COMMENTARY

Are Antipsychotics Overprescribed?

Larry Culpepper, MD, MPH; Nassir Ghaemi, MD, MPH

Disclosures

February 18, 2011

In This Article

A Return to Hippocratic Tradition

I would go farther still: it is little appreciated that if we reduce medicine to nothing but risk/benefit analysis, we will practice non-Hippocratically. In the Hippocratic tradition, the main role of the doctor is to identify diseases that cause symptoms, and then to treat those diseases that can be treated; the Hippocratic view strongly argued against using drugs to treat symptoms directly. Not that this should never be done; obviously it is part and parcel of daily medical practice. But the Hippocratic view is that we should de-emphasize symptom-oriented treatment, even when the risks seem low and there appear to be benefits. In the long run, this approach causes more harm than good. This is the thinking behind the maxim incorrectly translated as "First do no harm." It really was: "As to diseases, try to help, or at least not harm."

So I would take this a step farther and say that the use of atypical neuroleptics (or any drugs) for symptoms rather than diseases, frequently and long term, will produce more harm than good. We should avoid using drugs to treat sleep or anxiety or depressive symptoms as much as possible; or if we use drugs in those settings, it should be at low doses and for short durations. In contrast, we should vigorously look to identify and treat the diseases that commonly cause those symptoms, like unipolar depression or bipolar disorder, and then use those drugs that really work for those diseases, even if they have many risks and side effects, like lithium.

I think it is true that bipolar disorder is commonly misdiagnosed and underdiagnosed, not only in primary care, but unfortunately also in the specialty psychiatric setting. I agree, though, that one should not diagnose by prescription; there is not a good scientific or ethical rationale for using atypical neuroleptics in case the patient might have bipolar disorder. One should find out. A good start is to use a self-report screening tool that the patient can fill out in the waiting room: the Mood Disorder Questionnaire[8] is the most commonly used; my unbiased view is that the Bipolar Spectrum Diagnostic Scale[9] (a scale I helped develop and which is available freely online) is better. They can both be used, and each take 5 minutes. The physician can quickly review the scales and then discuss them with the patient in the course of getting more history.

It is important to emphasize that patient self-report is not sufficient to rule out bipolar disorder (though self-report usually suffices to rule it in). If a patient denies having had manic symptoms, it is key to confirm this with third parties. PCPs have the major advantage of usually knowing family, often in the waiting room; they should be invited into the exam room and interviewed along with the patient. Confidentiality is not an issue: the family is talking to the doctor; the doctor is not revealing any information to the family. Such interviewing will identify bipolar disorder in most cases, along with the help of the screening forms.

Even then, when bipolar disorder is diagnosed, I wouldn't recommend starting with atypical neuroleptic medication prescriptions, but rather with true mood stabilizers: lithium, lamotrigine, carbamazepine, or divalproex. Atypical neuroleptics can later be useful as adjuncts for acute mood episodes of mania, mixed, or depressive states – that is, added to standard mood stabilizers. But the biggest mistake I see is that atypical neuroleptics are given in place of standard mood stabilizers like lithium; I believe this is an error. In my view, we should be clear that atypical neuroleptics are not themselves mood stabilizers, but that's a topic for a future discussion.

In some patients, concern on the part of the physician regarding diagnosis – "I don't want to miss a bipolar patient – atypicals are safe for them" – has been suggested as a reason for reaching for the atypical in routine depression care. However, here, improved diagnostic assessment, either taking the time in the primary care setting or through referral to a mental health professional, is the necessary response. To do otherwise is a disservice both to the patient and in the long-run to the physician.

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