NIAAA Updates Guide on Helping Patients With At-Risk Drinking and Alcohol Use Disorders

Some newer antipsychotic medications are being prescribed to millions of Americans for depression, dementia, and other psychiatric disorders without strong evidence that such off-label uses are effective, according to a new analysis by the Agency for Healthcare Research and Quality (AHRQ) of the Department of Health and Human Services. The report calls attention to the medications' potential for serious side effects and emphasizes the urgent need for more research into new treatments, especially for the growing population of patients with dementia who experience severe agitation.

The 77-page review, which cites 125 references, was written by AHRQ's Southern California-RAND Evidence-Based Practice Center. The center examined 84 published studies that compared second-generation antipsychotics with placebo and with active treatments. The report summarizes evidence about the use of these medications to treat dementia, depression, obsessive-compulsive disorder, posttraumatic stress disorder (PTSD), Tourette's syndrome, and autism.

Some studies cited in the report suggest that second-generation antipsychotics may help patients with mental health conditions for which there are no approved alternatives. Risperidone and quetiapine, for example, have been found to help some patients with obsessive-compulsive disorder when used in conjunction with antidepressants. Risperidone and olanzapine improve sleep problems, depression, and other symptoms of persons with combat-related PTSD when these medications are used to augment therapy with other psychotropic medications.

Overall, however, researchers found that much of the scientific evidence for off-label use of antipsychotics was of insufficient quality because studies were too small or lacked scientific rigor. The report also noted that enrollment criteria for many studies were highly selective, rendering the results "only modestly applicable to the patients seen in typical office-based care."

Efficacy and Comparative Effectiveness of Off-Label Use of Atypical Antipsychotics is the latest analysis from AHRQ's Effective Health Care program. Information on the program, including the full report, can be found at www.effectivehealthcare.ahrq.gov.

CMHS publications on system transformation: The Center for Mental Health Services (CMHS) has released two publications in its Building Bridges Series. The series features reports of dialogue meetings convened by CMHS at which participants discuss their experiences, identify factors that promote and hinder change for people and systems, and offer recommendations. A 44-page report, Mental Health Consumers and Primary Health Care Representatives in Dialogue, discusses the findings of a two-day meeting. Topics discussed include availability, affordability, and quality of services; interactions between general health and mental health; and cross-training in primary care and mental health care. Consumers and Representatives of the Mental Health and Criminal Justice Systems in Dialogue is a 37-page publication that seeks to provide an understanding of consumers' experiences in the criminal justice system. Issues discussed include diversion and community reentry. The reports are available online at www.mentalhealth.samhsa.gov/publications.

CSG's national resource center on criminal justice policy: The Council of State Governments (CSG) has announced the creation of its Justice Center. The center, which is an outgrowth of a smaller initiative within the organization's Eastern Regional Conference, will develop nonpartisan, consensus-driven strategies to address complex public safety problems, particularly those at the intersection of the criminal justice system and other disciplines, such as public health. Strategies will be grounded in research and make efficient use of state and local resources. A group of senior-level state officials who shape criminal justice policy has been assembled to guide the 25-member Justice Center staff until a board of directors has been named. The center will coordinate projects on improving the system's response to people with mental illness, addressing prisoner reentry issues, and promoting justice reinvestment strategies. The Justice Center will have offices in New York City and Bethesda, Maryland. The center's Web site is at www.justicecenter.csg.org.

Kaiser issue brief on aging out of EPSDT: States have considerable flexibility in deciding which services for adults are covered by Medicaid. However, the Medicaid statute established uniform and higher standards for children under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. For children with disabilities, having continued access to a comprehensive range of services is especially important if they are to remain in the community as adults. The Kaiser Commission on Medicaid and the Uninsured has released a 13-page issue brief that discusses the challenges and implications for young people with disabilities when they become adults and lose their EPSDT benefits. The brief explains how recent changes to the Deficit Reduction Act of 2005 give states an opportunity to increase the availability of home- and community-based services that allow disabled individuals to lead as normal a life as possible in the community as they move into adulthood.

AHRQ-CDC report on genetic tests in depression treatment: There is insufficient evidence to determine whether gene-based tests intended to personalize dosages of serotonin reuptake inhibitors (SSRIs) improve treatment or aid in treatment decisions, according to an evidence report from the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC). Tests evaluating differences in genes belonging to the cytochrome P450 (CYP450) family that affect the rate at which a person metabolizes an SSRI are largely accurate, researchers have found. However, a comprehensive literature review found no well-designed studies that evaluated clinical outcomes. The likelihood that a person will experience relief from all symptoms of depression after one year of SSRI treatment is approximately 40%, and side effects cause 12% to 15% of patients to stop taking the drug. The report is the first step in the two-step process of CDC's Evaluation of Genomic Applications in Practice and Prevention, a pilot project to evaluate and make recommendations regarding use of gene-based tests. Later this year the project's working group will issue recommendations on the use of CYP450 tests and on research needs. Free copies of the report can be obtained by contacting the AHRQ Publications Clearinghouse at [email protected] or at 800-358-9295.