A brief analysis of suicide methods and trends in Virginia from 2003 to 2012.

BACKGROUND: The objective is to analyze and compare Virginia suicide data from 2003 to 2012 to US suicide data. METHODS: Suicide trends by method, age, gender, and race were obtained from Virginia's Office of the Chief Medical Examiner's annual reports. RESULTS: Similar to US suicide rates, suicide rates in Virginia increased between 2003 and 2012 from 10.9/100,000 people to 12.9/100,000 people. The most common methods were firearm, asphyxia, and intentional drug overdose, respectively. The increase in asphyxia (r = 0.77, P ≤ 0.01) and decrease in CO poisoning (r = -0.89, P ≤ 0.01) were significant. Unlike national trends, intentional drug overdoses decreased (r = -0.55, P = 0.10). Handgun suicides increased (r = 0.61, P = 0.06) and are the most common method of firearm suicide. Hanging was the most common method of asphyxia. Helium suicides also increased (r = 0.75, P = 0.05). Middle age females and males comprise the largest percentage of suicide. Unlike national data, the increase in middle age male suicides occurred only in the 55-64-year-old age group (r = 0.79, P ≤ 0.01) and decreased in the 35-44-year-old age group (r = -0.60, P = 0.07) and 10-14-year-old age group (r = -0.73, P = 0.02). Suicide in all female age ranges remained stable. Caucasians represent the highest percentage of suicide. CONCLUSION: There has been a rise in suicide in Virginia and suicide rates and trends have closely resembled the national average albeit some differences. Suicide prevention needs to be enhanced.

The 3 D's of geriatric psychiatry: depression, delirium, and dementia.

A Caucasian female octogenarian with multiple medical problems was admitted to the inpatient geriatric psychiatry unit with intermittent altered mental status and decline in memory. She had been hospitalized four times in the previous three months. She was admitted on more than 10 medications and received more than 20 different medications in this time period. It was determined that she had delirium concurrent with dementia and/or depression. During her hospital stay a urinary tract infection (UTI) was treated, her anticholinergic medications were minimized, and her digoxin dose was adjusted. As her mental status cleared, a workup was completed to differentiate between dementia and depression. She was initially treated with memantine, but as time progressed it became more evident she was experiencing depression and a "pseudodementia," which was treated with sertraline. Her Mini-Mental State Examination returned to 29/30 (her score previously was 26/29). This case demonstrates the complexity of treating an elder individual and the importance of differentiating among delirium, depression, and dementia. The pharmacy team played an active role in medication reconciliation. Additionally, they worked with the medical team to minimize her potentially harmful medications and optimize the treatment of her UTI and depression.

Tetrabenazine for the treatment of tardive dyskinesia.

OBJECTIVE: To evaluate the safety and effectiveness of tetrabenazine for the treatment of tardive dyskinesia. DATA SOURCES: Literature was accessed through MEDLINE (1966-September 2010) and The Cochrane Library using the terms tetrabenazine, tardive dyskinesia, and movement disorders. In addition, references from publications identified were reviewed. STUDY SELECTION AND DATA EXTRACTION: All English-language articles identified from the data sources were reviewed. DATA SYNTHESIS: Options available for the management of tardive dyskinesia are limited. Tetrabenazine is a central monoamine-depleting agent approved by the Food and Drug Administration for chorea associated with Huntington's disease. Three prospective studies of tetrabenazine in the treatment of tardive dyskinesia were identified, as well as 8 additional trials, 1 case series, and 8 case reports. Tetrabenazine may provide benefit in managing symptoms of tardive dyskinesia unresponsive to other treatment modalities. Treatment of tardive dyskinesia with tetrabenazine may be limited by cost and clinically significant adverse effects such as depression, parkinsonism, and somnolence. CONCLUSIONS: Small trials indicate tetrabenazine may be effective for the treatment of tardive dyskinesia. However, larger, well-conducted trials are needed to confirm these findings. Currently, there is a lack of data coupled with the risk of significant adverse effects to recommend the routine use of tetrabenazine in the management of tardive dyskinesia. Before using tetrabenazine for the management of tardive dyskinesia, all other options should be exhausted and careful monitoring employed.

Management of insomnia in elderly patients using eszopiclone.

Insomnia is a common sleep complaint in the elderly. The safety and efficacy of eszopiclone, a non-benzodiazepine hypnotic, in elderly patients with chronic insomnia has been established in two 2-week and one 12-week randomized, double-blind, placebo-controlled trials. Eszopiclone 1 mg was effective in reducing sleep latency. Eszopiclone 2 mg was effective in reducing latency to sleep and for increasing sleep maintenance. Eszopiclone doses of 1 mg and 2 mg reduced the number of daytime naps and decreased the duration of naps in elderly patients. Eszopiclone 2 mg improved the quality of life measures for mood, physical health, household activities, medication, leisure activities, and self-report of physical functioning and vitality in the 2-week trials, and vitality and general health in the 12-week trial. The most commonly reported side effects in the elderly included unpleasant taste, dry mouth, dizziness, and somnolence. The concurrent use of drugs that inhibit or induce the cytochrome P450 enzyme CYP3A4 can alter concentrations of eszopiclone and the dose may need to be adjusted. The recommended starting dose of eszopiclone for difficulty falling asleep is 1 mg at bedtime. For elders who complain of difficulty maintaining sleep, eszopiclone should be initiated at 2 mg at bedtime. Overall, eszopiclone is a safe and well-tolerated treatment option for elderly patients with insomnia.

Zolpidem modified-release in insomnia.

Zolpidem modified-release (MR) is the first hypnotic agent to be marketed in an extended-release formulation. Zolpidem MR is a two-layered, biphasic release tablet indicated for the management of induction of sleep and sleep maintenance. The pharmacokinetics of the drug are similar to those of immediate-release zolpidem. Two double-blind, placebo-controlled, parallel-group trials demonstrated efficacy in adults and elderly patients treated with zolpidem MR for 3 weeks without significant impairment in next-day psychomotor functioning. The most common adverse effects with zolpidem MR were dizziness, somnolence, and headache. A starting dose of zolpidem MR 12.5 mg is recommended for adults and 6.25 mg for elderly patients.

Polypharmacy in a 75-year-old patient with schizoaffective disorder.

A 75-year-old white female with schizoaffective disorder was admitted to an inpatient psychiatry unit for uncooperativeness in refusing to take scheduled medications. She complained of anticholinergic adverse effects and had abnormal involuntary movements in the oral/buccal region. The patient had been prescribed six psychotropic medications (i.e., thiothixene, lithium, divalproex sodium, amitriptyline, benztropine, and trazodone effects. The treatment team determined that the patient was noncompliant and experienced the effects of polypharmacy. She had been prescribed two mood stabilizers and suffered from anticholinergic adverse effects and the movement disorder tardive dyskinesia (TD). Four medications were discontinued: thiothixene, amitriptyline, lithium, and benztropine. Quetiapine, a second-generation antipsychotic, was recommended, with a daily titration schedule to reach a target dose of 600 mg per day in divided doses. This agent has less propensity to cause movement disorders compared with first-generation antipsychotics. All medications with additive anticholinergic properties also were discontinued. Lithium was stopped secondary to subtherapeutic levels and potential drug interactions. The pharmacist educated the inpatient team on the additive anticholinergic effects of each medication, reduced the total number of medications prescribed, and assisted in appropriate conversion to quetiapine to reduce TD symptoms.