IMPORTANCE Antipsychotic medications are associated with increased mortality in older adults with dementia, yet their absolute effect on risk relative to no treatment or an alternative psychotropic is unclear.OBJECTIVE To determine the absolute mortality risk increase and number needed to harm (NNH) (ie, number of patients who receive treatment that would be associated with 1 death) of antipsychotic, valproic acid and its derivatives, and antidepressant use in patients with dementia relative to either no treatment or antidepressant treatment.

Objective The use of antipsychotics to treat the behavioral symptoms of dementia is associated with increased mortality. However, there remains limited information regarding individual agents’ risks. Method This was a retrospective cohort study using national data from the US Department of Veterans Affairs (fiscal years 1999–2008) for patients ≥65 years old with dementia, beginning outpatient treatment with an antipsychotic (risperidone, olanzapine, quetiapine, and haloperidol) or valproic acid and its derivatives (as a non-antipsychotic comparison). The total sample included 33,604 patients. Individual drug groups were compared for 180-day mortality rates. Potential confounding was addressed using multivariate models and propensity adjustments. Results In covariate-adjusted intent to treat analyses, haloperidol users had the highest mortality rates (relative risk 1.54, 95% confidence interval 1.38–1.73) followed by risperidone (reference), olanzapine (RR 0.99, 95% CI 0.89–1.10), valproic acid and its derivatives (RR 0.91, 95% CI 0.78–1.06) and quetiapine (RR 0.73, 95% CI 0.67–0.80). Propensity-stratified and propensity-weighted models as well as analyses controlling for site of care and medication dosage showed similar patterns. Haloperidol risk was highest in the first 30 days and then significantly and sharply decreased. Among the other agents, mortality risk differences were most significant in the first 120 days and declined in the subsequent 60 days during 180-day follow-up. Conclusions There may be differences in mortality risks among individual antipsychotic agents. Further, the use of valproic acid and its derivatives as alternative agents to address the neuropsychiatric symptoms of dementia may carry associated risks as well.

Background Assessing predictors of suicide and means of completion in patients with dementia may inform the development of interventions to reduce suicide risk among the growing population of individuals with dementia. Methods This national, retrospective, cohort study used data from the Department of Veterans Affairs (fiscal years 2001–2005). The sample included patients ≥ 60 years old with the diagnosis of dementia (N=294,952), of which 241 died by suicide. Potential predictors of suicide were identified using logistic regression. Suicide methods are also reported. Results Increased suicide risk was associated with white race (OR 2.4, 95% CI: 1.2, 4.8), depression (OR 2.0, 95% CI: 1.5, 2.9), a history of inpatient psychiatric hospitalizations (OR 2.3, 95% CI: 1.5, 3.5), and prescription fills of antidepressants (OR 2.1, 95% CI: 1.6, 2.8) or anxiolytics (OR 2.0, 95% CI: 1.5, 2.7). Nursing home admission was associated with lower suicide risk (OR 0.3, 95% CI: 0.1, 0.8). Severity of medical comorbidity did not impact suicide risk. Sensitivity analysis indicated that the majority of suicides occurred in those with new dementia diagnoses. Firearms were the most common suicide method (73%). Conclusions Given the higher rate of suicide in those receiving treatment for psychiatric symptoms and the high proportion that died using firearms, closer monitoring and assessment of gun access may be an important part of initial treatment planning for older male patients with dementia, particularly those with symptoms of depression or anxiety.

Depression is a common disorder in women of childbearing age. Many women experience depressive symptoms during the postpartum period, ranging from mild postpartum blues to significant mood disorders such as postpartum depression and postpartum psychosis. The 'baby blues' are extremely common, affecting 30-75% of new mothers. This form of postpartum mood change is self-limited and requires no specific treatment other than education and support. While less common, occurring in 10-15% of births, postpartum depression has the potential for significant impact on both the health of the mother and baby. Unfortunately, affective illness in women frequently goes unrecognized and untreated. While there are effective pharmacological treatments for postpartum depression, the treatments for postpartum depression are often not utilized due to concerns about lactation. Postpartum psychosis is extremely rare, affecting one to two women per 1000 births; each case represents a true psychiatric emergency. Identifying and treating postpartum affective illness in women is critical to the health of both mother and infant. This paper reviews the literature on the diagnosis and treatment of mood disorders in the postpartum period: postpartum blues, postpartum depression and postpartum psychosis.

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