Fall 2020 - Vol. 15, No. 3




 
This is my 33rd article on Choosing Wisely from the Board of Internal Medicine Foundation. As previously noted, each specialty group is developing “Five or more Things that Physicians and Patients Should Know.”

 

I.  RECOMMENDATIONS FROM THE AMERICAN PSYCHIATRIC ASSOCIATION

1. Antipsychotic medications should not be prescribed for any indication without appropriate initial evaluation and appropriate ongoing monitoring.

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 metabolic and cardiovascular disorders.

Appropriate ongoing monitoring includes periodic reevaluation and documentation of dose, efficacy, and adverse effects; targeted assessment, including assessment of movement disorder or neurological symptoms; and monitoring of weight, waist circumference and/or BMI, blood pressure, heart rate, blood glucose level, and lipid profiles.

2. Concurrent prescription of two or more antipsychotic medications should not be done routinely. Generally, this practice 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. Treatment of behavioral and psychological symptoms of dementia should not routinely use antipsychotic drugs as first choice. 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 in this population, the potential benefits of antipsychotic medications tend to be outweighed by their risks (cerebrovascular effects, mortality, Parkinsonism or extrapyramidal signs, sedation, confusion and other cognitive disturbances, and increased body weight).

After non-pharmacologic measures have failed, and the patients’ symptoms may create a threat to themselves or to others, then use of antipsychotic medications may be considered. This item is also included in the American Geriatric Society’s list of recommendations for “Choosing Wisely.” ¹

4. Antipsychotic medications should not be routinely prescribed 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), and the few studies that exist show mixed results.

 

5. Antipsychotic medications should not be routinely prescribed to treat behavioral and emotional symptoms of childhood mental disorders in the absence of approved or evidence-supported indications. There are both on and off label clinical indications for antipsychotic use in children and adolescents. FDA approved and/or evidence-supported indications for antipsychotic medications in children and adolescents include: psychotic disorders, bipolar disorders, tic disorders, and severe irritability in children with autism spectrum disorders; there is increasing evidence that antipsychotic medication may be useful for some disruptive behavior disorders. Efforts should be made to combine evidence-based pharmacological therapy with psychosocial interventions and support. It is essential to discuss the potential risks and benefits of medication treatment with a child and their guardian.

 

REFERENCES

1. Richter T, Meyer G, and Mohler R, et al. Psychosocial interventions for reducing antipsychotic medication in care home residents. Cochrane Database Syst Rev. 2012 Dec 12;12:CD008634.