Differences Between General Internal Medicine and Family Medicine Physicians' Initiation of Pre-Exposure Prophylaxis.

OBJECTIVE: Preexposure Prophylaxis (PrEP) is under-utilized in primary care. Given differences in treatment approaches for other conditions between family medicine (FM) and general internal medicine (GIM), this study compared PrEP-prescribing between FM and GIM physicians. METHODS: De-identified electronic health record data from a multi-state health care system was used in this retrospective observational study. The time period from 1/1/13 to 9/30/21 was used to identify PrEP eligible patients using measures of current sexually transmitted disease and condomless sex at the time of eligibility. Receipt of PrEP was measured in the 12 months after PrEP eligibility. The odds of receiving PrEP in GIM as compared to FM was computed before and after adjusting for demographics and physical and psychiatric comorbidities. RESULTS: The majority of eligible patients were 18 to 39 years of age, 60.9% were female and 71.6% were White race. Among PrEP eligible patients, 1.1% received PrEP in the first year after index date. Receiving PrEP was significantly more likely among patients treated in GIM versus FM (OR = 2.30; 95% CI:1.63-3.25). After adjusting for covariates, this association remained statistically significant (OR = 2.02; 95% CI:1.41-2.89). CONCLUSIONS: PrEP is grossly under-utilized in primary care. The majority of Americans enter the health care system through primary care and not through HIV providers or other specialties. Therefore, educational interventions are needed to increase confidence and knowledge and to encourage PrEP prescribing by FM and GIM physicians.

Anxiety disorders, benzodiazepine prescription, and incident dementia.

BACKGROUND: Prescribing benzodiazepines to older patients is controversial. Anxiety disorders and benzodiazepines have been associated with dementia, but literature is inconsistent. It is unknown if anxiety treated with a benzodiazepine, compared to anxiety disorder alone is associated with dementia risk. METHODS: A retrospective cohort study (n = 72,496) was conducted using electronic health data from 2014 to 2021. Entropy balancing controlled for bias by indication and other confounding factors. PARTICIPANTS: Eligible patients were ≥65 years old, had clinic encounters before and after index date and were free of dementia for 2 years prior to index date. Of the 72,496 eligible patients, 85.6% were White and 59.9% were female. Mean age was 74.1 (SD ± 7.1) years. EXPOSURE: Anxiety disorder was a composite of generalized anxiety disorder, anxiety not otherwise specified, panic disorder, and social phobia. Sustained benzodiazepine use was defined as at least two separate prescription orders in any 6-month period. MAIN OUTCOME AND MEASURES: ICD-9 or ICD-10 dementia diagnoses. RESULTS: Six percent of eligible patients had an anxiety diagnosis and 3.6% received sustained benzodiazepine prescriptions. There were 6640 (9.2%) incident dementia events. After controlling for confounders, both sustained benzodiazepine use (HR 1.28, 95% CI: 1.11-1.47) and a diagnosis of anxiety (HR 1.19, 95% CI: 1.06-1.33) were associated with incident dementia in patients aged 65-75. Anxiety disorder with sustained benzodiazepine, compared to anxiety disorder alone, was not associated with incident dementia (HR 1.18, 95% CI: 0.92-1.51) after controlling for confounding. Results were not significant when limiting the sample to those ≥75 years of age. CONCLUSIONS: Benzodiazepines and anxiety disorders are associated with increased risk for dementia. In patients with anxiety disorders, benzodiazepines were not associated with additional dementia risk. Further research is warranted to determine if benzodiazepines are associated with a reduced or increased risk for dementia compared to other anxiolytic medications in patients with anxiety disorders.

Achievement of glycemic control and antidepressant medication use in comorbid depression and type 2 diabetes.

BACKGROUND: Existing studies designed to determine if depression treatment in patients with type 2 diabetes (T2D) is associated with improved glycemic control have produced inconsistent results. The present study investigated the link between acute phase antidepressant medication treatment and achievement of glycemic control in patients with T2D using nationally distributed electronic health record data. METHODS: A retrospective cohort study (n = 7332) was conducted using nationally distributed Optum® de-identified electronic health record data from 2010 to 2018. Eligible patients were 18-64 years old and had T2D, depression, and poor glycemic control. Antidepressant medication treatment was categorized into acute phase treatment (≥12 weeks), less than acute phase (<12 weeks) or no treatment. Glycemic control was defined as HbA1c < 7.0 % (53 mmol/mol). Propensity scores (PS) and inverse probability of treatment weighting (IPTW) controlled for confounding. Extended Cox models measured the association between duration of antidepressant medication treatment and glycemic control at 0 to 36 months, 36 to 72 months and ≥72 months. RESULTS: After controlling for confounding, compared to no treatment, acute phase treatment was significantly associated with achieving glycemic control within 36 months (HR 1.17, 95 % CI 1.02-1.34). No association was observed beyond 36 months. There was no association between acute vs. less than acute phase treatment and glycemic control. LIMITATIONS: We were unable to measure decreased depression severity which could contribute to glycemic control. CONCLUSIONS: For patients with T2D and hyperglycemia, acute phase antidepressant medication may enable glycemic control. Further research is needed to establish mechanisms for this association.

Diagnosis and Treatment of Bipolar Illness in the Primary Care Office.

Bipolar Affective Disorder (BPAD) is frequently encountered in the primary care office and must be considered in the differential diagnosis of all patients with mood dysregulation. Appreciation for the range of bipolar illness has evolved in recent years, and the overlap of bipolar illness with trauma-based diagnosis such as Post-Traumatic Stress Disorder (PTSD) and Borderline Personality Disorder must be considered. Treatment of BPAD is divided into manic, depressive, and maintenance phases, each with different pharmacologic considerations. First line agents for the acute manic phase include lithium, valproic acid, and second generation antipsychotics (SGAs). First line agents for depressive phase include lamotrigine, lithium, and the SGAs lurasidone and quetiapine. For bipolar maintenance therapy, lamotrigine, valproic acid, and lithium are first line options. Finally, nonpharmacologic interventions including psychoeducation can be extremely helpful for patients and their families to successfully participate in the management of their disease.

Mental health diagnoses and early removal of long-acting reversible contraception.

BACKGROUND: Having a mental health diagnosis is associated with contraceptive non-adherence and user-related contraceptive failures of short-acting methods. There is a lack of research on the relationship between mental health diagnoses and early discontinuation of highly effective long-acting reversible (LARC) methods such as the intrauterine device (IUD) and subdermal implant (SDI). METHODS: Using a Primary Care and Obstetrics and Gynecology Patient Data Registry, we conducted a cross-sectional analysis of the relationship between any mental health diagnosis (any anxiety disorder or depression) and early LARC removal (<1 year post-insertion) among 385 reproductive-aged (14-50 years) women in 2008-16. Adjusted logistic regression was used to calculate odds ratios and 95% confidence intervals. RESULTS: Almost 10% (n = 37) of the sample had an early LARC removal, of which 62.2% were hormonal IUD and 37.8% were SDI. Women with a mental health diagnosis had a higher prevalence of early LARC removal (13.6% vs. 8.0%, p = =.090). Although non-significant, there was a trend in adjusted analyses indicating twice the odds of early removal for women with a mental health diagnosis versus no diagnosis (OR = =2.04, 95% CI = =0.97-4.27). LIMITATIONS: This study is limited by a small sample size and availability of variables from a reportable medical record database. Pregnancy intentions and side effects of method use could not be accounted for which may have impacted timing of removal. CONCLUSIONS: Understanding why women choose early LARC removal can inform counseling to help women make informed choices about their contraceptive method that meets their reproductive needs.