carried
forward or ADs prescribed for subthreshold symptoms or for indications other than
depression, cannot be ascertained.
Among sociodemographic factors, the higher use of ADs in whites compared with blacks,
after controlling for depression and other clinical factors, may reflect patient preferences,
differential access to care, provider differences.7 This racial difference in AD use may
reflect disparities in quality of mental healthcare, although the design cannot assess clinical
appropriateness. Regarding age, its inverse relationship between AD use may reflect a
tendency not to treat subthreshold depressive symptoms in the older adults.8
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4. Among clinical factors, the positive relationship between total medications for
nonpsychiatric conditions and AD use, after controlling for depression diagnosis, may
reflect AD prescriptions for symptoms related to medical burden (e.g., fatigue, diminished
interest) that imitate clinical depression. Alternatively, providers who prescribe ADs may
tend to prescribe more medications overall. The association between ADs and
benzodiazepines may result from prescriptions written to reduce anxiety or sleep
disturbances frequently accompanying depression.
The NHHCS was limited by the reliance on medical records, which may fail to include
diagnoses because of transcription errors. Diagnoses may also get lost during patient
transitions.9 As with cross-sectional studies, causation and timing cannot be established.
Further investigation in longitudinal data could determine the timing and the circumstances
under which a physician writes the prescription.
Our study strength was the examination of the HHC population. HHC provides a window of
time in which patients are observed by HHC nurses, and in which the unmet healthcare
needs of the HHC patient can be addressed. HHC is also a service used by a broad sample of
the national population and represents an opportunity to address disparities in mental
healthcare. The use of the newly released NHHCS offered data from a broad population
sample of the HHC elderly, necessary to update the national patterns in AD use. These new
data indicated that AD use has become highly common in HHC patients, regardless of
depression diagnoses, and varied by sociodemographic, clinical, and functional factors. The
extent to which AD use in clinically appropriate is a question that needs to be addressed by
future research. Its importance is underscored by the sys tematic variation in ADs by
sociodemographic and clinical factors, even after controlling for documented depression.
Acknowledgments
Judith Weissman received support from the National Institute of Mental Health funded Tri-Site Collaborative
Training Program in geriatric mental health services research (T32 MH073553). Additional funding came from
NIMH (P30MH085943), Cornell ACISR in Late-Life Depression.
References
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TABLE 1
Logistic Regression Modeling Any AD as a Dependent Variable and Black Race, Age, Total Number of ADL
Impairments, Depression, Other Psychotropics, Antipsychotic Use, and Total Number of Nonpsychotropic
Medications as Independent Variables
Independent Variables OR (CI) Wald χ2 (df) (p)a
Black race 0.41 (0.24-0.70) 10.26 (1) (0.0014)
Age 0.96 (0.94-0.98) 14.98 (1) (0.0001)
Total ADL impairments 1.15 (1.05-1.26) 10.01 (1) (0.0016)
Depression 4.78 (2.65-8.60) 27.20 (1) (<0.0001)
Other psychotropics use 2.63 (1.88-3.69) 31.85 (1) (<0.0001)
Antipsychotic use 2.08 (1.29-3.36) 9.05 (1) (0.0026)
Total number of nonpsychotropic medications 1.07 (1.04-1.10) 28.64 (1) (<0.0001)
a
Wald χ2 test for significance of independent variables in the logistic regression model.
Am J Geriatr Psychiatry. Author manuscript; available in PMC 2013 June 17.