Late-life depression presents clinical challenges, including more comorbidities, longer time to treatment response, longer treatment duration, and older age stigmatization. Such characteristics may increase the perception that depressed older adults are difficult to treat, but evidence suggests that benefits from treatment are similar to these observed in younger adult patients. Antidepressant treatment may confer even greater protection against suicide in older than younger adults. However, a retrospective matched cohort study carried on in American managed care population showed that depression goes commonly untreated in older people compared with younger adults. Despite a high rate of comorbidity that was associated with more frequent antidepressant dispensing, this age group was at higher risk of untreated illness either by antidepressant (25.6% vs. 33.8%) or by psychotherapy (13.0% vs. 34.4%) and of later treatment after depression diagnosis (51 vs. 14 days), showing a lower access to treatment. In this study, before 2006, older adults treated for depression received more frequently antidepressants at lower prescribed doses, had poorer adherence and higher non-persistence to treatment than younger adults. However, these differences disappeared or reversed after Medicare Part D implementation, which improved the refunding of drugs in the elderly population. Similarly, a historical cohort study showed, in the French universal health care system, that antidepressant treatment duration and adherence were better in the treated older patients than in the younger ones. This favourable finding may be partly attributed to the universal healthcare system in which all subjects are treated in the same way, regardless of age. However, the reasons for the more appropriate use of antidepressants in the older subjects remain to be elucidated.

Many hypotheses have been made to explain the high rate of benzodiazepine consumption in France, including a general cultural and/or familial tendency to use certain types of psychotropic drugs. This study explored the association between lifetime medication use by parents and their children. Two hundred and twenty-one young patients (158 boys and 63 girls) consulting at a child and adolescent psychiatry department, six to 16 years of age (mean = 9.7 years), were screened for lifetime use of psychotropic drugs using a structured interview. Parents were asked about their own consumption, as well as their children’s. Lifetime consumption rates (at least once) were 22.2% in boys and 20.6% in girls, and 19.6% in children less than 11 years old. Higher rates were found in patients with emotional disorders (anxiety disorders and depression). In parents, 45.1% of mothers and 24.1% of fathers reported using medications at least once. A significant association was found between child and parental medication use: 34.1% of children had positive lifetime consumption when their mothers also used medications at least once versus only 13.6% in other children (odds ratio = 3.31 [1.68–6.50]; P = 0.001). The most significant association was found between medication use by girls and their mothers (odds ratio = 12.1 [2.38–61.5];P = 0.003). These data point to the existence of a family pattern of psychotropic drug consumption, especially in females.

The introduction of atypical antipsychotics has triggered a reevaluation of treatment strategies in schizophrenia. Although research findings inform about the efficacy and safety of drugs, it is the decisions made daily in ordinary practice that affect the vast majority of patients. The aim of this paper was to examine the use of atypical antipsychotics in clinical care, by means of a survey of prescribing practices for clozapine, risperidone, olanzapine, sertindole and quetiapine for all patients treated for DSM-IV schizophrenia within a psychiatric service. Seventy-five (26%) of the 286 patients identified were on atypical antipsychotics. Patients on clozapine were mostly male, had more than 15 years of contact with psychiatric services and were poor responders. Patients prescribed other atypicals had responded to prior treatment with typical neuroleptics and had less than five years of contact with psychiatric services. Gender distribution was equal in this group. The use of research criteria for treatment resistance identified only one patient, as prolonged use of high-dose neuroleptics was uncommon. The new atypical antipsychotics appear to be replacing older neuroleptics as the first-line treatment of schizophrenia while clozapine is mostly reserved for poor responders. Clinicians' definition of treatment resistance was variable and below the threshold used in research.

The risks associated with psychotropic drugs use should be accurately documented at the population level in view of the growing number of persons exposed to these drugs. The strengths of observational studies regarding the identification of drug-related harms mirror the limitations of randomised controlled trials and vice-versa. Observational studies can be carried out in large samples of unselected participants treated in real-life conditions and who may be followed up over long periods. Serious adverse effects undetected during pre-marketing clinical trials may be observed only in post-marketing use, such as metabolic effects of second-generation antipsychotics. Observational studies play a key role in the identification of teratogenic risks, such as those induced by prenatal exposure to anticonvulsants. These studies are the main source of information to investigate the long-term effects of drugs, such as the possible increased risk of dementia in benzodiazepine users. They may also contribute to the accurate assessment at population level of risks overestimated by studies carried out in non-representative samples, such as the risk of congenital heart diseases in babies prenatally exposed to lithium. Owing to the lack of random allocation of drugs, confounding by indication or by disease severity are the major sources of biases in observational studies exploring drug safety. An adverse outcome may be wrongly imputed to drug exposure while it is a symptom/outcome of the disease motivating the decision to prescribe. Such a bias may occur in studies investigating the link between exposure to antidepressants and suicidality. As several methods have been developed to lessen the impact of such biases, pharmaco-epidemiological studies based upon stringent methodological designs should be regarded as a valid approach for assessing psychotropic drug safety.

We establish the potential for outcomes evaluation of a long-term care population-based dataset. Data come from the Health Care Financing Administration's case-mix and quality demonstration project including all Medicare/ Medicaid certified homes of five U.S. states during 1992–1994. Using the Minimum Data Set, we identified nearly 70,000 residents over 65 years of age with congestive heart failure. We provide a preliminary analysis of pharmacotherapy of congestive heart failure and its effects on decline in physical functioning. Functional outcome, expressed as the rate of ADL decline, was improved for patients on combination therapy relative to those on digoxin or ACE-inhibitors alone. The availability of a population-based data set provides a means of evaluating current policies and practices.