Antipsychotic Drugs Associated With High Blood Sugar in Older Adults With Diabetes

Older patients with diabetes who take antipsychotic medications appear to have an increased risk of hospitalization for hyperglycemia (elevated blood glucose level), especially soon after beginning treatment, according to a report in the July 27 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

An increasing number of older adults are being prescribed antipsychotic drugs for dementia and other conditions, according to background information in the article. However, these medications may be associated with a—including Parkinson’s disease symptoms, stroke and diabetes—in the older population. “The risk of diabetes may be partly related to chronic effects of the weight gain associated with antipsychotic agents,” the authors write. “However, case reports of acute hyperglycemia after the initiation of therapy with these drugs suggest that they may also be associated with acute glycemic [blood glucose level] changes.”

Lorraine L. Lipscombe, M.D., M.Sc., of the Institute for Clinical Evaluative Sciences, University of Toronto and Women’s College Research Institute at Women’s College Hospital, Toronto, Ontario, Canada, and colleagues studied 13,817 individuals age 66 and older (average age 78) with diabetes who began treatment with antipsychotics between April 1, 2002, and March 31, 2006. Each patient who was hospitalized for hyperglycemia during the observation period—through March 31, 2007, an average of two years of follow-up—was considered a case and was matched with up to 10 control patients who were the same age and sex but were not hospitalized over the same time period. The researchers then compared the likelihood of hyperglycemia among those who were currently taking antipsychotic medications to those who had discontinued antipsychotic medications for more than 180 days.

Of the total group of 13,817 patients, 1,515 (11 percent) were hospitalized for hyperglycemia. Those who were currently taking antipsychotic drugs had a higher risk of hospitalization than those who had stopped the medications more than 180 days ago. The risk was highest among those who were just starting antipsychotic drug treatment.

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Treatment-Resistant Depression - Management Strategies

Approximately 32 to 35 million adults in the United States have an episode of major depression sometime during their lifetime, and many of them do not respond to initial treatment.1 The results of an analysis undertaken by Fava and Davidson2 suggest that between 29% and 46% of depressed patients fail to respond fully to antidepressant treatment of adequate dose and duration; about 15% of patients fail to respond to multiple treatment trials.3 Fagiolini and Kupfer4 have suggested that patients with treatment-resistant depression (TRD) may represent a biologically unique subtype of depressed patients. Unfortunately, the chances for full recovery diminish the longer a patient remains depressed—a fact that lends a sense of urgency for appropriate therapy.5

Management strategies

Before discussing the effectiveness of individual agents in TRD, it is important to review recent evidence regarding the principles of using these agents to maximize the chance of a response.6-9 Some of the most salient findings from the STAR*D trial on this topic are summarized in Table 1.

The standard strategy for managing patients who are depressed includes an adequate clinical trial; when the response is unsatisfactory, the clinician’s options are:

• Switch to another antidepressant

• Combine a second antidepressant with the first

• Add a second drug that is not approved as an antidepressant

• Start psychotherapy

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Psychiatric care for dementia could be assisted by blood pressure medication

Angiotensin-converting enzyme (ACE) inhibitors are important for control of blood pressure and have made a profound impact on patients with diabetes and congestive heart failure. The ACE inhibitors, which act outside the brain, have had minimal impact on dementia of any cause. However, there is now evidence indicating that ACE Inhibitors which act inside the brain, may have the ability to reduce cognitive decline.

Recent observational data from the Cardiovascular Health Study revealed that that centrally active ACE inhibitors did diminish cognitive decline by 65% per year of exposure, an effect that is likely related to the drug’s ability to cross the blood-brain barrier.

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Antidepressants, not sleep drugs, often prescribed for insomnia * Story Highlights * Doctors prescribed more antidepressants for insomnia

Insomnia, the inability to fall or stay asleep, can make the days feel fuzzy and the nights never-ending.

The disorder can increase the risk for depression and suicidal thoughts, lower work productivity and even raise blood pressure, studies have shown.

About 40 million Americans have chronic sleep disorders that prevent them from getting good rest. Singer Michael Jackson struggled with insomnia, a nutritionist who worked for him told CNN. Sources close to Jackson told CNN that during a world tour in the mid-'90s, the pop star traveled with an anesthesiologist who would "take him down" at night, then "bring him back up."

Stress or traumatic events can trigger the sleeping disorder. Insomnia drugs help the patient sleep, but they do not treat the underlying cause, which could be a result of another illness, life changes or shifting work schedules. And patients who seek relief for insomnia may not receive the most effective prescription.

Over the last two decades, doctors treating sleep disorders have prescribed more antidepressants than insomnia drugs, according to several published analyses. And there is insufficient evidence that most antidepressants are effective in treating insomnia, concluded a National Institutes of Health panel that convened on the topic in 2005.

Doctors may be factoring in cost considerations and their own familiarity with prescribing antidepressants relative to newer sleep medications, experts said.

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Study shows schools could help in reducing depression

Research by the University of Queensland has shown school intervention programs could help radically reduce the amount ofhttp://www.thetechherald.com/article.php/200930/4122/Study-shows-schools-could-help-in-reducing-depression being prescribed to adolescent boys.

School Counsellor Mark Taylor, who led the research, said that schools could help students deal with depression by teaching more conflict resolution and positive thinking, as well as encouraging more outdoor activities.

Dr Taylor said he was concerned not enough was being done to look at underlying conditions of adolescents' depression.

“Working in a school setting as a counsellor I became concerned about the numbers of students who were being prescribed antidepressants, without what I considered to be enough effort to find out what was going on in the lives of these students,” Dr Taylor said in a University of Queensland (UQ) news release.

“I wanted to substantiate that there are viable alternatives to antidepressants which can significantly reduce depressive symptoms.”

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New Insights Into Causes Of Anorexia

New imaging technology provides insight into abnormalities in the brain circuitry of patients with anorexia nervosa (commonly known as anorexia) that may contribute to the puzzling symptoms found in people with the eating disorder. In a review paper published online in Nature Reviews Neuroscience, Walter Kaye, MD, professor of psychiatry and director of the Eating Disorders Program at the University of California, San Diego, and colleagues describe dysfunction in certain neural circuits of the brain which may help explain why people develop anorexia in the first place, and behaviors such as the relentless pursuit of dieting and weight loss.

"Currently, we don't have very effective means of treating people with anorexia," said Kaye. "Consequently, many patients with the disorder remain ill for years or eventually die from the disease, which has the highest death rate of any psychiatric disorder."

A better understanding of the underlying neurobiology – how behavior is coded in the brain and contributes to anorexia —is likely to result in more effective treatments, according to the researchers.

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Can the relationship between doctors and drug companies ever be a healthy one?

Should the financial ties between doctors and drug companies be completely cut, or are healthy alliances between the two possible with the common aim of improving human health? A debate in this week's PLoS Medicine discusses whether the influence of drug company money on doctors is always a corrupting one.

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Number of Uninsured Appears Poised for Dramatic Surge

The researchers acknowledge that their model does not take into account the effect of job losses during the current recession, which could add millions to the ranks of the uninsured.

Rising health care costs and slow growth in personal income related to the current recession will add at least another 6.9 million nonelderly Americans to the rolls of the uninsured by 2010, according to a study published May 28 on the Web site of the journal Health Affairs.

In the study report, researchers Todd Gilmer, Ph.D., and Richard Kronick, Ph.D., of the University of California, San Diego, predicted that 19.2 percent of all nonelderly Americans will be uninsured by 2010, an increase of 2 percentage points from 2007.

The researchers used a complex method that involves several data sources to calculate an "affordability index," defined as the ratio of per-capita health spending for insured adults to the median income among workers. Those data sources included the National Health Accounts developed by the Office of the Actuary at the Centers for Medicare and Medicaid Services, the 1977 National Medical Care Expenditure Survey, the 1987 National Medical Expenditure Survey, and the 1996 and 1999 Medical Expenditure Panel Surveys. Their analysis also takes into account employment characteristics such as firm size, industry, and self-employment and part-time status, as well as demographic and socioeconomic characteristics such as age, sex, marital status, race and ethnicity, education, and home ownership. After using their index to derive predictions for uninsurance rates among workers, Gilmer and Kronick used the historical relationship between coverage rates for workers and for all nonelderly adults to generate predicted uninsurance rates for all nonelderly adults.

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Learning of Risk of Alzheimer’s Seems to Do No Harm

A genetic test that can find an increased risk of Alzheimer’s disease does no psychological harm to people who take it, even if they test positive for a risky gene, a new study finds.

The results challenge views long held by the medical establishment, which has discouraged people from being tested, arguing that the test is not definitive, that it may needlessly frighten people into thinking a terrible disease is hanging over them and that testing is pointless anyway because there is no way to cure or prevent the dementia caused by Alzheimer’s.

“There has been this extraordinary worry that disclosing risk was going to devastate people,” said Dr. Robert C. Green, a professor of neurology, genetics and epidemiology at Boston University, and the lead author of the study, which is being published on Thursday in The New England Journal of Medicine. “This has upended those assumptions.”

The idea behind the study was to treat information like a drug, something with risks and benefits that could be measured, Dr. Green said.

Dr. Green led a large team in the study, called Reveal, in which 162 adults who had a close relative with Alzheimer’s could find out if they had the genes that increased their risk for the disease. All participants had genetic testing, but 51, picked at random, were not told the results. The other 111 were told, and the two groups were compared.

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Depression Poses Pregnancy Risks

Thanks to high-profile celebrities like Brooke Shields, postpartum depression is out of the closet and discussed as something to recognize and treat.

But less well known is depression during pregnancy -- a common problem as well, and one that also can be risky for the unborn baby, experts now know.

A depressed woman, for instance, is more likely to give birth early, increasing health risks for the baby.

Depression during pregnancy is more common than most people believe, agree Dr. De-Kun Li, a reproductive perinatal epidemiologist in the research division at Kaiser Permanente in Oakland, Calif., and Dr. Diana Dell, a psychiatrist and obstetrician-gynecologist at Duke University Medical Center in Durham, N.C.

One or two of every 10 pregnant women have symptoms of major depression, according to the March of Dimes. Those who have had a bout of depression before are more likely to get it again. And Li said that others might have depressive symptoms -- short of clinical depression but still bothersome and unhealthy.

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Brain Stimulation: Electroconvulsive Therapy ECT, checkered past and all, is making a quiet comeback

Electroconvulsive therapy, also known from times of old as "shock therapy," is on the rise—albeit a relatively quiet one. Considering its beginnings as a crude and violent procedure, it's not surprising that ECT's comeback isn't loudly publicized. The treatment, which involves inducing a controlled seizure, is most often administered to patients with significant psychiatric illness—depression, mania, and bipolar disorder—and is one form of brain stimulation therapy for people whose symptoms don't respond to medications. Kitty Dukakis, actress and wife of 1988 presidential candidate Michael Dukakis, has spoken candidly in recent years about her reliance on the treatment, the only one that significantly alleviates her bouts with severe depression. Many clinical trials are currently investigating ECT to better understand why it seems to work against major depression—it puts 60 percent to 80 percent of people who try it into remission—and researchers at the National Institute of Mental Health are investigating the therapy's potential in treatment of schizophrenia that does not respond to common medications. Still, the treatment suffers stigmatization—in part due to its association with mental illness but also due to its checkered past since its inception in the late 1930s.

REDA MORE @ U.S. NEWS & WORLD REPORT"

Vets’ Mental Health Diagnoses Rising

A new study has found that more than one-third of Iraq and Afghanistan war veterans who enrolled in the veterans health system after 2001 received a diagnosis of a mental health problem, most often post-traumatic stress disorder or depression.

The study by researchers at the San Francisco Department of Veterans Affairs Medical Center and the University of California, San Francisco, also found that the number of veterans found to have mental health problems rose steadily the longer they were out of the service.

The study, released Thursday, was based on the department health records of 289,328 veterans involved in the two wars who used the veterans health system for the first time from April 1, 2002, to April 1, 2008.

The researchers found that 37 percent of those people received mental health diagnoses. Of those, the diagnosis for 22 percent was post-traumatic stress disorder, or PTSD, for 17 percent it was depression and for 7 percent it was alcohol abuse. One-third of the people with mental health diagnoses had three or more problems, the study found.

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Government can't ban drug advertising, but it can take the life out of the ads

Big Pharma experienced acute dizziness and irritability last month when House Ways and Means Chairman Charles B. Rangel (D-N.Y.) proposed rescinding the tax deduction for direct-to-consumer prescription drug advertising. This is the ad segment that brought you "Viva Viagra," the Ambien CR rooster and the Cialis couple-in-the-tubs, who I sincerely hope are soon struck by lightning. The segment accounts for about $5 billion in advertising per year. This is your IRS on drugs.

Predictably, the advertising/marketing community flew into a funk beyond the reach of Paxil and Cymbalta. Assn. of National Advertisers President and Chief Executive Bob Liodice, in high moral dudgeon, claimed in an Advertising Age editorial that the provision would violate the 1st Amendment (it wouldn't), endanger the public's health (hardly) and put Congress on a slippery slope of penalizing "controversial" products' advertising, which could "imperil many, if not all, product categories."

Indeed, the very foundations of the Republic rest on whether Pfizer can deduct the $121 million it spent in 2008 pushing Viagra on less-than-ardent oldsters.

I, for one, do not fear for the drug ad tax deduction. The pharmaceutical and health products industry disgorged more than $234 million upon Capitol Hill last year, according to the Center for Responsive Politics. I'm sure Big Pharma's voice will be heard.

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Schizophrenia Drug Limits May Have Led to Deaths (Update1)

Restrictions on the use of the antipsychotic medicine clozapine may have led to thousands of additional deaths in schizophrenia patients around the world, a study published in The Lancet medical journal found.

Researchers examined data from patients taking the six most frequently used antipsychotic drugs and found that clozapine was associated with the lowest death rate compared with use of the older medicine perphenazine. Clozapine was linked to a 26 percent reduction in mortality according to the study, led by Jari Tiihonen at the University of Kuopio in Finland.

Doctors can prescribe clozapine, first developed by Switzerland’s Novartis AG, only after two unsuccessful trials with other antipsychotics because it has been linked with agranulocytosis, a condition causing a severe decrease in white blood cells and problems such as fevers, fatigue and bleeding sores, Tiihonen said. Patients taking clozapine need weekly blood monitoring for six months followed by monthly testing to look for signs of the disorder, he said.

“Our results raise the issue of whether clozapine should be used as a first-line treatment, because it seems to be the safest antipsychotic in terms of mortality and it is also the most effective,” Tiihonen and colleagues wrote in the study. “However, clozapine is inexpensive, and hence it’s unprofitable for the pharmaceutical industry to market compared with other second-generation antipsychotic drugs.”

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Severe COPD Linked to Mental Decline - Doctors need to recognize challenges these patients face, researchers say

Severe chronic obstructive pulmonary disease appears linked to lower cognitive function in older adults, making it more difficult for them to remember and perform daily tasks, a new study finds.

Researchers at Mount Sinai School of Medicine in New York City analyzed national data on 4,150 Americans aged 50 and older, including 492 with COPD. Of those, 153 had severe COPD. On a 35-point cognition scale, scores among all COPD patients declined an average of one-point between 1996 and 2002. Further analysis showed that patients with severe COPD had significantly lower scores than those without COPD.

"Our findings should raise awareness that adults with severe COPD are at greater risk for developing cognitive impairment, which may make managing their COPD more challenging, and will likely further worsen their general health and quality of life," study author Dr. William W. Hung said in a news release.

The results suggest that patients with severe COPD have a 22 percent increase in the difficulty they experience with daily tasks.

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Map Of Your Brain May Reveal Early Mental Illness

John Csernansky wants to take your measurements. Not the circumference of your chest, waist and hips. No, this doctor wants to stretch a tape measure around your hippocampus, thalamus and prefrontal cortex.

OK, maybe not literally a tape measure, but he does want to chart the dimensions of the many structures in the human brain. From those measurements -- obtained from an MRI scan -- Csernansky will produce a map of the unique dips, swells and crevasses of the brains of individuals that he hopes will provide the first scientific tool for early and more definite diagnosis of mental disorders such as schizophrenia. Diagnosing the beginning stage of mental disorders remains elusive, although this when they are most treatable.

The shapes and measurements of brain structures can reveal how they function. Thus, Csernansky hopes his brain maps will reveal how the brains of humans with and without major mental disorders differ from each other and the time frame over which those differences develop.

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Childhood-onset schizophrenia remains a mystery

A study at the National Institute of Mental Health that has already spanned 18 years may yield crucial answers to the rare disorder.

So rare is the child form of schizophrenia, it has taken researchers at the National Institute of Mental Health 18 years to diagnosis and collect data on 110 children.

"We are trying to understand schizophrenia in a comprehensive way," says Dr. Nitin Gogtay, a researcher involved with the project in Bethesda, Md. "We see the illness in a very pure form. At that age, there are no confounding factors, like alcohol or drug abuse. We feel a lot of answers will come out of this study."

The study, the largest of its kind worldwide, has already yielded clues about the disease -- the most severe mental illness. Although schizophrenia afflicts about 1% of adults, it occurs in about one of every 30,000 to 50,000 children 13 and under. The causes of the disease are a mystery, although genes are known to play a role. In young children, a brain injury at or near the time of birth may contribute to its onset.

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ANALYSIS-Drug companies fight the tide, and may win

Governments on both sides of the Atlantic are fighting settlements between big pharmaceutical companies and generic firms that delay marketing of cheap versions of brand-name drugs.

But don't write off the chances of Big Pharma, which has already shown impressive clout in both the legal and political arenas.

The settlements are reached after generic companies indicate they plan to bring out cheaper copies of brand-name drugs, and the drugs' makers accuse the generics of infringement.

The U.S. Federal Trade Commission says the settlements are illegal if generic entrances are delayed in exchange for payment, but drug companies say the deals are no more than settlements of what could be expensive litigation.

EU Competition Commissioner Neelie Kroes said this week that she was determined to oppose such settlements, which she said had pushed up European consumers' bills by 20 percent between 2000 and 2007. The FTC puts the cost for U.S. consumers and insurers at an additional $3.5 billion a year.

Drug companies say the settlements can save consumers money by bringing generics to market before patents expire, while eliminating the uncertainties of court trials.

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Elderly patients boost sales of dangerous antipsychotics

Bill Wiggins believes a powerful antipsychotic medication helped save his wife, Kathye.

Helen Shields believes one of these drugs helped kill her mother, Helen Marciniszyn.

Two families, two drugs, two stories that capture the extremes of a debate about using these medicines to treat the diseases of aging when there are no other effective alternatives.

Kathye Wiggins took Johnson & Johnson's Risperdal. Marciniszyn took AstraZeneca's Seroquel. Both drugs are atypical antipsychotics, a category of psychotropic drugs that also includes Zyprexa from Eli Lilly & Co., Abilify by Bristol-Myers Squibb Co., and Pfizer Inc.'s Geodon.

The federal government approved atypicals in the 1990s to treat schizophrenia and bipolar disorder. Since then, they have become popular for treating disorders including autism and Alzheimer's, despite mixed evidence that they help and ample evidence that they hurt.

Doctors prescribe atypicals for these illnesses because they may calm people and help them sleep. Also, patients with Alzheimer's and dementia can lose touch with reality, as schizophrenics do, so, in theory, atypicals could help.

Sales of atypicals rose to $14.36 billion in 2008 from $8.4 billion in 2003, according to data provider IMS Health.

Elderly patients have been a major source of that growth. Studies suggest that 20 percent to 30 percent of nursing-home residents take an atypical, despite not having a psychosis diagnosis.

READ MORE @ PHILADELPHIA INQUIRER

Delirium in hospitalized adults: Situation critical, no relief available

Every year as many as seven million adults in the United States experience delirium during hospitalization. In a systematic review of the scientific literature on delirium prevention and treatment, investigators from Indiana University School of Medicine, the Regenstrief Institute and Wishard Health Services found that despite the significant health and financial burdens of delirium for hospitalized adults, no effective way to prevent or treat the condition has been identified.

"Having delirium prolongs the length of a hospital stay, increases the risk of post-hospitalization transfer to a nursing home and doubles the risk of death. We need to identify a safe and effective drug to prevent and treat delirium. With our review we are challenging the scientific community to come up with new therapeutic options," said Malaz Boustani, M.D., senior author of the study which appears in the July 2009 issue of the Journal of General Internal Medicine. Dr. Boustani is a Regenstrief Institute investigator and associate professor of medicine at the IU School of Medicine.

Delirium, experienced by a significant number of older patients in surgical and critical care units and over half of older adults who are hospitalized for broken hips, is a state of confusion in which the individual has undergone a sudden alteration of mental status. Delirium is not dementia, but individuals with dementia are more susceptible to developing delirium during hospitalization than individuals without dementia.

The researchers found that only 13 randomized controlled studies on promising drugs for delirium were conducted from January 1966 to October 2008. These studies identified and evaluated 15 drugs including first and second generation antipsychotics, the drugs currently prescribed by most physicians for patients with delirium. The researchers found that neither older agents nor newer, more expensive medications were effective in preventing delirium. The study also found no difference between antipsychotics in treating delirium. To date, there are no U.S. Food and Drug Administration approved drugs to prevent or manage delirium according to Dr. Boustani.

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