Reintroduction of quazepam: an update on comparative hypnotic and adverse effects Insomnia is a prevalent disorder that affects over one-third of the U.S. population to varying degrees and is highly disruptive towards quality of life. Pharmacological treatments for insomnia include benzodiazepines (BZs) and the non-BZ ‘Z-drugs’ (zolpidem, zaleplon, eszopiclone, zopiclone), which are amongst the most widely prescribed medications. Yet, these agents can produce adverse effects such as tolerance to the hypnotic effect, rebound insomnia, next-day residual drowsiness, as well as amnesia and complex behaviours such as sleep-walking, sleep-eating and sleep-driving. Quazepam, one of the five BZ approved for treatment of insomnia, was recently relaunched to the U.S. market in 2016 and is distinguished amongst hypnotic BZ by unique pharmacological characteristics including selectivity for sleep-promoting α1-subunit containing γ-aminobutyric acid (GABA-A) receptors and a significantly lower relative receptor binding affinity. These features likely drive the decreased rate of adverse events seen clinically with quazepam, such as tolerance, rebound insomnia and amnesic behaviours, compared with other BZ. Given the recent reintroduction of quazepam as a pharmacotherapeutic option, and the lack of head-to-head comparative trials against newer agents, the purpose of this review is to provide an update on distinguishing features of quazepam with regard to its pharmacology, pharmacokinetics, sleep efficacy and potential adverse effects compared to other agents used for insomnia.

A personal account of depressive illness and its antidepressant treatment Depression crept quietly over me as a shadow lengthens towards dusk. Probable contributory factors include familial predisposition, multiple bereavement, physical illness and being abused online. The first few days of antidepressant drug treatment were unsettling, but I responded steadily, the medication side effects proved tolerable, and my depressive and anxiety symptoms had remitted within 4 weeks. Insights from literature were helpful in recovery. I hope this experience of illness and treatment will enhance my clinical practice and contribute to discussions about depression and antidepressant medicines.

Concomitant use of alcohol and benzodiazepine hypnotics in psychiatric outpatients: a cross-sectional survey Concomitant use of benzodiazepines and alcohol appears prevalent in a clinical setting. The objectives of this study were as follows: (1) to investigate the prevalence of concomitant use of benzodiazepine hypnotics and alcohol in psychiatric outpatients, (2) to examine the clinical characteristics and factors associated with the concomitant use, and (3) to investigate the awareness of the psychiatrists-in-charge about the concomitant use. Outpatients with schizophrenia, depression, and insomnia who were receiving benzodiazepine hypnotics were asked to fill in a sleeping diary for seven consecutive days in which use of hypnotics and alcohol was also recorded. Clinical characteristics were assessed, and logistic analysis was performed to examine factors associated with the concomitant use. In addition, psychiatrists-in-charge were asked as to whether they thought their patients were concomitantly using them. The prevalence rate of the concomitant use was 39.8% (37/93). The CAGE score showed significant positive association with the concomitant use (odds ratio = 2.40, 95% confidence interval = 1.39–4.16, P = 0.002). Only in 32.4% of the concomitant users were suspected by their psychiatrists. The results suggest that concomitantly used benzodiazepine hypnotics and alcohol appears prevalent, and has been frequently overlooked by treating psychiatrists. The CAGE questionnaire may be helpful to screen such potentially hazardous users.

Compliance in schizophrenia spectrum disorders: the role of clinical pharmacist The inability of patients with psychiatric illness to achieve full compliance with treatment during the postdischarge period is a major problem. In this study, our aim was to evaluate whether drug education provided by a clinical pharmacist during discharging period has an effect on compliance. Forty adult patients diagnosed with psychotic disorders were included. A number of scales were used to evaluate the severity of illness, medication adverse effects and compliance. At time of discharge, it was emphasized to patients by a clinical pharmacist that medication compliance was important to prevent exacerbation or hospitalization. Six to eight weeks after discharge, patients were invited to be reevaluated using the same scales as those applied during hospitalization. There was a statistically significant increase in compliance after drug education (P < 0.001). A decrease in the baseline compliance score was associated with an increase in the total number of hospitalizations and the number of psychotropic drugs used. When the risk factors that may affect compliance were evaluated, akathisia was found to have the highest impact on compliance (P = 0.012). It is necessary to take advantage of counseling on medication use and to develop strategies in order to improve compliance in psychiatry.

Long-term effects of paliperidone palmitate on hospital stay and treatment continuation There is a growing need for real world data on long-term clinical and health resource utilization outcomes. The main purpose of this study was to establish the effects of 1-monthly Paliperidone Palmitate (PP1M) on treatment continuation and hospital stay in routine clinical practice. This is a naturalistic, 6-year mirror-image study examining retention and hospitalization rates 3 years pre-PP1M and 3 years post-PP1M initiation. One hundred seventy-three patients were included; 120 (70%) had a primary diagnosis of schizophrenia and 53 (30%) other diagnosis. In total, 77% of patients continued PP1M for one year, 66% for two years and 55% for three years. For the patients who continued with PP1M for 3 years (n = 95), the mean number of hospital admissions decreased significantly from 1.44 to 0.53 and the mean number of bed days from 93 to 29 bed days 3 years before and 3 years after PP1M initiation (P < 0.001). The group of patients with schizophrenia who continued for 3 years (n = 79) demonstrated similar outcomes. The introduction of PP1M had a significant impact on long-term clinical outcomes. More than half of patients were still continuing on PP1M at 3 years after initiation and had no admission during 3 years follow-up.

Trends of antidementia drugs use in outpatients with Alzheimer’s disease in six major cities of China: 2012–2017 Alzheimer’s disease is a devastating neurodegenerative disease that requires pharmacological intervention. We conducted a descriptive study using pharmacy prescription data of antidementia drugs. Prescription information of 99 541 patients was obtained from 55 hospitals. Overall the number of Alzheimer’s disease outpatients of sampling days increased from 10 239 in 2012 to 20 546 in 2017. The main age range of patients suffering Alzheimer’s disease was 75–84, while the patients aged above 85 was increasing. Nonusers of antidementia drugs, cholinesterase inhibitors (ChEIs) and memantine slowly decreased over the study period. The percentage of patients taking ChEIs and ChEIs-combined memantine increased. The most frequently prescribed ChEI was donepezil. These results are mostly in line with the guideline recommendations and clinical evidence during the study period. Efforts should be made to reduce the number of nonusers and optimize the use of antidementia drugs.

Impact of Ramadan fasting on medical and psychiatric health Ramadan is a religious month dedicated to prayer, fasting and feasting. Recently, there has been an increased interest among healthcare providers regarding possible health-related complications as a consequence of religious fasting such as that seen during Ramadan. In May 2018, a 34-year-old female patient with a diagnosis of schizoaffective disorder, depressive type, was admitted for inpatient hospitalization to an inpatient psychiatric hospital in Buffalo, New York. The earliest date of initial diagnosis is unclear; however, the patient reports an increase in symptoms during her early twenties. Upon admission, the patient was continued on haloperidol, lithium and fluphenazine decanoate which had been initiated prior to this admission. Medication administration and meal times were adjusted to accommodate her observance of Ramadan. Despite efforts to mitigate the potential impact, the patient complained of dizziness and weakness following initiation and titration of clozapine. Due to psychiatric exacerbation, inpatient hospitalization and continuous monitoring, clozapine titration occurred quickly. Upon admission, the patient’s blood pressure was 137/85 mmHg, which decreased to a low of 87/58 mmHg as her clozapine dose was increased, leaving the patient requesting bedrest due to significant dizziness and weakness. On the 21st day of Ramadan, the patient broke her fast due to substantial adverse effects. Five days after breaking her fast, the patient’s blood pressure increased and returned to baseline. Individuals participating in Ramadan tend to have disrupted sleep cycles, including nocturnal sleep reduction and broken sleep patterns, which can impact overall health. Additional health-related complications that have been reported include dehydration and changes in blood glucose, blood pressure, lipid panel, body weight and exacerbation of psychiatric symptoms. These adverse effects can result in serious complications in fasting individuals with acute medical and psychiatric illness. Clozapine was initiated and rapidly titrated during the patient’s observance of Ramadan. She exhibited signs and symptoms of hypotension, which were also subjectively reported by the patient. The significant drop in blood pressure while fasting, and rapid increase once the fast was broken, confirm that medication changes implemented during religious fasting, such as that seen during Ramadan, can increase a patient’s risk of serious adverse effects.