Antipsychotics as First-Line Insomnia Treatment a No-No

Fran Lowry

June 08, 2015

Antipsychotics should not be routinely used to treat primary insomnia in children, adults, or the elderly, according to new recommendations issued by leading Canadian psychiatric organizations.

This and 12 other evidence-based recommendations were released by a joint working group of the Canadian Psychiatric Association (CPA), the Canadian Academy of Child and Adolescent Psychiatry (CACAP), and the Canadian Academy of Geriatric Psychiatry (CAGP) for the Choosing Wisely Canada (CWC) campaign.

"Many antipsychotics have sedative properties and are often prescribed off-label for complaints of insomnia," Chris Wilkes, MD, head of Child and Adolescent Outpatient and Specialized Services in the Department of Psychiatry, University of Calgary, Alberta, and president of CACAP, told Medscape Medical News.

"These drugs carry significant risk of potential side effects, including weight gain and metabolic disorders," said Dr Wilkes.

Instead, the CWC psychiatry working group recommends thorough assessment to establish possible behavioral causes (eg, poor sleep-wake schedule, use of caffeine and nicotine), emotional causes (eg, stress), and psychiatric or physical causes (eg, pain, sleep apnea) of insomnia.

After the assessment, nonpharmacologic interventions, including patient education about proper sleep hygiene techniques and behavioral modification, should be the first treatment option offered in most cases, according to the CWC.

The CWC also suggests that melatonin be tried to help regulate sleep-wake cycles.

"If pharmacotherapy is determined to be necessary, one of the approved agents to treat insomnia can be initiated, with an aim to use the lowest effective dose for the shortest period of time, and in conjunction with nonpharmacological strategies," Dr Wilkes said.

"Aggressive pharmacological interventions may offer symptomatic benefit in the short term, but may also lead to numerous potential complications in the long term," he added.

Nix "Sledgehammer" Approach

"Using antipsychotics to treat insomnia is a little like using a sledgehammer to drive in a thumbtack, especially in light of a variety of effective treatment options, both nonmedication and medication, with far fewer side effects," said Donovan Maust, MD, from the University of Michigan, in Ann Arbor, when asked by Medscape Medical News to comment on the Choosing Wisely Canada initiative.

The aim of the CWC initiative is to help physicians and patients engage in conversations about unnecessary tests, treatments, and procedures and to help physicians and patients make smart and effective choices to ensure high-quality care.

"We are in some ways keeping up with our American cousins who started this process in 2012 to avoid duplication of tests and complications from overtreatment.

"Obviously, we want to promote optimal quality of care and avoid complications of overtreatment here in Canada as well. This has been occurring in the US, UK, New Zealand, Australia, and some European countries, with good effect on patient satisfaction and reduction of overinvestigation," Dr Wilkes said.

During the last 10 years, there has been a significant increase in the use of emergency department visits, hospitalizations, and medications in children, he said.

"There has been a 47% increase in ER services, a 37% increase in hospitalization rates, and now, 1 in 12 kids are on medications," Dr Wilkes said.

"We know there has been a disproportionate use of second-generation antipsychotics during the last 10 years, but the incidence of child youth mental health has not increased. But as a community, we are medicalizing more of our kids and do not always use age-appropriate supports, like ensuring adequate sleep, nutrition, and exercise. Also, we have an epidemic of obesity, and some of these meds carry a significant risk of obesity," he said.

"The whole idea of CWC is to foster discussion between patient and doctor to improve mental health literacy about mental health problems and a mental illness with appropriate interventions but not overtreatment. Insomnia is a big issue," Dr Wilkes concluded.

The new recommendations can be found online at http://www.choosingwiselycanada.org/recommendations/psychiatry/.

Dr Wilkes and Dr Maust report no relevant financial relationships.

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