On April 23, 2015 APA published a revision to the third item on its Choosing Wisely list to better reflect that there are instances in which dementia-associated symptoms (e.g., aggressive behavior due to paranoid delusions) pose an acute threat to the individual and others, and in these instances antipsychotic medications must be used before formal nonpharmacologic measures can be instituted. With the addition of the word "routinely", the Choosing Wisely statement acknowledges this reality.
APA's list includes the following five recommendations:
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 may occur in patients receiving antipsychotic medications for any indication. Thorough initial evaluation to identify side effects are are essential. "Appropriate initial evaluation" includes: (a) thorough assessment of possible underlying causes of target symptoms including medical, psychiatric, environmental or psychosocial problems; (b) consideration of medical conditions; and (c) assessment of any family history of 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.
Concurrent prescription of two or more antipsychotic medications is common, although the evidence for the efficacy and safety of this practice is limited. In addition, concurrent use of more than one antipsychotic medication may increase the potential for side effects, drug-drug interactions, and difficulties with adherence. There may be some circumstances when it is appropriate and beneficial to prescribe two or more antipsychotic medications concurrently, such as when changing from one medication to another or when an optimal dose of one antipsychotic medication is not sufficient to reduce symptoms of schizophrenia. However, even in the treatment of schizophrenia, before prescribing two or more antipsychotic medications concurrently, it is important to consider other strongly evidence-based options such as a trial of clozapine or adding an evidence-based psychotherapy.
3. Don't routinely use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
Behavioral and psychological symptoms of dementia are non-cognitive symptoms and behaviors, including agitation or aggression, anxiety, irritability, depression, apathy and psychosis. The evidence in this population shows that the 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. Clinicians should generally limit the use of antipsychotic medications to situations in which non-pharmacologic measures have failed and the patients' symptoms may create a threat to themselves or others. The American Geriatric Society’s list of recommendations for "Choosing Wisely" echo this point.
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 an antipsychotic medication to treat behavioral and emotional symptoms of childhood mental disorder without 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 disorder, tic disorders, and severe irritability in children with autism spectrum disorders. There is increasing evidence that antipsychotic medication may be helpful for some disruptive behavior disorders. Prescribe antipsychotics to children and adolescents only after a careful diagnostic assessment with attention to comorbid medical conditions, a review of the patient's prior treatments, and trials of other medications with a more substantial evidence base for the target of treatment. Combine both evidence-based pharmacological and psychosocial interventions and support. Limited availability of evidence based psychosocial interventions may make it difficult for every child to receive this ideal combination. It is critical to discuss potential risks and benefits of medication treatment with the child and their guardian. A short and long term treatment and monitoring plan with regular follow-up visits is critical to assess outcome, side effects, metabolic status and discontinuation, if appropriate. The evidence base for use of atypical antipsychotics in preschool and younger children is limited and therefore caution is warranted in prescribing in this population.
More than 80 national and state medical specialty societies, regional health collaboratives and consumer partners have joined the Choosing Wisely effort promoting conversations about appropriate care. Over the next year, more than 30 other specialty society partners will release Choosing Wisely lists.
How this list was created
The APA created a work group of members from the Council on Research and Quality Care* 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 Council on Research and Quality Care; the Council on Geriatric Psychiatry; the Council on Children, Adolescents, and Their Families; and the Assembly, which is APA's governing body consisting of representative psychiatrists from around the country. After the work group incorporated feedback from the two large surveys, APA's Board of Trustees Executive Committee reviewed and unanimously approved the final list.
*Now two separate councils: Council on Quality Care and Council on Research.