REVIEW ARTICLE
Zolpidem-Associated Consequences
An Updated Literature Review With Case Reports
Joseph Westermeyer, MD, MPH, PhD*† and Tegan M. Carr, BS†
Abstract: A post-2000 literature search reviewed prevalence of health conse-
quences associated with zolpidem, plus two salient case reports. Common
zolpidem-related harms encompassed accidents, falls, overdoses, delirium, and
infections. Risks to others included assaults, vehicular accidents, various crimes,
and civil actions that occurred during zolpidem-induced delirium, withdrawal,
and other impediments. Remarkably, much harm occurred while patients were
taking therapeutic doses of licitly prescribed zolpidem (10–30 mg). Zolpidem-
associated health, behavioral, and social problems comprise an international pan-
demic of preventable heath misfortunes.
Key Words: Zolpidem, sedative, delirium, withdrawal, consequences
(J Nerv Ment Dis 2020;208: 28–32)
A 2011 review described 28 legal cases in which zolpidem effects on
patients potentially reduced their criminal or civil liability (Daley
et al., 2011). Six civil cases concerned employment and vehicular dam-
age. The remaining 22 criminal cases consisted of 10 vehicular-related
incidents, seven violent crimes, two problematic court pleas, two false
reports, and one sexual offense. Two of seven “violent cases” involved
homicide; that is, a man who killed his wife and a woman who hit a
pedestrian while driving (both convicted of manslaughter). Two sub-
sequent zolpidem-related homicides, both reported in New York,
consisted of a man who killed his wife (convicted, second-degree mur-
der) and a woman who killed her husband (convicted, manslaughter)
(Paradis et al., 2012).
Despite such tragedies and vastly greater public health conse-
quences, zolpidem has become the most widely prescribed sedative
drug in the United States over the last 25 years (Kripke et al., 2012;
Walsh and Schweitzer, 1999). Its rapid onset of action and relatively
short half-life has made it a popular soporific internationally. Overlap
between its therapeutic and delirium-producing dosage has created
problems among the elderly and those with mood, anxiety, and sub-
stance use disorders. Morbid and mortal complications from zolpidem
have ensued from its ability to disable neurons widely distributed in
brain, such as GABA-A agonists (Crestani et al., 2000), produce depen-
dence and withdrawal with cross-tolerance to benzodiazepines and al-
cohol (Victorri-Vigneau et al., 2007), damage chromosomes (Amerio
et al., 2015), and foster infections (Huang et al., 2014). It has achieved
notoriety as the psychotropic agent most commonly associated with
emergency department (ED) visits (Hampton et al., 2014).
In this report, we first consider medical, social, and legal impli-
cations of current zolpidem practices based on post-2000 published
studies. We then describe two delirium cases that exemplify the range
of zolpidem consequences, from self-limited recovery to zolpidem-
associated homicide. The first author recently assessed and treated the
first, fairly prosaic case in an ED. He also served as an expert witness
*Addiction Recovery Service, Mental Health Service, Minneapolis VA Health Care Cen-
ter; and †Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota.
Send reprint requests to Joseph Westermeyer, MD, MPH, PhD, 1935 Summit Ave, St
Paul, MN 55105. E‐mail: weste010@umn.edu.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0022-3018/20/20801–0028
DOI: 10.1097/NMD.0000000000001074
28 www.jonmd.com The Journal of Nervous and Mental Disease • Volume 208, Number 1, January 2020
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
in the second, high-profile legal case entailing characteristics similar
to more common zolpidem consequences.
METHODS
We conducted an updated post-2000 literature review of
zolpidem-associated medical problems and epidemiological prevalence
rates using PubMed. Our initial search focused on titles with zolpidem
with another term (i.e., toxicology, death, mortality, homicide, suicide,
benefit, risk, odds ratio [OR], morbidity, insomnia, sleep, complica-
tions, abuse, dependence, emergency). Next, we reviewed the refer-
ences in these articles to obtain additional publications. Lastly, we
conducted a second round of PubMed searches with additional terms
noted in the citations (i.e., fall, accident, fracture, cancer, infection,
overdose) plus the terms “sedatives” and “benzodiazepines.”
Comparing prevalence rates involved ORs, defined as follows:
odds of problem A with drug Z ðe:g:; zolpidemÞ present
OR ¼
odds of problem A without drug Z ðe:g:; zolpidemÞ
If the OR were greater than 1, then problem A may be associated with
the presence of zolpidem. If the OR is less than 1, problem A may be
less associated with zolpidem. The probability of the OR can then be
calculated to determine whether the association is meaningful. If the
probability meets or exceeds that statistical significance set by the in-
vestigators as being meaningful, one can then calculate the 95% confi-
dence interval (CI). The latter consists of an OR range, within which
fall 95% of possible OR distributions. In addition, two illustrative cases
are presented.
RESULTS
Zolpidem Toxicity Within Therapeutic Dose Range
The Physician Desk Reference or PDR (Medical Economics,
1998), a widely used clinical reference, contained the following Federal
Drug Administration (FDA)–approved warning two decades ago:
“In the elderly, the dose for Ambien (zolpidem) should be 5 mg.
This recommendation is based on several studies in which the
mean peak concentrations, elimination half-life, and AUC (area
under the curve) were significantly increased when compared with
results in young adults.”
The 1998 PDR also warned against use of benzodiazepines
in the elderly, as well as in cases of any age involving depression
or psychosis.
Pharmacodynamics research has provided a possible explanation
for enhanced toxicity when zolpidem and selective serotonin reuptake
inhibitors [SSRIs] are combined (Toner et al., 2000). Both medications
are highly protein-bound in blood. Theoretically, SSRI may force more
zolpidem into the free-state during transport, thereby increasing the ac-
tion of zolpidem on target GABA-A sites. A case report demonstrated
that eliminating zolpidem in a hallucinating patient concurrently receiv-
ing an SSRI eliminated the hallucinosis (Singh and Loona, 2013).
The Journal of Nervous and Mental Disease • Volume 208, Number 1, January 2020
Epidemiology of Homicide and
Psychotropic Categories
During the last decade, the prevalence rates of several psy-
chotropic agents have been investigated in various circumstances.
Epidemiological research has examined whether consequences of
specific drug use are higher, equivalent to, or lower than rates without
the specific drug. Thus agents studied have included antidepressants,
antipsychotics, benzodiazepines, cannabis, opioids, stimulants, and
nonbenzodiazepines “z-sedative” drugs. Studies involving homicide
have not yet been conducted with nonbenzodiazepine compounds such
as zolpidem.
A 9-year study of 959 homicide offenders in Finland examined
the OR of medication categories, setting the significance level at
p < 0.005 and using rates adjusted for risk variables associated with
homicide (Tiihonen et al., 2015). Benzodiazepines and opioids were
significantly associated with increased risk of perpetrating homi-
cide, with adjusted ORs of 2.52 for benzodiazepines (95% CI,
1.90–3.35) and 2.16 for opioids (95% CI, 1.41–3.30). Swedish inves-
tigators also found an increased OR of 2.6, linking benzodiazepines
among combined homicide victims and offenders at p < 0.002
(Hedlund et al., 2014).
In an Australian study of 478 homicide cases, drugs overrepre-
sented in homicide perpetrators included opioids with OR = 1.53, psy-
chostimulants with OR = 1.59, and cannabis with OR = 2.39. Agents
underrepresented among homicide perpetrators included antidepres-
sants (OR = 0.22), antipsychotics (OR = 0.23), and benzodiazepines
(OR = 0.53). Australia may comprise a special case vis-à-vis benzodi-
azepines and homicide, however. Australian courts and coroners have
taken actions based on zolpidem-related cases, and both medical
journals and the mass media have issued warnings regarding adverse ef-
fects from benzodiazepines and zolpidem use. Australian clinicians and
the population at large have received guidelines to reduce sedative use,
doses, and durations (McMahon, 2016).
Note that none of these studies regarding homicide have yet ex-
amined zolpidem specifically. However, the benzodiazepine findings
could be extrapolated to nonbenzodiazepine sedatives such as
zolpidem, given the considerable similarities in the pharmacological ef-
fects, distribution via legal channels, and cross-tolerance for overdose
and withdrawal syndromes.
Risks to Self
Consequences of zolpidem dosing have affected people con-
suming zolpidem, as contrasted to harms affecting nonusers in the
population at large. Published reports on consequences to consumers
have included falls, fractures, suicide, infections, vehicular accidents,
and doctor-shopping for prescription drugs of abuse. Many harms to
consumers originate from prescriptions initiated by prescribers. For
example, brief in-hospital zolpidem prescribing for sleep has signifi-
cantly increased the risk of inpatient falls, with an unadjusted OR of
4.28 and p < 0.001 (Kolla et al., 2013). The adjusted risk for 11 demo-
graphic and clinical characteristics produced only a slightly higher OR
of 4.37 for falls during zolpidem administration (p < 0.001), suggesting
that the act of brief, in-hospital prescribing comprised the overriding
factor in these falls as compared with individual patient characteristics.
Fractures—a consequence of falls, vehicular accidents, and other
traumata—have also shown a link to zolpidem in a study using relative
risk (RR), rather than OR. RR analyses resemble OR analyses, but they
compare probabilities rather than ratios (e.g., the probabilities of frac-
ture with and without zolpidem prescribing). Zolpidem increased the
RR for any fracture to 1.92, with a 95% CI of 1.65 to 2.24, p < 0.001
(Park et al., 2016). Among fracture sites, hip fracture was most highly
associated with zolpidem.
In another cohort study, a risk for increased prevalence of hip
fracture consisted of taking zolpidem for a longer period (Lin et al.,
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Zolpidem Consequences
2014). The latter investigation suggested that developing tolerance to
longer-term zolpidem dosing did not reduce the risk of hip fracture.
Zolpidem has been associated with increased suicide attempts
and suicide completion with an OR of 2.08 (Sun et al., 2016). Hospital-
ization for two common conditions has also been associated with in-
creased zolpidem use before admission; that is, hospitalization for
serious infections with an OR of 2.08 (Huang et al., 2014) and hos-
pitalization for vehicular accident injuries with an OR of 1.74 (Yang
et al., 2011).
“Doctor-shopping” as a means for obtaining zolpidem has also
been investigated, because licit drugs with illicit market value can ex-
pose clinicians to criminal activities. To this end, researchers used the
Doctor Shopping Index to measure unlawful visits to doctors' offices
to support prescription drug dependence. Findings revealed a 2.2% in-
dex for “zolpidem shopping,” as compared with 2.8% for “opioid shop-
ping” and 2.1% for “benzodiazepine shopping” (Ponté et al., 2018).
Zolpidem-Precipitated Homicide: Pharmacogenic
Syndrome or Crime?
When our homicide case (described later) is added to four pub-
lished cases of zolpidem-associated homicide (Daley et al., 2011;
Paradis et al., 2012), we find that all five cases were receiving treatment
for a mood or anxiety disorder. Four of five victims were spouses or co-
habiting partners of the perpetrator; the fifth involved a traffic accident.
The five perpetrators were aged 50 years or older and taking prescribed
zolpidem in 10- to 30-mg doses at bedtime. None had a previous con-
viction for violent crime. Violence inflicted on the victims considerably
exceeded that necessary to kill them (e.g., >20 stab wounds, numerous
blows to the head with a metal pipe or hammer). Multiple homicidal
methods included blows to the head plus a plastic bag over the head
in one case, and blows to the head plus stab wounds in another case.
All perpetrators were taking SSRI or serotonin-norepinephrine reuptake
inhibitor medication. Three of them developed suicidal thoughts after
the homicide, and one attempted suicide by consuming all of her re-
maining medication. None concealed responsibility for the homicide.
The nature of these tragic and horrific homicides caused public
outrage in the communities where they occurred, leading to public out-
cries for maximum punishment. Despite public sentiments, convictions
were ultimately reduced, usually to second-degree murder or man-
slaughter. Legal outcomes revealed elements of muted-but-punitive
incarceration, with sentences from 6 to 25 years in four cases. Our
case was unusual in its “not guilty” jury decision. To our knowledge,
none of these cases produced legal or professional redress against
the prescribing physicians.
Nonviolent, goal-directed behavior during delirium has occurred
in numerous published reports on zolpidem, so that violence is not
an inherent aspect of zolpidem delirium (Daley et al., 2011). In ad-
dition, seemingly unintended homicide during delirium has accom-
panied other sedative drug and alcohol intoxication and withdrawal
(Hedlund et al., 2014). Thus, zolpidem is not a unique sedative agent
in these regards.
Case 1: Delirium With Rage, Self-Harm, and
Property Violence
Presenting Problem
The 34-year-old, divorced, unemployed man presented to the ED
seeking admission for problems relating to “not taking my sleep medi-
cine properly.” Three weeks previously, he had asked his psychiatrist to
prescribe zolpidem for continuing insomnia because it had relieved his
insomnia 3 years earlier. He received a 30-day regimen of 10 mg
zolpidem at bedtime. However, he immediately began taking 30 mg
at bedtime. Eleven days later, following one night without zolpidem,
he began hearing “whispering voices,” which he initially interpreted
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Westermeyer and Carr The Journal of Nervous and Mental Disease • Volume 208, Number 1, January 2020
as a group communicating with him. Over the following 2 days, he be-
came fearful that unspecified people were “against me.” Next, he be-
came angry with his roommates for no apparent reason and felt like
“attacking them” and “hurting them.” He broke a window in his room,
injuring his hand. He then began throwing furniture around the room,
destroying several pieces. On the third day, he became disoriented to
time and place and could not understand what was happening to him.
He had no recall for the ensuing 3 days, but did become lucid on the
seventh day without zolpidem. Noting that he had destroyed all of his
photos in the previous days, he decided that he was unable to manage
himself. He called his mother and asked her to take him to the hospital
where he had received care several years earlier. At the time of ad-
mission, his medications included duloxetine 60 mg at bedtime,
mirtazapine 45 mg at bedtime, atomoxetine 80 mg daily for attention
deficit disorder, and verapamil 240 mg for hypertension.
Course
He remained in the hospital overnight and slept well. The next
morning, his mental status examination was within normal limits. Ar-
rangements were made for admission to residential treatment the fol-
lowing week. In the meantime, he returned to his mother's home and
resumed his previous medication regimen, minus zolpidem.
Background Information
He consumed alcohol heavily while in the military, leading to
marital discord and resulting in his wife's divorcing him. Subsequently,
he tapered his drinking and started methamphetamine use supple-
mented with occasional opioid, sedative, cannabis, and nicotine use.
His substance use resulted in job loss, financial problems, and alien-
ation from friends and family. He had considered suicide.
Over the previous decade, he had attended four treatment pro-
grams and was hospitalized three times. During the previous year, he
had his longest period of sobriety (lasting several weeks), but had re-
lapsed with “intense craving,” feelings of worthlessness, and low self-
esteem. Currently, he was on probation for selling drugs and failing to
pay child support. His roommates had been able to achieve sobriety
and obtain work, whereas he lost jobs within days of starting.
Case 2: Delirium With Homicide
Present Problem
This 67-year-old man (Mr. A) had been incarcerated at a Florida
jail for 8 months at the time of this assessment. He was accused of mur-
dering Ms. B, his intimate partner of 30 years. They retired from their
respective jobs in a northern state to their current community 15 years
earlier. Their combined resources were invested in their private home.
Each partner received retirement funds.
His current depression began with insomnia and anorexia the
day before Christmas. His only major problem involved his vehicle
needing expensive repairs. The day after Christmas, he spoke to Ms.
B about his symptoms and concern that he was becoming depressed.
Ms. B took him to a primary care physician (PCP), who prescribed an-
tidepressant medication. When Mr. A's symptoms failed to remit over
the ensuing days, another PCP referred him to a psychiatrist. Regarding
his psychiatric treatment, he recalled, “I told him I was feeling better,
but I wasn't feeling better. The nervousness, not thinking straight some-
times, I don't think I was responding to the treatment.” Within 1 week,
he could not enjoy anything and felt “terrible” day and night. He wor-
ried constantly about his finances, health, and failure to respond to treat-
ment. His recent memory was worse than during previous depressive
episodes. His medication regimen consisted of venlafaxine 100 mg,
trazodone 100 mg, alprazolam 1 mg, and zolpidem 20 mg at bedtime.
On examination, 8 months following the homicide, he was un-
shaven with hair unkempt, tended to stare at floor, and appeared
30 www.jonmd.com
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fatigued. Nonetheless, he was cooperative with the interview, asked
for clarification appropriately, and requested breaks when needed.
Speech was primarily monotone, with normal articulation. He was
fully oriented to person, place, and time. Mood was depressed, with
congruence of affect with thoughts. Thought processes were logical
and coherent.
The Homicide
On the morning of the homicide, Ms. B was watching television
in the living room. Mr. A recalled joining her for a cup of coffee and
then went into his bedroom to make his bed. On the way back to the liv-
ing room, he went through an attached garage and picked up a hammer.
He could recall no intent to harm Ms. B before picking up the hammer,
adding, “I didn't know why I was doing it.” Upon re-entering the living
room and seeing Ms. B, he had the thought that he should hit Ms. B in
the head with it although he did not know why this thought occurred to
him. He volunteered, “I remember being very, very calm. Even when I
hit her, I didn't feel anything.” Next, he recalled turning off the TV, but
could not recall hitting her in the head numerous times, stabbing her
with a knife, covering her up, or disconnecting the telephones (all noted
in the police report). Then he drove off in his vehicle, driving slowly
and stopping to allow other vehicles to pass. At a public telephone, he
called a neighbor friend, requiring help from a bystander to put the
coins in the phone and dial the number. After leaving a message on
the friend's answering machine, he resumed driving. It then occurred
to him that he should turn himself into the police for killing Ms. B,
so he looked for a familiar landmark. At a parking area, he was able
to orient himself and then drove to the police station. Mr. A could not
provide a cogent explanation for his depression and the subsequent ho-
micide. He reported that he and Ms. B were getting along better recently
than they had in the past. She had been solicitous during his recent de-
pression, and he was dependent on her to drive him to the doctor and the
pharmacy. He added, “I have a lot of remorse. It never should have hap-
pened. I loved [Ms. A].”
Course
Beginning the day of incarceration, about 24 hours after his last
dose of zolpidem, Mr. A recalled “seeing things” in his jail cell, on the
walls, or crawling on or near him. These visions included spiders,
snakes, and wildcats (lions, tigers), as well as his daughter at one point.
Prison staff notes recorded his seeing his grandchildren, his mother, and
a friend, visual images that would “come and go.” These visual hal-
lucinations reoccurred until haloperidol treatment began about
1 month after admission to jail. He denied hallucinations previously
or subsequently in his lifetime. While incarcerated, his weight fell
from 175 lb to 136 lb—a 39-lb loss. Mr. A was found not guilty in a jury
trial. The court released him, with the recommendation that he pursue
continued psychiatric treatment.
Background Information
Mr. A and Ms. B met at their mutual work place 38 years earlier.
Ms. B had a gambling habit that led to bankruptcy several years earlier.
They kept their finances separate in the event that her gambling
problem recurred.
Mr. A's first depression occurred in his early 20s, beginning sud-
denly after 4 months in the Navy. Symptoms included insomnia, feeling
sad, anorexia, 5-lb weight loss, and decreased libido. He recovered
completely with electroconvulsive treatments (ECTs), given without
anesthesia, but he developed a lifetime dread of ECT and aversion to
hospitals and physicians. At age 50 years, he again developed insomnia,
inability to enjoy life, anorexia, and decreased libido. At the time, his
company was moving, and he would lose his job if he did not move.
During this period, his wife divorced him rather than leave her home-
town. Inpatient treatment involved medication and rehabilitation.
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
The Journal of Nervous and Mental Disease • Volume 208, Number 1, January 2020
His general health was fair. Current problems included dyspnea
with exertion. He had bilateral unrepaired inguinal hernias and reduced
hearing acuity, for which he had not sought care due to his phobia to-
ward health care. However, despite his aversion to physicians, he
praised those who recently cared for him (especially his initial psychia-
trist and later prison psychiatrist). Before his incarceration, his diet was
balanced. He used alcohol infrequently, with one drink or less per time.
He began smoking at age 16, acquiring over 100 pack-years. Before
incarceration, he had two or three cups of coffee and one cola per day
(about 400 mg caffeine daily). Mr. A denied any lifetime use of
illicit drugs.
An only child, Mr. A had no family history of mental illness or
substance use disorder. His three children were healthy, married, em-
ployed, and living in his home state. While incarcerated, he sought so-
lace in the Bible, prayer, and pastoral visits. “I pray to God and to
[Ms. B] for forgiveness. I tell her I'm sorry for taking her life.” His close
social network consisted of his partner Ms. B, his three children and
their families, several coworkers, several neighbors, and a few friends.
DISCUSSION
In reports of delirium and hallucinations associated with
zolpidem plus antidepressant dosing, symptoms resolved over periods
ranging from 20 minutes (Singh and Loona, 2013) to several hours after
single zolpidem doses (Elko et al., 1998). In our two cases and other
cases involving dosing over a week or longer, delirium symptoms
persisted for days to a month (Paradis et al., 2012). Other contributors
to zolpidem-associated delirium have entailed medications or illicit
drugs, head injury, sleep apnea, anoxia, dehydration, sepsis, and/or
comorbid psychopathology.
As a result of widespread zolpidem delirium in the United States
and elsewhere, the FDA and other expert sources have recommended
5 mg maximum doses, especially for women and the elderly. However,
in one study only 16% of zolpidem prescriptions complied with FDA
recommendations (Harward et al., 2015). Another problem has in-
volved duration of zolpidem prescribing. Although recommendations
for its use in insomnia have ranged around 3 to 30 days, the Agency
for Healthcare Research and Quality data observed that two-thirds of
zolpidem users had filled three or more zolpidem prescriptions
(Moore, 2015). In Web site advertisements, pharmaceutical chains to-
day advertise low-cost 90-day zolpidem prescriptions, with cut-rate
prices for initial prescriptions (under $10 for 90-day prescriptions). Na-
tional Health and Nutrition Examination Survey data have shown that
one-fourth of zolpidem users were also using opioids, perhaps contrib-
uting to the opioid mortality epidemic (Bertisch et al., 2014). An anal-
ysis of zolpidem prescription recipients revealed that 77.4% of patients
possessed two or more contraindications to hypnotic agents (Moore and
Mattison, 2018). In an FDA-sponsored meta-analysis, zolpidem studies
employed doses of 10 to 30 mg, technically legal but well above the
dose considered reasonably safe when used alone (Buscemi et al.,
2007). In the latter study, when all “z-hypnotics” were analyzed to-
gether, they failed to show a significant increase in total nightly sleep
even at these higher doses. In a study of insomnia during posttraumatic
stress disorder that included patients on sedatives, the number of night-
time awakenings objectively detected by actigraphy considerably
exceeded (and bore no correlation to) subjective reports of awakening
on sleep logs (Westermeyer et al., 2007). The latter two studies, taken
together, suggest that hypnotic-induced amnesia may account for the
subjectively improved sleep rather than objectively reduced sleep awak-
enings. Finally, zolpidem users can expect rebound insomnia when they
try to stop zolpidem, even after brief use.
Taken together, these data demonstrate that the substance use
disorder endemic to America is highly nuanced and greatly supple-
ments the opioid epidemic taken in isolation. The unusually low
OR for sedatives and homicide in Australia offers hope that
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Zolpidem Consequences
clinicians, public health officials, and legal sectors in the United
States and elsewhere might effectively counter blasé zolpidem pre-
scribing (McMahon, 2016).
CONCLUSIONS
These epidemiological reports on zolpidem from the last two de-
cades reveal the growing consequences from this sedative pandemic.
Zolpidem can produce dependence within a week or two on therapeutic
doses. Even single doses can produce delirium. Victims of zolpidem
trust the producers, pharmacists, and clinicians who furnish zolpidem,
often without knowing that it can contribute to falls, accidents, delir-
ium, and other health consequences.
Published reports from the last two decades document the nature
and extent of diverse consequences from prescribed zolpidem. This in-
formation, readily available to clinicians, the media, patients and their
families, plus others harmed by taking zolpidem, has not sounded a
public alarm regarding real-world consequences. We hope that these
two cases can be meaningful in ways that prevalence rates alone do
not communicate.
Case studies furnish contextualized, real-world agonies that
can afflict individual patients, their families, and communities.
Disturbing consequences that may affect average citizens can pro-
voke concerned individuals to bring such endemics to an end—
just as people ended smallpox, plague, and cholera epidemics and
endemics in past centuries.
Epidemiologic prevalence rates and case reports tap into differ-
ing but connected realities. They can supply essential qualitative and
quantitative information on endemic realities facing us as clinicians
and guardians of the public's health.
ACKNOWLEDGMENT
We appreciate the recommendations and critique for this report
provided by Patricia Dickmann, MD, Erica Dimitropoulos, PharmD,
and Heather Swanson, MD, from the Minneapolis VA Health Care Cen-
ter and the Department of Psychiatry at the University of Minnesota.
DISCLOSURE
Dr. Westermeyer is currently a site investigator for a Veterans
Administration–funded grant (Lithium-plus, CSP590). Over past de-
cades, he has been a site investigator with various pharmaceutical
companies in testing psychotropic medications (benzodiazepines, anti-
depressants, antipsychotics). He has received grants to conduct studies
of substance use disorder and gambling disorder from the National In-
stitute of Health, National Institute of Drug Abuse, National Institute of
Alcohol Abuse and Alcoholism, World Health Organization, US Agency
for International Development, State of Minnesota, and several founda-
tions. Neither author has a conflict of interest. No external funds were re-
ceived for this study. Literature searches were conducted at the University
of Minnesota library. All opinions expressed reflect those of the authors,
and not the Veterans Administration or the University of Minnesota.
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