The Management of Posttraumatic Stress Disorder and Acute Stress Disorder: Synopsis of the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline.

DESCRIPTION: The U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) worked together to revise the 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. This article summarizes the 2023 clinical practice guideline (CPG) and its development process, focusing on assessments and treatments for which evidence was sufficient to support a recommendation for or against. METHODS: Subject experts from both departments developed 12 key questions and reviewed the published literature after a systematic search using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) method. The evidence was then evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Recommendations were made after consensus was reached; they were based on quality and strength of evidence and informed by other factors, including feasibility and patient perspectives. Once the draft was peer reviewed by an external group of experts and their inputs were incorporated, the final document was completed. RECOMMENDATIONS: The revised CPG includes 34 recommendations in the following 5 topic areas: assessment and diagnosis, prevention, treatment, treatment of nightmares, and treatment of posttraumatic stress disorder (PTSD) with co-occurring conditions. Six recommendations on PTSD treatment were rated as strong. The CPG recommends use of specific manualized psychotherapies over pharmacotherapy; prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy; paroxetine, sertraline, or venlafaxine; and secure video teleconferencing to deliver recommended psychotherapy when that therapy has been validated for use with video teleconferencing or when other options are unavailable. The CPG also recommends against use of benzodiazepines, cannabis, or cannabis-derived products. Providers are encouraged to use this guideline to support evidence-based, patient-centered care and shared decision making to optimize individuals' health outcomes and quality of life.

A clinician's guide to the 2023 VA/DoD Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder.

A clinical practice guideline (CPG) is a rigorously established set of recommendations based on currently available evidence about the efficacy, safety, acceptability, and feasibility of interventions to assist with clinical decision-making. The 2023 Department of Veterans Affairs /Department of Defense Clinical Practice Guideline for Management of Posttraumatic Stress Disorder and Acute Stress Disorder is described herein. The CPG recommendations are accompanied by a clinical algorithm, which incorporates principles of evidence-based practice, shared decision-making, and functional and contextual assessments of goals and outcomes. An overview of the CPG recommendations is combined with a discussion of questions that clinicians and patients may face in implementing the CPG and suggestions for how to effectively work with the CPG.

The Management of Major Depressive Disorder: Synopsis of the 2022 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline.

DESCRIPTION: 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. METHODS: 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. RECOMMENDATIONS: 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.

Strategies Associated With Reducing Benzodiazepine Prescribing to Older Adults: A Mixed Methods Study.

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.

Benzodiazepine Prescribing from VA and Medicare to Dually Enrolled Older Veterans: A Retrospective Cohort Study.

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<0.001) or, accounting for Part D, from 10.0 to 7.7% (p<0.001). Among those prescribed BZDs between July 2016 and June 2017, 37.0%, 10.2%, and 52.8% received prescriptions from VA only, both VA and Part D, or Part D only, respectively. Older age was associated with higher odds of obtaining BZDs through Part D (e.g., compared to those 65-74, Veterans ≥85 had adjusted odds ratio [AOR] for Part D vs. VA only of 1.8 [95% highest posterior density interval (HPDI), 1.69, 1.86]). Veterans with substance use disorders accounted for few BZD prescriptions from any source but were associated with higher odds of prescriptions through Part D (e.g., alcohol use disorder AOR for Part D vs. VA alone: 1.9 [95% HPDI, 1.63, 2.11]) CONCLUSIONS: The decline in BZD use by older Veterans with Part D coverage remained after accounting for Part D, but the majority of BZD prescriptions came from Medicare. Further reducing BZD prescribing to older Veterans should consider prescriptions from community sources.

Impact of an interdisciplinary intervention for distress behaviors in dementia on psychotropic drug use in Veterans Health Administration Community Living Centers: STAR-VA impact on psychotropic drug utilization.

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.

Patient centered medical homes did not improve access to timely follow-up after ED visit.

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 7days. Practices with PCMH designation were less likely to offer appointments within 7days (23.4% vs. 33.1%, p=0.03). However, callers were more likely to obtain an appointment in 7days 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.

A Call to Restructure Psychiatry General and Subspecialty Training.

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.

Increased risk among older veterans of prescribing psychotropic medication in the absence of psychiatric diagnoses.

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.

Clinical Outcomes of Intravenous Ketamine Treatment for Depression in the VA Health System.

Objective/Background: Intravenous (IV) ketamine is effective for reducing symptoms of major depressive disorder in short-term clinical trials; this study characterized clinical outcomes of repeated infusions in routine clinical practice and the frequency and number of infusions used to sustain symptom improvement.Methods: Records of IV ketamine infusions for depression and associated Patient Health Questionnaire-9 (PHQ-9) scores were identified from Veterans Health Administration (VA) electronic medical records for patients treated in Fiscal Year 2020 and up to 12 months following the date of their first infusion.Results: Sample patients (n = 215) had a mean baseline PHQ-9 score of 18.6 and a mean of 2.1 antidepressant medication trials in the past year and 6.1 antidepressant trials in the 20 years prior to their first ketamine infusion. Frequency of infusions decreased from every 5 days to every 3-4 weeks over the first 5 months of infusions, with a mean of 18 total infusions over 12 months. After 6 weeks of treatment, 26% had a 50% improvement in PHQ-9 score (response) and 15% had PHQ-9 score ≤ 5 (remission). These improvements were similar at 12 and 26 weeks. No demographic characteristics or comorbid diagnoses were associated with 6-week PHQ-9 scores.Conclusions: While only a minority of patients treated with IV ketamine for depression experienced response or remission, symptom improvements achieved within the first 6 weeks were sustained over at least 6 months with decreasing infusion frequency. Further study is needed to determine optimal infusion frequency and potential for adverse effects with repeated ketamine infusions for depression.

The role of consultation-liaison psychiatrists in improving health care of patients with schizophrenia.

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.

Comparison of mental health outcomes of augmenting medications for patients with posttraumatic stress disorder: A national veterans affairs study.

RATIONALE: Posttraumatic stress disorder (PTSD) is highly prevalent among veterans. Many veterans with PTSD respond well to serotonin reuptake inhibitors (SRIs). Nonresponders may be prescribed augmenting medications, which are not as well-studied in PTSD. AIMS AND OBJECTIVES: We used Veterans Health Administration electronic records to compare mental health outcomes (PTSD symptoms and rates of mental health hospitalizations and psychiatric emergency room visits) in patients with PTSD who were prescribed four different groups of augmenting medications (atypical antipsychotics, mirtazapine, prazosin or tricyclic antidepressants) in addition to SRIs-from the year before to the year after the start of the augmenting medication. METHOD: We included data from 169,982 patients with a diagnosis of PTSD (excluding patients with comorbid bipolar or psychotic disorders) seen in Veterans Affairs care from 2007 to 2015 who were taking an SRI and filled a new prescription for one of the four augmenting medications for at least 60 days. RESULTS: Patients evidenced minimal (<2%) reduction in PTSD symptoms and a larger reduction in psychiatric hospitalizations and psychiatric emergency room visits after receiving augmenting medications; this effect was largely similar across the four medication groups. Initiating augmenting medications was preceded by increases in PTSD symptoms, psychiatric hospitalizations and psychiatric emergency room visits. After initiating an augmenting medication, PTSD symptoms/hospitalizations/emergency room visits returned to baseline levels (before the start of the augmenting medication), but generally did not improve beyond baseline. CONCLUSION: Importantly, these effects could be explained by regression to the mean, additional interventions or confounding. These findings should be further explored with placebo controlled randomized clinical trials.

Impact of a metabolic screening bundle on rates of screening for metabolic syndrome in a psychiatry resident outpatient clinic.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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%). CONCLUSION: 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.

Evaluation of Antipsychotic Reduction Efforts in Patients With Dementia in Veterans Health Administration Nursing Homes.

OBJECTIVE: The 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. METHODS: The 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. RESULTS: Antipsychotic 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%. CONCLUSIONS: Antipsychotic 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.

Benzodiazepine Use among Medicare, Commercially Insured, and Veteran Older Adults, 2013-2017.

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.

Trends in Medication Prescribing in Patients With PTSD From 2009 to 2018: A National Veterans Administration Study.

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.

Behavioral observations reflected on consultation requests from primary medical-surgical services: are they predictive of delirium diagnosis and outcomes?

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.

Prescription Benzodiazepine Use Among Older Adults: A Critical Review.

OBJECTIVES: Despite evidence for many potential risks, use of benzodiazepines (BZDs) 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 BZDs 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 (1) included 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: Thirty-one studies met the inclusion criteria. Of the three clinical indications evaluated, treatment of insomnia had the greatest available evidence for use of BZDs among older adults, with 21 of 25 trials demonstrating improved sleep outcomes with use of BZDs. Only one trial was found to meet eligibility criteria for BZD use in anxiety disorders, demonstrating benefit over placebo. Five studies for use in behavioral disturbances in dementia were included, of which only one demonstrated improvement over placebo. CONCLUSION: This systematic review suggests that BZD prescribing to older adults is significantly in excess of what the available evidence suggests 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.