APA Aims to Nix 'Knee-Jerk' Antipsychotic Prescribing

Nancy A. Melville

September 25, 2013

A list of 5 key antipsychotic prescribing recommendations released by the American Psychiatric Association (APA) addresses some of the most common diversions from what should be standard practice, most of which can be attributed to one common culprit ― the knee-jerk reaction to go directly to an antipsychotic before considering other alternatives.

"The point isn't to say that some of this prescribing should never occur but that it shouldn't be done routinely as an initial practice when there are evidence-based alternatives that are safer and may be less costly," Joel Yager, MD, chair of the APA's Council on Quality Care and professor in the University of Colorado School of Medicine’s Department of Psychiatry, in Denver, told Medscape Medical News.

Released last week and reported by Medscape Medical News at that time, the APA list is part of the Choosing Wisely effort, an initiative of the American Board of Internal Medicine Foundation that was designed to spur discussion on appropriate care regarding procedures and tests that are known to be overused or inappropriate. The initiative includes more than 80 medical specialty societies.

Providing Context

Dr. Yager provided some context for the APA’s list of 5 key recommendations relating to antipsychotic prescribing.

Don't prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring

This recommendation may seem obvious, but Dr. Yager noted that with second-generation antipsychotics in particular, monitoring is essential.

"Patients on these drugs need to be monitored for the known metabolic adverse effects, and that can include taking a lipid profile and monitoring their weight, in addition to monitoring for potentially serious neurological side effects, such as tardive dyskinesia and extrapyramidal symptoms," he said.

Don't routinely prescribe 2 or more antipsychotic medications concurrently

The operative word is "routinely," Dr. Yager emphasized.

"There will always be circumstances when psychiatrists will want to prescribe 2 different medications, perhaps in an effort to work with different target profiles, for instance, but the admonition is that you shouldn't start out prescribing 2 antipsychotic medications before you are able to see the effects of 1."

Don't use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia

Clinicians will too often turn to antipsychotic drugs as a first-line treatment for dementia when other behavioral measures should be first considered, Dr. Yager said.

"This recommendation is shared by the Society for Geriatric Medicine, and again, the recommendation isn't that antipsychotics should never be used for dementia, they just shouldn't be used first."

"Initial measures that should instead be considered in managing dementia include behavioral interventions, such as training family members on how to work with patients with techniques such as lighting orientation, kindness, music, or enlisting the help of skilled caregivers ― these are all measures that can help patients with dementia settle down."

Don't routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults

"Antipsychotics are far down on the list of medications that should be used for insomnia, yet there are some prescribers using quetiapine (Seroquel [AstraZeneca Pharmaceuticals LP]), for instance, as a first line for sleep," Dr. Yager said. "No one in the sleep field thinks that makes any sense."

Instead, begin with measures such as sleep hygiene, which can include measures ranging from avoiding stimulants or napping to making sure the bedroom is dark and the bed is comfortable.

"The issue, again, is to avoid getting in the routine habit of using antipsychotics as a first response but to instead be thoughtful and ask, 'What is the problem? What do I know about it? What can I do to help the patient behaviorally? And then, if I do need to go to medication, what is a good algorithm?" Dr. Yager said.

Don't routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders

"There has been about a 30% increase in antipsychotic prescriptions to children and adolescents in recent years, and there has absolutely not been a 30% increase in the rate of psychosis," Dr. Yager said.

"Again, it has become a first reaction in trying to get on top of a child's or adolescent's behavioral problem quickly, but the bottom line is that antipsychotic drugs are not to be used simply for a child who has frequent temper tantrums."

"Too many practitioners prescribe these drugs as a first option instead of trying to understand what they're dealing with and making a more accurate diagnosis."

As with dementia and insomnia, consider alternative options such as cognitive-behavioral therapy for child or adolescent issues that are not clearly psychotic disorders, said Dr. Yager.

Think Before Prescribing

Philip R. Muskin, MD, a professor of psychiatry at Columbia University Medical Center in New York City, commented that a comprehensive list of routine antipsychotic prescribing habits that should be discouraged could feasibly be much longer, but he said the list captures key prescribing issues.

"Of course, there could be many others, but I would say these are the heavy hitters," he told Medscape Medical News.

He noted that with dementia in particular, antipsychotics have become much more of a "go-to" drug than they should be.

"It's not bad to put a patient on an antipsychotic for dementia, but it shouldn't be the first thing you do because there's really no evidence that antipsychotics treat dementia," Dr. Muskin said.

"They are sometimes necessary ― if patients with dementia become psychotic or aggressive, for instance, and are in a nursing home or hospital environment where they can become dangerous to others ― then the drugs may be necessary.

"But otherwise, it's important to consider other options, such as environmental changes. If someone wanders, for instance ― wouldn't it be better to change the locks than just give them an antipsychotic?"

Likewise with the liberal use of antipsychotics for children with behavioral issues that do not fit the profile of having true psychotic disorders.

"It could be that the family needs therapy or the adolescent can benefit from therapy without the antipsychotics," Dr. Muskin said.

"But prescribing antipsychotics shouldn't be a knee-jerk reaction ― that's the way I read this.

"These medications can be great, and they can indeed change people's lives for the better, but they come with some serious side effects, so you really need to think before you prescribe."

Dr. Yager and Dr. Muskin report no relevant financial relationships.

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