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In defense of antipsychotic drugs for dementia

By Daniel Carlat, Special to CNN
  • Daniel Carlat: Report implies evil doctors are giving deadly drugs to nursing home patients
  • But antipsychotics are most effective drug for calming agitation in dementia, he writes
  • Carlat: No drugs are FDA-approved for this agitation, a terrible condition
  • The solution, he writes: Develop safer and more effective treatments of dementia

Editor's note: Daniel Carlat is a psychiatrist and publisher of The Carlat Psychiatry Report, a medical education newsletter for physicians and nurses. He is the author of "Unhinged: The Trouble with Psychiatry" and is an associate professor of psychiatry at Tufts University School of Medicine. He blogs at The Carlat Psychiatry Blog.

(CNN) -- The Office of the Inspector General believes it has just unearthed a public health scandal. Evidently, according to a report it released recently, predatory psychiatrists are prescribing deadly, ineffective drugs to our senior citizens in nursing homes throughout the country.

The full report is a blizzard of statistics, but the headlines have latched on to 95%. In the first half of 2007, 95% of antipsychotic prescriptions for elderly nursing home residents were "off-label," meaning written for conditions the drugs aren't FDA-approved to treat. To make matters worse, these drugs are said to "nearly double" (increase by 1.6-1.7 times) the rate of death in the demented elderly patients, who make up most of the nursing home population.

Daniel Levinson, inspector general of the Department of Health and Human Services, has ratcheted up the rhetoric, quoted in The New York Times describing antipsychotics for the elderly as "potentially lethal" and saying we as a nation should "be outraged and seek solutions." The report says more than half the antipsychotics that Medicare paid for in the first half of 2007 were "erroneous." As a psychiatrist who has dared to prescribe these antipsychotics to patients with dementia and agitation, apparently I'm about to be charged with attempted murder.

Daniel Levinson talks about the OIS study

It is true that we psychiatrists are far too quick to reach for our prescription pads, and that the pharmaceutical industry has, in many cases, illegally manipulated our prescribing habits. In fact, I just wrote a book about these very problems. But in this particular case, the Office of the Inspector General has it wrong, and Levinson's statements on behalf of Health and Human Services reflect an astonishingly poor understanding of the workings of medical care in general and psychiatric care in particular.

The unfortunate fact is that no medications are FDA-approved for the agitation of dementia, and yet the condition is common.
--Daniel Carlat

Although it's true that a prescription for antipsychotics to treat agitation in dementia is "off-label," this hardly means they are ineffective or that Medicare claims for these drugs are "erroneous." In fact, large placebo-controlled trials have shown that antipsychotics are the most effective medications for the agitation that often bedevils patients with dementia.

When these drugs are successful, they soothe the inner turmoil that makes life intolerable for these patients, improving their quality of life dramatically.

Off-label prescribing simply means the medicine has not undergone the vastly expensive process of gaining FDA approval. Doctors are allowed to prescribe medications off-label; indeed, without this prerogative, much of medical care would grind to a halt. More than 60% of drugs prescribed by both pediatricians and oncologists are "off-label," and almost all drugs prescribed by obstetricians fall into that category. Has your doctor every given you Valium to help you sleep? If so, your doctor was "erroneously" billing your insurance, according to the Office of the Inspector General, because Valium is FDA approved for anxiety, not for insomnia.

The unfortunate fact is that not a single medication is FDA-approved for the agitation of dementia, and yet the condition is common. About 15% of people over 65 have dementia, and half of them will develop agitation at some point. Anybody who has visited a loved one in the Alzheimer's unit of a nursing home understands agitation only too well; it includes combativeness, shouting, verbal abuse, extreme hyperactivity and sometimes outright violence to caregivers and family.

Agitation is often due to psychosis. For example, I recall one unfortunate gentleman with Alzheimer's disease who ripped an IV line out of his arm because he woke up in a strange room and believed his wife was in the next room calling his name. The room that seemed strange to him was a nursing home room he had occupied for three years, and his wife had died 15 years earlier.

This kind of agitation is dangerous for the patient, for staff and very upsetting for family members. When geriatric psychiatrists are asked to treat agitation, they look first for potential triggers that can be solved without resorting to behavioral drugs. Infections, drugs interacting with drugs, or pain are sometimes the culprits. At times, changes in the environment can help, such as increasing contact with a caregiver, changing roommates, or even adjusting the room's temperature.

But in many cases, such measures don't help enough.

Antipsychotics, such as Risperdal, Seroquel, and Zyprexa, have all been shown to be convincingly more effective than placebos in quelling agitation in the elderly. Their vaunted "lethal" risks are based on data that is surprisingly unimpressive. When each antipsychotic was studied separately, no significant difference in mortality was found between patients on drugs or on placebos. But when data on thousands of patients were combined, the mortality rate with four specific drugs was 4.5% in the medication group vs. 2.6% in the placebo group. The most common causes of death? Heart failure and pneumonia, which are the most common causes of death for all patients with dementia.

Physicians are not prescribing these medications in order to do harm to their patients. They are using them because there are no better options. Antipsychotics, by helping patients to be calm, are humane treatments for patients who are reaching the end of their days.

The solution is to expand research on safer and more effective treatments of dementia. It is not, as proposed by Levinson, to hire government auditors to decide whether doctors are prescribing drugs "appropriately." God help us if they do.

The opinions in this commentary are solely those of Daniel Carlat.