American Psychiatric Association

Five Things Physicians and Patients Should Question

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1

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

Metabolic, neuromuscular and cardiovascular side effects are common in patients receiving antipsychotic medications for any indication, so thorough initial evaluation to ensure that their use is clinically warranted, and ongoing monitoring to ensure that side effects are identified, are essential. “Appropriate initial evaluation” includes the following: (a) thorough assessment of possible underlying causes of target symptoms including general medical, psychiatric, environmental or psychosocial problems; (b) consideration of general medical conditions; and (c) assessment of family history of general medical conditions, especially of metabolic and cardiovascular disorders. “Appropriate ongoing monitoring” includes re-evaluation and documentation of dose, efficacy and adverse effects; and targeted assessment, including assessment of movement disorder or neurological symptoms; weight, waist circumference and/or BMI; blood pressure; heart rate; blood glucose level; and lipid profile at periodic intervals.

2

Don’t routinely prescribe two or more antipsychotic medications concurrently.

Research shows that use of two or more antipsychotic medications occurs in 4 to 35% of outpatients and 30 to 50% of inpatients. However, evidence for the efficacy and safety of using multiple antipsychotic medications is limited, and risk for drug interactions, noncompliance and medication errors is increased. Generally, the use of two or more antipsychotic medications concurrently should be avoided except in cases of three failed trials of monotherapy, which included one failed trial of Clozapine where possible, or where a second antipsychotic medication is added with a plan to cross-taper to monotherapy.

3

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

Behavioral and psychological symptoms of dementia are defined as the non-cognitive symptoms and behaviors, including agitation or aggression, anxiety, irritability, depression, apathy and psychosis. Evidence shows that risks (e.g., cerebrovascular effects, mortality, parkinsonism or extrapyramidal signs, sedation, confusion and other cognitive disturbances, and increased body weight) tend to outweigh the potential benefits of antipsychotic medications in this population. Clinicians should limit the use of antipsychotic medications to cases where non-pharmacologic measures have failed and the patients’ symptoms may create a threat to themselves or others. This item is also included in the American Geriatric Society’s list of recommendations for “Choosing Wisely.”

4

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

There is inadequate evidence for the efficacy of antipsychotic medications to treat insomnia (primary or due to another psychiatric or medical condition), with the few studies that do exist showing mixed results.

5

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

Recent research indicates that use of antipsychotic medication in children has nearly tripled in the past 10 to 15 years, and this increase appears to be disproportionate among children with low family income, minority children and children with externalizing behavior disorders (i.e., rather than schizophrenia, other psychotic disorders and severe tic disorders). Evidence for the efficacy and tolerability of antipsychotic medications in children and adolescents is inadequate and there are notable concerns about weight gain, metabolic side effects and a potentially greater tendency for cardiovascular changes in children than in adults. Additional information on medication use in children and adolescents.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The American Psychiatric Association (APA), founded in 1844, is the world’s largest psychiatric organization. It is a medical specialty society representing more than 33,000 psychiatric physicians from the United States and around the world. Its member physicians work together to ensure humane care and effective treatment for all persons with mental disorders, including intellectual disabilities and substance use disorders. APA is the voice and conscience of modern psychiatry. Participating in the Choosing Wisely® campaign furthers APA’s mission to promote the highest quality care for individuals with mental disorders (including intellectual disabilities and substance use disorders) and their families.

For more information, visit www.psychiatry.org.

The American Psychiatric Association (APA) created a work group of members from the Council on Research and Quality Care (CRQC) to identify, refine and ascertain the degree of consensus for five proposed items. Two rounds of surveys were used to arrive at the final list: the first round narrowed the list from more than 20 potential items by inquiring about the extent of overuse, the impact on patients’ health, the associated costs of care and the level of evidence for each treatment or procedure; and the second gauged membership support for the top five and asked for suggested revisions and comments. The surveys targeted the CRQC; the Council on Geriatric Psychiatry; the Council on Children, Adolescents, and Their Families; and the Assembly, which is the APA’s governing body consisting of representative psychiatrists from around the country. After the work group incorporated feedback from the two large surveys, the APA’s Board of Trustees Executive Committee reviewed and unanimously approved the final list.

For APA disclosure and conflict of interest policy please visit www.psychiatry.org

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