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STAR-VA is an interdisciplinary behavioral approach for managing distress behaviors in residents with dementia, implemented at Veterans Health Administration nursing homes. This study evaluated the impact of STAR-VA implementation on psychotropic drug use. The study design is a retrospective, quasi-experimental cohort analysis of residents enrolled as STAR-VA training cases compared with eligible residents at untrained sites to evaluate treatment effects on psychotropic medication use. We matched 229 STAR-VA cases with 1,163 comparisons. STAR-VA cases experienced an average reduction of 0.92 “as-needed” doses per month (95% confidence interval [CI] -1.82, -0.02) compared with controls. No significant effect on non-STAR-VA cases in trained facilities was detected. STAR-VA programs are an important option for reducing potentially inappropriate psychotropic use.

BACKGROUND: There has been a reduction in BZD prescribing in the Veterans Affairs (VA) health care system since 2013. It is unknown whether the decline in VA-dispensed BZDs has been offset by Medicare Part D prescriptions. OBJECTIVES: To examine (1) whether, accounting for Part D, declines in BZD prescribing to older Veterans remain; (2) patient characteristics associated with obtaining BZDs outside VA and facility variation in BZD source (VA only, VA and Part D, Part D only). DESIGN: Retrospective cohort study with mixed effects multinomial logistic model examining characteristics associated with BZD source. PATIENTS: A total of 1,746,278 Veterans aged ≥65 enrolled in VA and Part D, 2013–2017. MAIN MEASURES: BZD prescription prevalence and source. KEY RESULTS: From January 2013 to June 2017, the quarterly prevalence of older Veterans with Part D filling BZD prescriptions through the VA declined from 5.2 to 3.1% (p

OBJECTIVES: Despite evidence for many potential risks, use of benzodiazepines (BZD) among older adults is common. The authors evaluated the available evidence for BZD effectiveness and tolerability for use in older adults in three psychiatric conditions for which BZD are commonly prescribed: insomnia, anxiety disorders, and behavioral and psychological symptoms of dementia. DESIGN: Electronic databases including PubMed/MEDLINE were searched to identify articles that included: 1) patients ≥50 years of age; 2) focused on patients diagnosed with insomnia, anxiety disorders, or behavioral and psychological symptoms of dementia; and 3) were either a randomized, placebo-controlled trial or a randomized trial comparing a BZD with either another psychotropic medication or psychotherapy. RESULTS: A total of 31 studies met the inclusion criteria. Of the three clinical indications evaluated, treatment of insomnia had the greatest available evidence for use of BZD among older adults, with 21 of 25 trials demonstrating improvement in sleep outcomes with use of BZD. Only one trial was found to meet eligibility criteria for BZD use in anxiety disorders, demonstrating benefit over placebo. A total of 5 studies for use in behavioral disturbances in dementia were included; of which only one trial demonstrated improvement over placebo. CONCLUSION: The results of this systematic review suggest that BZD prescribing to older adults is significantly in excess of what the available evidence would suggest is appropriate. Future trials should focus on efforts to reduce both acute and chronic BZD use among older adults while improving access to effective non-pharmacologic treatment alternatives.

Objective This study uses Veterans Health Administration (VHA) pharmacy and encounter claims to evaluate the use of psychotropic medications without a psychiatric diagnosis across age groups. Methods National VHA administrative data for fiscal year 2010 (FY2010) were used to identify all veterans who filled a prescription for at least one psychotropic medication from VHA (N = 1.85 million). Bivariate and multivariate analyses were used to compare the proportion of these veterans without any psychiatric diagnosis, across age groups, adjusting for possible medical indications. Analyses were repeated for six different classes of psychotropic medications and comparing mental health utilizers and non–mental health utilizers. Comparisons were made to prescribing of HIV and diabetes medications without an indicated diagnosis. Results Of all VHA patients prescribed a psychotropic medication in FY2010, 30% had no psychiatric diagnosis, with highest proportions among veterans ages 65–85. This practice was most frequent among nonmental health utilizers and far more prevalent for psychotropic medications than for HIV or diabetes medications. Logistic regression analysis found that age greater than 65 was the strongest predictor of being prescribed a psychotropic without a psychiatric diagnosis. Adjustment for possible medical use of psychotropics and overall medical comorbidity did not substantially alter these trends. Conclusion Older veterans, especially those not using specialty mental healthcare, are more likely to be prescribed psychotropic medications in the absence of a psychiatric diagnosis, perhaps representing unnecessary use, under-diagnosis of mental illness, or incomplete documentation.

Objective:National data from Veterans Health Administration (VHA) electronic medical records were used to examine rates of mental illness and service use among older veterans since mental health care transformation efforts were implemented in 2005.Methods:Data were extracted from VHA electronic medical records for each fiscal year from 2005 through 2013 for veterans ages 65 and older. Among those receiving any health care services, the number and proportion treated for a confirmed mental illness and the utilization of non–mental health care services were identified.Results:In 2013, 2.6 million older veterans utilized services in VHA, 14% of whom had a confirmed mental illness, which was a 57% increase from 2005. Older veterans with confirmed mental illness accounted for a sizable and growing proportion of non–mental health service utilization.Conclusions:Preparing the workforce to address the mental health needs of older veterans and nonveterans is essential.

OBJECTIVE This study used a private insurance claims database to examine the use of diverse classes of psychotropic medications among patients without a psychiatric diagnosis. METHODS MarketScan claims data for 2009 were used to identify privately insured individuals who filled a prescription for at least one psychotropic medication (5.1 million patients). Bivariate and multivariate analyses were used to compare the proportion of patients with and without a psychiatric diagnosis who received a prescription for six different classes of psychotropic medications. The analyses were adjusted for potential medical indications and severity of comorbid general medical illness. RESULTS Altogether, 58% of individuals who were prescribed a psychotropic medication in 2009 had no psychiatric diagnosis during the year. The proportion of patients who were prescribed a psychotropic medication without a psychiatric diagnosis was highest among individuals aged 50 to 64 (69%) and among individuals who did not receive any mental health specialty care (67%). The odds of being prescribed psychotropic medication without a psychiatric diagnosis were 2.9 times higher among patients aged 50 to 64 than among younger patients. Diagnoses signifying potential medical indications for use and severity of comorbid medical conditions were only weakly related to absence of a psychiatric diagnosis and did not alter these age trends. CONCLUSIONS In a large private claims database, a majority of recipients of psychotropic medication, especially older patients and those not utilizing mental health specialty care, lacked a clear indication for such use. This phenomenon deserves further study and may reflect less than desirable care.

Concerns about opioid-related adverse events, including overdose, prompted the Veterans Health Administration (VHA) to launch an Opioid Safety Initiative and Overdose Education and Naloxone Distribution program. To mitigate risks associated with opioid prescribing, a holistic approach that takes into consideration both risk factors (e.g., dose, substance use disorders) and risk mitigation interventions (e.g., urine drug screening, psychosocial treatment) is needed. This article describes the Stratification Tool for Opioid Risk Mitigation (STORM), a tool developed in VHA that reflects this holistic approach and facilitates patient identification and monitoring. STORM prioritizes patients for review and intervention according to their modeled risk for overdose/suicide-related events and displays risk factors and risk mitigation interventions obtained from VHA electronic medical record (EMR)-data extracts. Patients' estimated risk is based on a predictive risk model developed using fiscal year 2010 (FY2010: 10/1/2009-9/30/2010) EMR-data extracts and mortality data among 1,135,601 VHA patients prescribed opioid analgesics to predict risk for an overdose/suicide-related event in FY2011 (2.1% experienced an event). Cross-validation was used to validate the model, with receiver operating characteristic curves for the training and test data sets performing well (>.80 area under the curve). The predictive risk model distinguished patients based on risk for overdose/suicide-related adverse events, allowing for identification of high-risk patients and enrichment of target populations of patients with greater safety concerns for proactive monitoring and application of risk mitigation interventions. Results suggest that clinical informatics can leverage EMR-extracted data to identify patients at-risk for overdose/suicide-related events and provide clinicians with actionable information to mitigate risk. (PsycINFO Database Record

Objective: To examine the prevalence and correlates of concomitant anxiolytic prescription fills in Veterans Health Administration (VHA) patients with metastatic cancer who have extensive prescription opioid use. Design, Setting, and Participants: National VHA data for fiscal year 2012 were used to identify veterans diagnosed with metastatic cancer (ICD-9 codes 196-199) who also had extensive prescription opioid use (at least 10 opioid prescriptions during the year, comprising the highest 29 percent of opioid users). Bivariate and multivariate analyses were used to examine correlates of receiving anxiolytic medication among veterans with metastatic cancer and extensive prescription opioid use. Results: Of the 5,950 veterans with metastatic cancer and extensive prescription opioid use, 51 percent also received anxiolytic medication, of whom 64 percent had a medical indication and 85 percent had a psychiatric or medical indication for psychotropics. Of those with extensive prescription opioid use who filled an anxiolytic, 64 percent also received antidepressants and 38 percent received three or more classes of psychotropic medication (ie, polypharmacy). In multivariate analyses, factors associated with receipt of an anxiolytic included any anxiety disorder, insomnia, the prescription of antidepressants or antipsychotics, bipolar disorder, younger age, more emergency department visits, and greater number of opioid prescriptions. Conclusions: VHA patients with metastatic cancer and extensive prescription opioid use who are prescribed anxiolytics are likely to have a Food and Drug Administration-approved indication for psychotropics, and anxiolytics in particular, but represent a clinically vulnerable group which merits careful monitoring.

Appropriate use of antipsychotic medications in older adults with dementia can be challenging due to several important safety concerns. This article reviews the risks and benefits of using antipsychotic medications in the treatment of patients with neuropsychiatric symptoms of dementia through the framework of an informed-consent conversation. Informed-consent discussions help provide patients, surrogate decision-makers, and caregivers with the essential data necessary to make informed treatment choices. [ Psychiatr Ann . 2015;45(7):348–353.]

We used national data for fiscal year 2012 to examine demographic, psychiatric and medical diagnoses, indications for psychotropics, and service use correlates of psychotropic medication fills in Veterans with at least 10 opioid prescriptions during the year (the highest 29% of opioid users); and whether the Veteran was treated in a specialty mental health clinic. Of the 328,398 Veterans who filled at least 10 opioid prescriptions, 77% also received psychotropics, of whom: 74% received antidepressants, 55% anxiolytics/sedatives/hypnotics, and 26% three or more classes of psychotropic medications. Altogether, 87% had a psychiatric or medical indication; and 54% received mental health treatment. Veterans treated in a mental health clinic were prescribed more psychotropics and were more likely to have a documented psychiatric or medical indication than those treated solely in other settings. Indicated psychiatric diagnoses were the strongest predictors of specific class of psychotropics prescribed; anxiety disorder and insomnia were most strongly associated with anxioloytics/sedatives/hypnotics receipt. Since psychotropics and opioids can produce harmful side effects, especially when combined, and since they are likely prescribed by separate providers in different settings, coordinated consideration of the risks and benefits of co-prescribing these medications may be needed, along with further study of related adverse events.

Dire shortages of psychiatrists with special expertise in geriatrics, substance abuse, forensics, and psychosomatics create barriers to care for populations with complex mental disorders and pose a significant public health concern. To address these disparities in access to care, we propose streamlining graduate medical education to increase efficiency and enhance cost-effectiveness while simultaneously increasing the number of psychiatric subspecialists in these key areas. We propose that trainees interested in subspecialties complete their general training in 3 years, while meeting ACGME required milestones, and then utilize their 4th year to complete subspecialty fellowship training. Eligible trainees would then qualify for psychiatry subspecialty certification and general psychiatry ABPN certification at the end of 4 years.

Historically, inpatient sexuality has been a neglected issue in hospital policy. Recent studies have confirmed sexual activity among individuals with mental illness and have noted several areas of concern surrounding patient care and sexuality. We surveyed private mental health facilities within the state of Ohio. Twenty-five percent of the responding hospitals had a formal sexual policy and the majority (72%) said that sexual behavior was an infrequent problem. Considering the short-term stays common at these facilities, policies at such institutions should focus on dealing with situations when they occur and properly training and informing staff on issues surrounding sexual activity in psychiatric inpatients.

Although it is widely acknowledged that second-generation antipsychotics are associated with cardiometabolic side effects, rates of metabolic screening have remained low. The authors created a quality-improvement (QI) intervention in an academic medical center outpatient psychiatry resident clinic with the aim of improving rates of screening for metabolic syndrome in patients being prescribed antipsychotic medications.The core components of the QI intervention included resident education and creation of a metabolic screening bundle for the electronic medical record. Quarterly audits of individual patient electronic medical records assessed whether a patient was currently prescribed antipsychotics and whether metabolic-syndrome screening had been documented at any time in the preceding 12 months.In each audit period, from 131 to 156 patients (30%-36% of total clinic sample) were prescribed antipsychotic medication. After the intervention, rates of documentation of the components of the metabolic screening bundle increased between 3.5- and 10-fold (final rates: 39% for blood pressure, 44% for BMI, and 55% for glucose and lipid panel). Rates of documenting the full bundle increased nearly 30-fold (final rate: 31%).Provider-education combined with introduction of a documentation bundle in the electronic medical record increased rates of documented metabolic screening in patients being prescribed antipsychotic medications by psychiatry residents.

Objective We studied 405 patients evaluated by the Psychosomatics Service to investigate whether the behavioral description as reflected on consultation request from primary medical–surgical teams could be utilized to predict the final clinical diagnosis of delirium. We explored whether outcomes differed in patient with delirium with different consultation requests. Methods Patients with delirium (n=114) were divided into subtypes based on consultation requests for the management for cognitive dysfunction [altered mental status (AMS), n=46], for agitation or behavior disturbance (BEH, n=26), for depression (DEP, n=18), and for all other reasons (MISC, n=33). Adjusted multivariate regression models were used to examine group differences. Results Consult requests for AMS had a high likelihood ratio (LR+=14.22) and requests for BEH had moderately high likelihood ratio (LR+=4.79) of receiving a diagnosis of delirium. The DEP group (n=18) tended to be younger and had higher 30-day readmission rates. The BEH group (n=26) had more comorbid systemic medical conditions, higher rate of being discharged to home, and lower mortality rate. Delirium subtypes did not show any significant difference in clinical outcomes. Conclusion Behavioral observations on consultation requests as formulated by primary medical–surgical teams may be useful in the classification of patients with delirium. Whether the behavioral observations on the request may be used to predict delirium outcomes deserves further research.

Although patients with schizophrenia have reduced brain size, there is no conclusive evidence that they have reduced head size. This begs the question: 'What is the precise relationship between head size and brain size?' We used a unique osteological collection to explore the relationship between external head measures and cranial capacity. The external measures accounted for, at most, 60% of the variance in cranial capacity - a value low enough to question the oft-assumed tight relationship between head measures and brain size. Obviously, various tissues and spaces [skull, sinus, muscle (frontalis, temporalis and occipitalis), subcutaneous fat and epidermal layers] contribute to head size without contributing to brain volume. The contribution of these other tissues and spaces tends to decrease the signal and increase the noise in the estimation of brain volume. Thus, it is understandable that patients with schizophrenia can have reduced cranial capacity and not reduced head size.

In the past year, we had a remarkable glimpse of brain activity during hallucination in a patient with schizophrenia (Silbersweig; figure). In his typical hallucination, a patient saw moving, coloured scenes with rolling, disembodied heads, which were giving him instructions. 150 positron emission tomography and an image-analysis protocol, designed to image transient subjective experiences, illustrated which areas had increased regional cerebral blood flow during the hallucinations. Increased brain activity was noted in visual and auditory-associated cortices, as well as paralimbic and subcortical areas. Such studies provide clues to the pathophysiology of schizophrenia and to the neural substrate of conscious perceptual experience. Fascinating new clues to schizophrenia also emerged on the genetics/epidemiology front. Gorwood and colleagues tested the hypothesis that the age of onset of schizophrenia decreases in successive generations. This inheritance pattern, "anticipation", results from unstable trinucleotide repeat DNA sequences at the disease locus. The study took place on an island in the Indian Ocean and was based on 97 patients with schizophrenia belonging to 24 families with at least two generations of patients. In the younger generation, the age of onset was significantly less than the expected age of onset based on the data from the older generation. This evidence could accelerate the search for pathological genetic processes implicated in schizophrenia. Psychiatrists are concerned about the potential iatrogenic effects of typical antipsychotics, which are linked to tardive dyskinesia. These effects may be relieved by the findings of McCreadie and colleagues. Dyskinesia was assessed in four groups of elderly individuals including normal people, relatives of schizophrenics, nevermedicated patients with schizophrenia, and medicated patients. The prevalence of dyskinesia was similar in never-medicated and medicated patients (about 40%), and was significantly higher than that in first-degree relatives and normal controls (15%). McCreadie reported that never-medicated patients had "classic tardive dysthinesia", including chewing movements, tongue protrusion, lip smacking, and writhing. The researchers conclude that it is the illness per se that is associated with dyskinesias in elderly schizophrenic patients. However, psychiatrists may be chagrined by the work of Mojtabai and Nicholson. These researchers evaluated the inter-rater reliability of ratings of delusions and bizarre hallucinations among 50 psychiatrists selected randomly from the American Psychiatry Association Membership Directory. The inter-rater reliability estimates were quite low (K about 0-40), and call into question the adequacy of psychiatric training.