Editor's note: Antipsychotics are now the top-selling class of medications in the United States, with prescription sales of $14.6 billion in 2009. Many clinicians worry these agents are being overprescribed and used inappropriately. Medscape recently hosted an email discussion between Dr. Nassir Ghaemi, a psychiatrist, and Dr. Larry Culpepper, a primary care physician with expertise in psychiatry, exploring the question of whether antipsychotics are being used appropriately by prescribing clinicians.
Are Antipsychotics Overprescribed? Introduction
Nassir Ghaemi, MD, MPH: I think antipsychotics are overprescribed. Let's first think about the most legitimate uses, and then we can identify how and why they're overprescribed. These agents are most legitimately used, obviously, for schizophrenia in both the short term and long term. They are also legitimately used in the short term (meaning a few months) for acute mania. That's about it, in my view.
Now, some antipsychotics are US Food and Drug Administration (FDA) indicated for maintenance treatment of bipolar disorder. But for various scientific reasons, I believe the studies on which these approvals are based are deeply flawed.[4,5] So despite the president's stamp of approval, I don't think we can give a scientific stamp of approval. I think [antipsychotics] are scientifically proven for only a few months of mania, and then they should be stopped in general, both due to lack of proven efficacy (despite what the FDA says) and for safety concerns associated with some of the drugs.[4,5]
Antipsychotics are also used for bipolar depression, and some have FDA indications for the condition. Here too I am skeptical about the related studies. But even if accepted, the evidence only supports short-term use (8 weeks), not long-term use for prevention; hardly any data exist with any antipsychotics by themselves in the prevention of bipolar depression, and what little data does exist are subject to many scientific problems.[4,5]
Then there is so-called major depressive disorder, or plain old depression. Certain antipsychotics have an FDA indication here, but again only for short-term use. Hence, short-term use might be justifiable, but scientifically long-term use is not.
Are Anxiety and Sleep to Blame?
Now let's look at anxiety and sleep: these are major sources of overuse. [Antipsychotics] may have some symptomatic benefit [in these conditions]; they can be sedating and some, like quetiapine, which is a many-fold more potent antihistaminic than diphenhydramine, have anxiolytic effects. But then again, so does diphenhydramine, without risk of [cardiovascular disease].
These scenarios are where antipsychotics are most overused among general practitioners. The long-term treatment of bipolar disorder is where they are most overused by psychiatrists. In the former case, an unthinking reliance on symptom-oriented treatment is a major factor in overuse (as opposed to a disease-oriented approach, as advocated in the Hippocratic tradition). In the latter, I believe spinning of the science, along with misinterpretations of FDA labeling, leads to overuse.
Of these causes, I believe the most important is the non-Hippocratic symptom-oriented approach to medical practice, which has bedeviled our professions for 2 millennia. This is the long twilight struggle we need to keep waging, I believe: to teach our colleagues and our patients that if every symptom is met with a drug, we do more harm than good, and that the best doctor is he who recognizes diseases and knows how to treat them, and he who recognizes symptoms that are not based in disease and knows how to avoid treating them.
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Cite this: Are Antipsychotics Overprescribed? - Medscape - Feb 18, 2011.