Shrink Rap News

Antipsychotics and the psychiatrist’s dilemma


A few weeks ago, I highlighted the blog post of National Institute on Mental Health Director Dr. Thomas Insel, in which he discussed how some patients with schizophrenia do better on lower doses of antipsychotic medications (or even off medications), over the long-run.

Soon afterward, the American Psychiatric Association announced that psychiatrists should use care when prescribing antipsychotics, and specific recommendations were made, along with information that was posted to the Choosing Wisely website. Choosing Wisely is an initiative of the ABIM Foundation aimed at promoting discussions between physicians and patients about the overuse of medical tests and procedures. The APA "identified five targeted evidence-based recommendations" that can be used to prompt conversations with patients:

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

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

• Don’t prescribe antipsychotics as a first-line intervention to treat behavioral and psychological symptoms of dementia.

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

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

"As clinicians, we know we can improve the care we deliver by engaging our patients in conversations about their care. The recommendations from APA released today provide valuable information to help patients and physicians start important conversations about treatment options and make informed choices about their health care," Dr. Jeffrey Lieberman, APA president, said in the announcement. "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."

We can add to this call for caution the growing information we have that psychiatric medications are a mixed blessing for some patients. In a June 1, American Journal of Psychiatry article, "Relapse Duration, Treatment Intensity, and Brain Tissue Loss in Schizophrenia: A Prospective Longitudinal MRI Study," Dr. Nancy C. Andreasen and her colleagues reported data that left us with the perplexing conundrum that decreasing brain volume is associated both with longer duration of psychosis (but not with increased number of episodes) and with increased exposure to antipsychotic medications.

The authors noted, "Relapse prevention is important, but it should be sustained using the lowest possible medication dosages that will control symptoms." However, the only way to ascertain the lowest possible dose is to decrease the dosage until the patient becomes symptomatic, thereby risking another episode of psychosis (Am. J. Psychiatry 2013;170:609-15).

Whenever news circulates about the downside of commonly used psychotropic medications, the media is quick to circulate the news. As if on cue, USA Today printed an article 3 days after the APA released its list, headlined "Doctors: Antipsychotic meds overused for dementia, kids."

The study by Dr. Andreasen recirculated on Twitter recently but has been quoted by antipsychiatry sources on and off over the past 5 years. To most psychiatrists, it is not quite news that these medications might be overprescribed or that they can have adverse effects.

We’re in a really tough place. The longer antipsychotic medications are available, the more we become aware of the health problems associated with them, hence the justified call for caution. On the other hand, the morbidity and mortality from the conditions these medications address are considerable, and we often don’t have safe, effective alternatives with side effect profiles that are acceptable to patients.

And to state the obvious, the general public seeking psychiatric care has come to agree that symptoms are caused by "chemical imbalances," and both patients and their caretakers now request medications to fix their problems. This isn’t all bad; there’s more awareness of psychiatric symptoms and more willingness to seek treatment, and for many patients, their suffering (or the suffering of their caretakers) is eased. For the psychiatrist, however, the options are often limited, and it seems possible that we’re damned if we do prescribe and damned if we don’t.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

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