Are Antipsychotics Overprescribed?

Editor’s note: Antipsychotics are now the top-selling class of medications in the United States, with prescription sales of $14.6 billion in 2009.[1] Many clinicians worry these agents are being overprescribed and used inappropriately. Medscape recently hosted an email discussion between Dr. Nassir Ghaemi, a psychiatrist, and Dr. Larry Culpepper, a primary care physician with expertise in psychiatry, exploring the question of whether antipsychotics are being used appropriately by prescribing clinicians.

Are Antipsychotics Overprescribed? Introduction

Nassir Ghaemi, MD, MPH: I think antipsychotics are overprescribed. Let’s first think about the most legitimate uses, and then we can identify how and why they’re overprescribed. These agents are most legitimately used, obviously, for schizophrenia in both the short term and long term.[2] They are also legitimately used in the short term (meaning a few months) for acute mania.[3] That’s about it, in my view.

Now, some antipsychotics are US Food and Drug Administration (FDA) indicated for maintenance treatment of bipolar disorder. But for various scientific reasons, I believe the studies on which these approvals are based are deeply flawed.[4,5] So despite the president’s stamp of approval, I don’t think we can give a scientific stamp of approval. I think [antipsychotics] are scientifically proven for only a few months of mania, and then they should be stopped in general, both due to lack of proven efficacy (despite what the FDA says) and for safety concerns associated with some of the drugs.[4,5]

Antipsychotics are also used for bipolar depression, and some have FDA indications for the condition. Here too I am skeptical about the related studies. But even if accepted, the evidence only supports short-term use (8 weeks), not long-term use for prevention; hardly any data exist with any antipsychotics by themselves in the prevention of bipolar depression, and what little data does exist are subject to many scientific problems.[4,5]

Then there is so-called major depressive disorder, or plain old depression. Certain antipsychotics have an FDA indication here, but again only for short-term use. Hence, short-term use might be justifiable, but scientifically long-term use is not.[6]

By Larry Culpepper, MD, MPH; Nassir Ghaemi, MD, MPH
Medscape Psychiatry

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