Nowadays, they're widely used in bipolar disorder, depression, and as a new paper reveals, increasingly in anxiety disorders as well.The authors, Comer et al, looked at the NAMCS survey, which provides yearly data on the use of medications in visits to office-based doctors across the USA.
Back in 1996, just 10% of visits in which an anxiety disorder was diagnosed ended in a prescription for an antipsychotic. By 2007 it was over 20%. No atypical is licensed for use in anxiety disorders in the USA, so all of these prescriptions are off-label.
Not all of these prescriptions will have been for anxiety. They may have been prescribed to treat psychosis, in people who also happened to be anxious. However, the increase was accounted for by the rise in non-psychotic patients, and there was a rise in the rate of people with only anxiety disorders.
The increase was driven by the newer, "atypical" antipsychotics.
Whether the modern trend for prescribing antipsychotics for anxiety is a good or a bad thing, is not for us to say. The authors discuss various concerns ranging from the side effects (obesity, diabetes and more), to the fact that there have only been a few clinical trials of these drugs in anxiety.
But what's really disturbing about these results, to me, is how fast the change happened. Between 2000 and 2004, use doubled from 10% to 20% of anxiety visits. That's an astonishingly fast change in medical practice.
Why? It wasn't because that period saw the publication of a load of large, well-designed clinical trials demonstrating that these drugs work wonders in anxiety disorders. It didn't.
But as Comer et al put it:
An increasing number of office-based psychiatrists are specializing in pharmacotherapy to the exclusion of psychotherapy. Limitations in the availability of psychosocial interventions may place heavy clinical demands on the pharmacological dimensions of mental health care for anxiety disorder patients.In other words, antipsychotics may have become popular because they're the treatment for people who can't afford anything better.
These data show that antipsychotics were over twice as likely to be prescribed to African American patients; the poor i.e. patients with public health insurance; and children under 18.
Comer JS, Mojtabai R, & Olfson M (2011). National Trends in the Antipsychotic Treatment of Psychiatric Outpatients With Anxiety Disorders. The American journal of psychiatry PMID: 21799067
16 comments:
Just in time. a few days ago a friend was given Abilify. He is not psychotic AFAIK but maybe hypomania, concentration and impulse problems with fears of something bad and uncontrollable to happen.
I wonder if a mood stabilizer and/or SSRI would be safer.
When you have a hammer, the whole world looks like a nail. In the case of atypical antipsychotics, we're talking about a pneumatic hammer.
The effect of a hot female Abilify/Risperdal/Seroquel rep never ceases to amaze me. The effect of paying KOLs to speak never ceases to amaze me. The affect of offering physician inducements like travel and conference expenses never ceases to amaze me. The effect of a high-end dinner with a hot rep never ceases to amaze me. The effect of all things marketing literally never ceases to amaze me. The righteous indignation from the medical profession whenever it is suggested that such marketing changes their prescribing habits no longer amazes me.
I've also been very worried about how often antipsychotics are being prescribed for things that fall well short of being psychosis.
I'm especially worried about how much more they're being prescribed to children. We have no idea what kind of effects they might have on a child's development, and yet lots and lots of children are taking them, usually just for sedation.
Just give it a few years and expect an epidemic of long term toxicity from use of these drugs in nonpsychotic patients. The big KOL selling pitch for them was lower incidence of tardive dyskinesia, which can be pretty disfiguring. What the KOLs gloss over when pimping these drugs for nonpsychotic depression and anxiety and OCD is that TD still does occur, and at nontrivial rates. A recent estimate* in elderly patients reported a 2-year incidence of 11.1% for Lilly’s drug olanzapine (Zyprexa) and 7.2 % for Janssen’s drug risperidone (Risperdal). So when these drugs are used widely as the marketers hope in primary care, look for around 100,000 cases of tardive dyskinesia for every million patients. That’s a lot of TD and a lot of potential lawsuits. Oh and then there are the metabolic issues…
* MG Woerner et al Neuropsychopharmacology 2011; 36: 1738-1746.
I honestly fail to see how any rational medical system could allow physicians to prescribe drugs off-label. This seems to be little more than the expected outcome of allowing pharmaceutical lobbyists to coerce drug regulation agencies into allowing unscientific practices for the sake of additional profits. Expensive cancer drugs which purportedly stave off death for a few extra weeks are bad enough, but prescribing untested medications with no evidence of a benefit is just despicable.
I have an extended family member that's on an atypical antipsychotic that was prescribed for insomnia. This troubles me. Her doc did not tell her the drug is an antipsychotic. The drug is enough of a dose that it dulls her senses which makes her less likely to complain about the med. I genuinely hope her doctor has uncommon prescription practices; they strike me as highly unethical.
I don't, however, see off-label prescriptions as an inherent evil. The two prescriptions I take every day were prescribed off-label. I take these drugs to treat symptoms rare enough that the drug companies don't seek approval to claim these indications.
Appreciate the article, I commented about atypicals a few articles back. Hands down, it has been the drug that I have seen first hand do the most damage to children. I have witnessed clients go from thing to morbidly obese on Atypicals on many occasions. I've seen this drug given to the 'group home' population of children/adolescents in the past at an amazingly high rate--where for awhile, any of the more behaviorally acting out clients were automatically given this 'treatment' regardless of diagnostic label.
My issue with off label uses, is that sometimes its promoted by the drug companies with no valid backing, and even rudimentary neuroscience would suggest that the usage would have little real therapeutic effect. If the effect is truly meant to sedate a client, why not just skip the smoking mirrors and sedate them, with something that doesn't promote type2 diabetes, TD (as Mr. Carroll mentioned), N.M.S.
Is it going to take millions of children becoming adults with severe liver damage, tardive, early death, Diabetes, and big lawsuits decades later to make changes? The lawsuit mechanism, continues to seem lousy, since generally speaking many of the drugs can rake in billions in profits, with not much risk of paying more than 100 million in lawsuits. The greed imperative of some, don't mind making billions, and paying out 100's of millions later on, since they still made their billions.
Despite the benefits of some drugs, I still see children who are overly medicated, treated like lab rats, and have no say in the large amounts of drugs the keep them on. As a non MD mental health professional, you can't advocate effectively for clients in regards to medication, even though most MD's in some areas have 1000 clients, don't know the names, and spend 15 minutes doing consults--to determine their biological conditions. Extraordinary drugging, should require extraordinary data, time, and biometric data, not more of the same old "chemical imbalance" bullshit--that they tell to the uninformed.
It strikes me as rather bizarre that atypicals are now seemingly considered to be better general purpose sedatives than, say, benzodiazepines. Hence the title of my post.
Benzo's have a bad reputation nowadays because of causing dependence, abuse potential, and all that.
But no-one ever got akathisia, diabetes or TD off a benzo.
Then again, no drug company has made money off a benzo since... the 90s I guess? Maybe earlier.
The racial slant speaks for itself.
What a disgrace to the profession of psychiatry, which continues to cover itself in ignominy.
The problem is, each individual doctor does not recognize that he or she is adding to the problem. When cornered, they accuse GPs of all the overdrugging.
Eventually, the public will start avoiding psychiatrists. Pharmapsychiatry deserves to go out of business.
@Beth: "I take these drugs to treat symptoms rare enough that the drug companies don't seek approval to claim these indications."
Still, it follows that if such symptoms are so rare as to lead pharmaceutical companies to avoid seeking drug approval for them, then they are unlikely to make up the majority of cases where off-label drugs are prescribed. And how exactly does it help people with rare symptoms if there is no legitimate oversight to confirm whether or not the drugs they are taking actually affect their underlying symptoms? It wouldn't be a problem if the medical profession was self-regulating its own members. But medicine is too often a cottage industry, where individual doctors may use such widely varying practices as to make the question of self-regulation moot.
Heh. As if on cue, a large clinical trial has just come in JAMA out showing no benefit of the atypical risperidone as an add-on treatment for PTSD.
PTSD being the anxiety disorder associated with most atypical prescribing in this survey...
According to Dr. Allen Frances, "chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC.", 5% of ALL prescriptions, not all psychiatric prescriptions, but ALL prescriptions are being written for anti-psychotics and it is a 10 billion dollar a year industry http://www.blogtalkradio.com/thecoffeeklatch/2011/02/03/dr-allen-frances (Listen to minutes 8:04 to 10:07, approx.) The whole interview is quite sad as the mother is so reticent to believe that there is "not a pill for that."
He is the bad guy recently, saying that autism is a fad diagnosis, and driving neurotic parents insane. Bless his heart, all he is saying is, quit looking to psychiatry to raise your basically normal kids for you.http://www.psychologytoday.com/blog/dsm5-in-distress/201105/the-autism-epidemic-marches
I'm not quite sure that we may not pay a cost for medicalizing childhood. Long term studies are kinda sparse.
My son has a label and it's been no walk in the park, but I wonder if Dyslexic might have been a better label in school than autistic.
Yeah. To be honest, 10-15 years ago, when autism "hit the mainstream", I think a wise observer could have predicted that it would become overdiagnosed.
Even if it isn't being overdiagnosed today (and I'm not sure it is, yet) - it will be. It's only a matter of time.
Indeed I would predict that autism will come to replace ADHD and "pediatric bipolar" as the overdiagnosed disorders of the next decade.
Shits and giggles...
http://www.thefix.com/content/jj-sued-illegal-promotion-drugs-kids#.TkL5buXA_yN.twitter
A picture tells a thousand words.
I know this is an old post, but for prosperity...
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