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Friday, February 06, 2015

Beware Off-Label Use of Antipsychotics

Antipsychotic use in the U.S. increased from 6.2 million treatment visits in 1995 to 14.3 million visits by 2008. Abilify, an antipsychotic, has been the top-selling drug in America for several years. Are we all psychotic now? No. Not exactly. Treatment of psychosis is not what made Abilify the top-selling drug in the United States. Abilify is now widely prescribed as an adjunctive drug for depression; it is also approved as a treatment for irritability in autism (as is Risperdal). And it's prescribed for off-label uses.

The nasty little secret about drugs is that any doctor can prescribe any drug off-label for any reason. It's illegal for the drug manufacturers to promote a drug for off-label uses, but doctors are often persuaded (either by drug company salespeople or word of mouth, or whatever) that certain off-label uses are okay, and there is nothing illegal about doctors prescribing drugs off-label.

In my forthcoming book, Of Two Minds (due out later this month), I talk about the recent trend toward off-label prescription of antidepressants, antipsychotics, and other psychiatric drugs. (Get a free sample here. More samples coming soon! Stay tuned!)

A recent paper (PDF version here) looked at prescribing information drawn from the National Disease and Therapeutic Index (NDTI). It found that only 34.5% of antipsychotics prescriptions are for schizophrenia and other psychotic disorders (see table below). Somewhat disturbingly, 7.4% of prescriptions for these drugs are written for dementia patients. I say "disturbingly" because it's known that these drugs are associated with increased mortality in elderly patients. NDTI contains over 211,000 mentions of these drugs being given for non-psychiatric reasons, which is also disturbing. There is no legitimate reason to prescribe antipsychotics for non-psychiatric conditions, unless perhaps you're using Zyprexa's known weight-gain side effects to treat anorexia.

Prescriptions for antipsychotics: Category tally (NDTI database).
From Mark, T.L., CNS Drugs. 2010 Apr;24(4):319-2.
Diagnosis category
Drug mentions (thousands)
%
Mood disorders
7195
39
Schizophrenia and other psychotic disorders
6368
34.5
Delirium/dementia/amnestic or other cognitive disorders
1369
7.4
Attention-deficit/conduct/disruptive behaviour disorders
1046
5.7
Anxiety disorders
1019
5.5
Disorders usually diagnosed in infancy/childhood/adolescence
426
2.3
Personality disorders
268
1.5
Impulse control disorders not elsewhere classified
223
1.2
Substance-related disorders
130
0.7
Developmental disorders
86
0.5
Miscellaneous mental disorders
79
0.4
Adjustment disorders
36
0.2
Non-psychiatric
211
1.1
Other hereditary and degenerative nervous system conditions
36
0.2
Intracranial injury
30
0.2
Other aftercare
19
0.1
Diabetes mellitus with complications
14
0.1
Nausea and vomiting
12
0.1
Other nutritional, endocrine and metabolic disorders
9
0.1
Other
92
0.5
Unclassified
345
1.8

Abilify is commonly prescribed as an adjunctive drug for depression. Its usefulness in this application is doubtful. Most antipsychotic prescriptions are now either for mood disorders or other non-schizophrenia-related conditions, and many people taking these drugs have not been properly informed as to the possible serious side effects, ranging from Type II diabetes to dystonia, akathisia, and tardive dyskinesia (which tends to be irreversible). The movement disorders (so-called extrapyramidal side effects) happen less often with atypical antipsychotics than old-school antipsychotics but still happen, even with the newer drugs. In children treated with these drugs, tardive dyskinesia  usually doesn't happen while on the drug, but only after withdrawing from it. It resolves by itself around half the time. For some people, it doesn't resolve without going back on the antipsyhotic. All antipsychotics, atypical or otherwise, bring  risk of weight gain and Type II diabetes.

Please, before taking antipsychotics of any kind (or allowing someone you know to take them), educate yourself on the possible side effects. The following video shows some of the side effects in actual patients. Please also see Part II of this video here.



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2 comments:

  1. Few aspects of American culture survived the last decades of the 20th century as monolithic beliefs held by all. There was constant bickering and factionalism about gay and women's rights, climate, diversity, federalism and one could go on forever. Strangely unnoticed, pharmacologism, or the unquestioning belief in pharmacology, slipped by under the radar. From dope users to crash dieters, body sculpters to cancer victims and diabetics, everyone in America seems hooked on the idea that "there is a drug for that." It's a glib, superficial and naive belief that chemicals do the one thing you want them to. Doctors were in no way immunized against this by their schooling, and have created epidemics of narcotic addiction in addition to the antipsychotic abuse described here. Just like the resurgence of the measles virus, this is a proxy for the advances of scientific illiteracy.

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    1. Indeed, I think the saddest part about it is the way doctors bought into the drug-company sales pitch, uncritically. Doctors are, of course, busy people; they can't be expected to do deep reading on every drug. However, it is their profession; it's their domain. They should do the responsible thing and not simply let drug makers manipulate them into prescribing the latest/greatest drugs (which are rarely, in fact, better than older drugs). Pharmacologism (as you so aptly put it) is what happens when we focus strictly on symptoms and lose sight of the big picture. It creates expectations (as you say) that there's always "a drug for that," when in fact it's often the case that the drugs, themselves, add new problems.

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