Where Does This Leave Us?
This takes us far beyond the initial topic of this discussion: we both agree that atypical neuroleptics are overused in the primary care setting – and I would say they are also overused in the psychiatric specialty setting – because they are given for symptoms, rather than diseases, and they are given outside of the areas where they are scientifically proven. It seems we differ somewhat on their long-term use when given for syndromes where they are mainly proven to only have short-term benefit, as in acute mania and acute severe depression.
Dr. Culpepper: I can see Dr. Ghaemi's points, and do agree with most of them – our patients are best served when treatment is informed by science. However, we as clinicians must translate the evidence available to us through RCTs and other studies about groups of patients into decisions for individual patients. The reality is that most medicines, especially in the psychiatric realm, are effective in only a minority of patients treated, thus even for treatments deemed effective by RCTs, one of our tasks is to remove those not beneficial to a particular patient. So our job is to work with our patients over time – using our knowledge of them, their past histories both with the disease process and other medications, and our knowledge of their resources and liabilities – as well as our understanding of available "science" to identify, monitor, and refine the treatment plan that is of greatest benefit to them. Within such a framework of active management of individualized treatment over time, if a patient's response demonstrates continued benefit greater than adverse effects in the judgment of the clinician, and there are no less deleterious treatments available for the particular patient, then the physician is doing his best for the patient, including honoring the Hippocratic mandate: "I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone."
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Cite this: Are Antipsychotics Overprescribed? - Medscape - Feb 18, 2011.