October 2, 2013
Common Uses of Antipsychotic Medications Come
Under Question

Arlington, VA—Pharmacists who have concerns when filling antipsychotic medications now have some guidance on what specific practices to question.

In fact, some common usages of antipsychotic medications are unnecessary and could even be harmful, according to information recently released by the American Psychiatric Association (APA).

The APA offered five recommendations as part of the Choosing Wisely campaign, an initiative of the American Board of Internal Medicine (ABIM) Foundation. Here’s what the organization suggests:

• Antipsychotic medications should not be prescribed to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring. According to the APA, “appropriate initial evaluation” includes thorough assessment of possible underlying causes of target symptoms including general medical, psychiatric, environmental or psychosocial problems; consideration of general medical conditions; and 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.

• Two or more antipsychotic medications shouldn’t routinely be prescribed concurrently. The APA recommendations cite research indicating that use of two or more antipsychotic medications occurs in 4% to 35% of outpatients and 30% to 50% of inpatients, despite the risk for drug interactions, noncompliance, and medication errors as well as the lack of evidence for efficacy and safety.

• Antipsychotics shouldn’t be used as first choice to treat behavioral and psychological symptoms of dementia. Risks such as cerebrovascular effects, mortality, Parkinsonism or extrapyramidal signs, sedation, confusion, and other cognitive disturbances, as well as increased body weight usually outweigh the potential benefits of antipsychotic medications in this population, according to the APA. It instead advises that antipsychotic medications only be used in cases where non-pharmacologic measures have failed and symptoms may create a threat to the patient or others.

• Antipsychotic medications shouldn’t be routinely prescribed as a first-line intervention for insomnia in adults because effectiveness has not been proven.

• Antipsychotic medications shouldn’t be routinely prescribed as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders, according to the recommendations, which suggest that the drugs are especially overused in children with low family income, minority children and children with externalizing behavior disorders rather than schizophrenia, other psychotic disorders and severe tic disorders. There also are questions about efficacy in young people as well as possibly intolerable side effects.

“This is not to preclude the use of antipsychotic medications for these indications and populations, but to suggest that other treatment options should be considered first and patients should be engaged in discussion of the rationale for use and the potential benefits and risks,” said Jeffrey Lieberman, MD, APA president.

U.S. Pharmacist Social Connect