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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.

In February 2022, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline (CPG) for the management of major depressive disorder (MDD). This synopsis summarizes key recommendations.Senior leaders within the VA and the DoD assembled a team to update the 2016 CPG for the management of MDD that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy CPGs. The guideline panel developed key questions, systematically searched and evaluated the literature, created two 1-page algorithms, and distilled 36 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Select recommendations that were identified by the authors to represent key changes from the prior CPG are presented in this synopsis.The scope of the CPG is diverse; however, this synopsis focuses on key recommendations that the authors identified as important new evidence and changes to prior recommendations on pharmacologic management, pharmacogenomics, psychotherapy, complementary and alternative therapies, and the use of telemedicine.

ObjectiveThe Veterans Health Administration (VHA) and the Centers for Medicare and Medicaid Services (CMS) each created initiatives to reduce off-label use of antipsychotics in patients with dementia in nursing homes. Although CMS has reported antipsychotic reductions, the impact on prescribing of antipsychotic and other CNS-active medications in the VHA remains unclear. The authors evaluated national trends in antipsychotic and other CNS-active medication prescribing for nursing home patients with dementia in the VHA.MethodsThe study sample was all veterans with dementia residing in VHA nursing homes for more than 30 days (N=35,742). Using an interrupted time-series design, the quarterly prevalences of antipsychotic, antidepressant, antiepileptic, anxiolytic, opioid, and memory medication prescribing were evaluated from FY2009 through FY2018.ResultsAntipsychotic prescribing in VHA nursing homes declined from FY2009 to FY2018 (from 33.7% to 27.5%), with similar declines in anxiolytic prescribing (from 33.5% to 27.1%). During this period, prescribing of antiepileptics, antidepressants, and opioids increased significantly (antiepileptics: from 26.8% to 43.3%; antidepressants: from 56.8% to 63.4%; opioids: from 32.6% to 41.2%). Gabapentin served as the main driver of antiepileptic increases (from 11.1% to 23.5%). Increases in antidepressant prescribing included sertraline, mirtazapine, and trazodone. From FY2009 to FY2018, the overall prescribing of non-antipsychotic psychotropic medications grew from 75.0% to 81.1%.ConclusionsAntipsychotic and anxiolytic prescribing for VHA nursing home residents with dementia declined, although overall prescribing of other psychotropic and opioid medications increased. Policies focused primarily on reducing antipsychotic use without considering use in the context of other medications may contribute to growth in alternative medication classes with even less evidence of benefit and similar risks.

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

PURPOSE: Unlike in many community-based settings, benzodiazepine (BZD) prescribing to older veterans has decreased. We sought to identify health care system strategies associated with greater facility-level reductions in BZD prescribing to older adults. METHODS: We completed an explanatory sequential mixed methods study of health care facilities in the Veterans Health Administration (N = 140). Among veterans aged ≥75 years receiving long-term BZD treatment, we stratified facilities into relatively high and low performance on the basis of the reduction in average daily dose of prescribed BZD from October 1, 2015 to June 30, 2017. We then interviewed key facility informants (n = 21) who led local BZD reduction efforts (champions), representing 11 high-performing and 6 low-performing facilities. RESULTS: Across all facilities, the age-adjusted facility-level average daily dose in October 2015 began at 1.34 lorazepam-equivalent mg/d (SD 0.17); the average rate of decrease was −0.27 mg/d (SD 0.09) per year. All facilities interviewed, regardless of performance, used passive strategies primarily consisting of education regarding appropriate prescribing, alternatives, and identifying potential patients for discontinuation. In contrast, champions at high-performing facilities described leveraging ≥1 active strategies that included individualized recommendations, administrative barriers to prescribing, and performance measures to incentivize clinicians. CONCLUSIONS: Initiatives to reduce BZD prescribing to older adults that are primarily limited to passive strategies, such as education and patient identification, might have limited success. Clinicians might benefit from additional recommendations, support, and incentives to modify prescribing practices.

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.

Objective To evaluate longitudinal prescription practice trends for patients diagnosed with posttraumatic stress disorder (PTSD) using a national cohort of veterans who engaged in Veterans Health Administration (VHA) care from 2009 to 2018. Methods Using ICD-9 and ICD-10 codes to determine diagnoses, 1,353,416 patients diagnosed with PTSD in VHA care were retrospectively identified who were not diagnosed with bipolar or psychotic spectrum disorder. Veterans were included in the analytic sample starting in the year of their first PTSD diagnosis for each year that they were active in VHA care. Outpatient prescription records were examined from 2009 to 2018 for medications that are commonly used as recommended (selective serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reuptake inhibitors [SNRIs]) or second-line/adjunctive (atypical antipsychotics [AAPs], mirtazapine, prazosin, trazodone, tricyclic antidepressants, and non-benzodiazepine hypnotics) medications for PTSD. Benzodiazepine prescriptions were also examined. Results From 2009 to 2018, the percentage of patients active in VHA care who received at least one of the examined recommended or second-line/adjunctive medications for PTSD in a calendar year declined by 9.0% (absolute change). The largest absolute change in rates of prescribing for medication classes over the last decade were observed among SSRIs (-12.3%) and SNRIs (+6.4%). AAP use decreased 5.4% from 2009 to 2018, with most of this change (-4.3%) occurring from 2009 to 2013. Conclusions Consistent with clinical practice guidelines, SSRIs/SNRIs were the most common prescriptions for patients in the current study. Reductions in the percentage of patients receiving PTSD medications may reflect concerns regarding effectiveness, adverse side effects, increases in access to evidence-based psychotherapy for PTSD, and/or symptom improvement such that medication was no longer needed.

BACKGROUND/OBJECTIVES Benzodiazepines (BZDs) are widely prescribed to older adults. Although prescribing has declined in the U.S. Department of Veterans Affairs (VA), Medicare introduced BZD coverage in 2013. It is unknown whether declines in the VA have been widespread among older adults in the United States. DESIGN Observational study in traditional fee‐for‐service Medicare, commercial insurance, and the VA. SETTING United States, 2013–2017. PARTICIPANTS Adults aged 55 and older in traditional Medicare (234,290,693 person‐months), commercial insurance (337,827,125 person‐months), and the VA (256,590,369 person‐months). MEASUREMENTS (1) Change in BZD and BZD‐opioid co‐prescribing modeled by Poisson regression over time; and (2) standardized ratios of BZD and BZD‐opioid co‐prescribing, using Medicare as the reference. RESULTS From April 2013 to December 2017, the monthly percentage of adults aged 55 and older who received BZDs fell from 10.4% to 9.3% in Medicare, 6.6% to 6.5% in commercial insurance, and 5.7% to 3.0% in the VA. Monthly BZD‐opioid co‐prescribing over the same time fell from 4.0% to 3.0% in Medicare, 2.3% to 2.0% in commercial, and 2.2% to .6% for the VA. Age‐ and sex‐adjusted rates of decline for BZD and BZD‐opioid co‐prescribing were statistically significant for all systems. Annual BZD rate reductions were .98 (Medicare), .99 (commercial), and .87 (VA; P < .001 for all); co‐prescribing rate reductions were .95, .99, and .75 (P < .001 for all). Using standardized ratios accounting for demographic and clinical characteristics, both prescribing and co‐prescribing were lowest for the VA relative to Medicare (standardized BZD ratio = .40; 95% confidence interval [CI] = .39–.40; standardized BZD‐opioid co‐prescribing ratio = .35; 95% CI = .35–.35). Prescribing in commercial insurance was also lower (BZD = .65; 95% CI = .65–.65; BZD‐opioid co‐prescribing = .65; 95% CI = .65–.65). CONCLUSION BZD prescribing has declined much more to older adults receiving care through the VA than Medicare or commercial insurance. Other systems may learn from strategies implemented in the VA.

Background Patients newly insured through coverage expansion under the Affordable Care Act (ACA) may have difficulty obtaining timely primary care follow-up appointments after emergency department (ED) discharge. We evaluated the association between availability of timely follow-up appointment with practice access improvements, including patient-centered medical home (PCMH) designations or extended-hours appointments. Methods We performed a secret-shopper audit of primary care practices in greater New Haven, Connecticut. Two callers, posing as patients discharged from the ED, called these practices requesting follow-up appointments. They followed standardized scripts varying in ED diagnosis (uncontrolled hypertension, acute back pain) and insurance status (commercial, exchange, Medicaid). We linked our findings with data from a previously completed survey that assessed practice characteristics and examined the associations between appointment availability and practice access improvements. Results Of the 58 included primary care practices, 49 (84.5%) completed both the audit and the survey. Overall, 167/536 calls (31.2%) obtained an appointment in 7 days. Practices with PCMH designation were less likely to offer appointments within 7 days (23.4% vs. 33.1%, p = 0.03). However, callers were more likely to obtain an appointment in 7 days from practices offering after-hour appointments (36.3% vs. 27.8%, p = 0.04). After adjusting for insurance type, there were no significant associations between practice improvements and 7-day appointment availability or appointment wait time. Conclusion PCMH designation and extended-hours appointments were not associated with improved availability of timely primary care follow-up appointment for discharged ED patients. EDs should engage local clinicians and other stakeholders to strengthen linkage and care transition with outpatient practices.

OBJECTIVE To describe how use of antidepressants, benzodiazepines, and other anxiolytic/sedative-hypnotics among older adults (age ≥ 65 years) has changed over time among visits to primary care providers and psychiatrists. METHODS Data were from the National Ambulatory Medical Care Survey (years 2003-2005 and 2010-2012), a nationally representative cross-section of outpatient physician visits. Analysis focused on visits to primary care providers (n = 14,282) and psychiatrists (n = 1,095) at which an antidepressant, benzodiazepine, or other anxiolytic/sedative-hypnotic was prescribed, which were stratified by demographic and clinical characteristic (including ICD-9-CM diagnosis) and compared across study intervals. Odds of medication use were calculated for each stratum, adjusting for demographic and clinical characteristics. RESULTS The visit rate by older adults to primary care providers where any of the medications were prescribed rose from 16.4% to 21.8% (adjusted odds ratio [AOR] = 1.43, P < .001) while remaining steady among psychiatrists (75.4% vs 68.5%; AOR = 0.69, P = .11). Primary care visits rose for antidepressants (9.9% to 12.3%; AOR = 1.28, P = .01) and other anxiolytic/sedative-hypnotics (3.4% to 4.7%; AOR = 1.39, P = .01), but the largest growth was among benzodiazepines (5.6% to 8.7%; AOR = 1.62, P < .001). Among patients in primary care, increases primarily occurred among men, non-Hispanic white patients, and those with pain diagnoses as well as those with no mental health or pain diagnoses. CONCLUSIONS From 2003 to 2012, use of the most common psychotropic medications among older adults seen in primary care increased, with concentration among patients with no mental health or pain diagnosis. As the population of older adults grows and receives mental health treatment in primary care, it is critical to examine the appropriateness of psychotropic use.

Late-life veteran suicide is a public health concern, and may overlap with recent high-risk medication use. We identified use in the 6 months prior to attempt and assessed salient risk factors. 13,872 veterans aged 50 years and older that attempted suicide were compared with demographically-matched controls utilizing VHA healthcare in a similar time period. Medications potentially related to suicide risk were included. Other variables were psychiatric and medical diagnoses, fatality of attempt and means. Compared with controls, veterans who attempted were nearly 3 times more likely to have been prescribed benzodiazepines and opioids, even when controlling for other diagnoses. Those taking 3 or more high-risk medications were between 7 and 11 times more likely to attempt than controls, with a higher risk of death particularly by drug overdose. These findings begin to uncover the complex contribution of prescription medications and polypharmacy to late-life veteran suicide, with implications for prevention. Part of a symposium sponsored by the Aging, Alcohol and Addictions Interest Group.

This session, sponsored by the Public Policy Caucus, will explore the upcoming November 2020 Congressional and Presidential elections, the potential composition of the 117th Congress, and what those factors may mean for advocates of mental health and aging policies and programs. It will provide participants with a look forward to the 2020 elections and the impact of those elections on health care and aging issues.

This session, sponsored by the Public Policy Caucus, will provide updates on recent federal and state mental health legislation and policy issues and will feature Public Policy Caucus members who have been engaged advocates for geriatric mental health over this past year. Presenters from our advocacy partners in the APA Department of Government Relations will review the key current issues in aging and mental health policy, with specific focus on current federal and state health care legislation that may have impact on our patients and our practice. Presenters will review their advocacy work this past year, which highlight ways in which AAGP members can be involved in: being engaged at the community and state level; representing AAGP in the AMA House of Delegates; and working on Capitol Hill.

As the nation’s largest integrated healthcare system, the Veterans Health Administration (VHA) is faced with challenges in caring for a growing number of older adult Veterans with comorbid medical, mental health, neurocognitive, and behavioral care needs. These Veterans can pose significant risk of harm to self or others and can lead to inefficient, ineffective, or inappropriate use of VHA resources. Using an implementation science framework, this presentation will describe the development and expansion of the Care of Patients with Complex Problems (CP)^2 Program, outcomes, and implications. A national needs assessment of 138 VHA medical centers estimated 42% of inpatient beds are occupied by Veterans with complex problems, with 38% indicating access to inpatient care related challenges. Through leadership feedback and group consensus, an interdisciplinary task force and a VHA senior leadership steering committee selected one of six promising practices to launch the (CP)^2 Program. The key components of the program include: dissemination of promising practices; a national learning collaborative and webinar series (participation averaging 200 staff/month); and centralized technical assistance. Three medical centers were invited to participate in the initial launch of the program with a regional dissemination of the promising practice model that supports transitioning Veterans from inpatient care to more appropriate and less costly community settings. Following promising outcomes (i.e. reductions in costs and hospital readmissions) and over 30 briefings/stakeholder meetings, support was garnered for a national training and expanded dissemination of the model. Implications for practice, development of VHA/community partnerships, and lessons learned were identified.

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.

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 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.

The impact of STAR-VA on psychotropic drug use among residents with behavioral symptoms of dementia was evaluated through a difference-in-differences framework. STAR-VA residents enrolled 2013-2017 were evaluated longitudinally pre-post intervention. The primary outcome was the number of as needed administrations with an indication of ‘anxiety’ or ‘agitation’. The analytical cohort included 214 training cases and 1,870 controls from untrained sites meeting eligibility criteria. STAR-VA cases were less white (48% vs. 54%), less black (11% vs. 14%), and had significantly longer median length of stay (830 vs. 261 days), respectively. STAR-VA cases had on average 3.5 as needed doses/month of psychotropic medication before the intervention and 1.7 after, controls averaged 1.8 doses/month. After adjustment for person-time-fixed effects, enrollment was associated with 55% (95% CI:30, 68) reduction or an average 0.8 as needed psychotropic doses/month. Findings demonstrate effectiveness in decreasing as-needed psychotropic drug use among CLC residents, supporting continued implementation of STAR-VA.

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.

Objectives To establish the rate of new and continuation of benzodiazepine use in older adults seen by nonpsychiatrist physicians and to identify subpopulations at risk of new and continuation benzodiazepine use. Design Cross-sectional analysis. Setting National Ambulatory Medical Care Survey (2007–10). Participants Adults visiting office-based nonpsychiatrist physicians (n = 98,818) who were prescribed a benzodiazepine (new or continuation). Measurements Percentage of benzodiazepine visits of all outpatient encounters according to patient age and corresponding annual visit rate per 1,000 population. Analysis was then limited to adults aged 65 and older, demographic, clinical, and visits characteristics were used to compare visits of benzodiazepine users with those of nonusers and visits of continuation users with those of new users. Results The overall proportion of benzodiazepine visits ranged from 3.2% (95% confidence interval (CI) = 2.7–3.7) of those aged 18 to 34 to 6.6% (95% CI = 5.8–7.6) of those aged 80 and older, and the proportion of continuation visits increased with age, rising to 90.2% (95% CI = 86.2–93.1) of those aged 80 and older. The population-based visit rate ranged from 61.7 (95% CI = 50.7–72.7) per 1,000 persons in the youngest adults to 463.7 (95% CI = 385.4–542.0) in those aged 80 and older. Only 16.0% (95% CI = 13.5–18.8) of continuation users had any mental health diagnosis. Of all benzodiazepine users, fewer than 1% (95% CI = .4–1.8) were provided or referred to psychotherapy, and 10.0% (95% CI = 7. 2–13.3) were also prescribed an opioid. Conclusion In the United States, few older adult benzodiazepine users receive a clinical mental health diagnosis, and almost none are provided or referred to psychotherapy. Prescribing to older adults continues despite decades of evidence documenting safety concerns, effective alternative treatments, and effective methods for tapering even chronic users.

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.]

Increasing numbers of aging Veterans with complex and interacting medical, mental health, neurocognitive, and/or behavioral concerns are receiving care in Veterans Health Administration (VHA) facilities. VHA recognized that Veterans with complex care needs may not receive well-integrated care across inpatient care settings (medical/ surgical, mental health, skilled nursing, rehabilitation). A national, interdisciplinary VHA Task Force was established to recommend evidence-based strategies to achieve safe and effective care for this population. The Task Force noted a number of systemic challenges for caring for these patients, including silos of medical, mental health, or geriatric care; gaps in staff competencies; and inconsistent coordination of care across services and settings. Task Force recommendations focused on patient/family-centered models emphasizing care in place when possible, prevention, strengthening of interdisciplinary and integrated medical and mental health care, and attention to staff skills development. Plans for implementing recommendations and conducting systematic evaluation are underway.

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.

Background Development of the commercial genomics sector within the biotechnology industry relied heavily on the scientific commons, public funding, and technology transfer between academic and industrial research. This study tracks financial and intellectual property data on genomics firms from 1990 through 2004, thus following these firms as they emerged in the era of the Human Genome Project and through the 2000 to 2001 market bubble. Methods A database was created based on an early survey of genomics firms, which was expanded using three web-based biotechnology services, scientific journals, and biotechnology trade and technical publications. Financial data for publicly traded firms was collected through the use of four databases specializing in firm financials. Patent searches were conducted using firm names in the US Patent and Trademark Office website search engine and the DNA Patent Database. Results A biotechnology subsector of genomics firms emerged in parallel to the publicly funded Human Genome Project. Trends among top firms show that hiring, capital improvement, and research and development expenditures continued to grow after a 2000 to 2001 bubble. The majority of firms are small businesses with great diversity in type of research and development, products, and services provided. Over half the public firms holding patents have the majority of their intellectual property portfolio in DNA-based patents. Conclusions These data allow estimates of investment, research and development expenditures, and jobs that paralleled the rise of genomics as a sector within biotechnology between 1990 and 2004.

One key challenge for care of the next generation of patients with schizophrenia is reducing and preventing medical morbidity. To improve their healthcare, we suggest that consultation-liaison (C-L) psychiatrists should be leaders in an effort to close the gap between psychiatric and medical care for patients with schizophrenia. We contend that C-L psychiatrists are well equipped to help manage the care of these patients because of their expertise in caring for complex patients, working in teams, and collaborating with medical and surgical colleagues. We provide specific examples (antipsychotic-induced metabolic monitoring; smoking cessation; infectious disease screening) of how C-L psychiatrists can rise to the challenge now and moving forward.

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.

Although there has been a great deal of discussion about healthcare quality in recent years, the best way to identify high-quality healthcare remains a matter of some debate. Within the field of mental health, this debate is often focused on the optimal use of clinical rating scales and outcomes assessment tools. Much of the current thinking regarding the use of these scales is presented in this book. This chapter will provide the context for the use of these instruments as a core component of quality improvement efforts.